Increasing lack of formal obstetric services in rural US negatively affecting birth locations, outcomes

By Liz Meszaros, MDLinx
Published May 16, 2018

Key Takeaways

Loss of hospital-based obstetric services in many rural areas throughout the United States has led to increased out-of-hospital births, preterm births, and hospital births without obstetric units, according to results of a recent study published in JAMA.

To study the effects of the decrease in hospital-based obstetric services that has occurred in the rural US, researchers led by Katy B. Kozhimannil, PhD, MPA, Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, conducted this retrospective study.

They sought to determine the relationship between the loss of services and the location and outcomes of childbirth in rural counties. They identified all births that occurred from 2004 to 2014 in rural US counties by using birth certificates linked to the American Hospital Association Annual Surveys. In all, 4,941,387 births in 1,086 rural US counties were included.

In a previous study, Dr. Kozhamannil and fellow researchers found that during the same period, the total percentage of rural counties in the US with hospital-based obstetric services declined from 55% to 46%.1

During the current study period, the team also found that 179 rural counties lost their hospital-based obstetric services. Women who gave birth in this cohort were a mean age of 26.2 years, 75.9% were non-Hispanic white, and almost half (49.7%) were college graduates.

In rural counties that were not adjacent to urban areas losing hospital-based obstetric services, Dr. Kozhimannil and colleagues observed a significant 0.70 percentage point increase in out-of-hospital births in the year after services were lost, as well as significant increases in births in a hospital without an obstetric unit (3.06 percentage points), and in preterm births (0.67 percentage points).

In an accompanying editorial, Neel T. Shah, MD, MPP, Harvard T.H. Chan School of Public Health, Boston, MA, noted that the increase in preterm births is most worrisome: “Of greatest concern is the relationship between inadequate access to care and the observed increased rates of prematurity following service closures in the more geographically isolated counties. Even after adjusting for maternal age, race/ethnicity, education, and common clinical conditions at the county level, the significant association with increased prematurity remained, with a 0.67 percentage point (95% CI: 0.02-1.33) increase in the year after closure. Prematurity is a major cause of both neonatal mortality and lifelong morbidity in the United States, particularly in rural areas that may be hours away from a hospital neonatal intensive care unit.”2

Although the effect was not as pronounced in rural counties that were adjacent to urban areas losing hospital-based obstetric services, researchers also found significant increases in births in a hospital without obstetric services (1.80 percentage points), with a decreasing trend (–0.19 percentage points per year) after the year after loss of services.

“Obstetric services are structured with high fixed costs and low reimbursements, making maternity wards financial loss leaders in community hospitals across the country. In recent years, an increasing number of hospital obstetric units with small volumes and large shares of Medicaid recipients have closed.3,4 As Kozhimannil and colleagues report in this issue of JAMA,5 the consequences of this trend may be particularly important for rural US families who have no other local options to access care,” wrote Dr. Shah.

He also noted that in families that live in rural counties, access to and quality of childbirth care seem to be inadequate—and getting worse—as local obstetric services and geographic isolation combine.

Dr. Kozhimannil and colleagues concluded: “Altogether, the results of this study indicate significant changes in birth location and outcomes immediately following rural obstetric unit closures, with sustained changes over time in rural counties that are not adjacent to urban areas. Such changes may affect clinical care in an already-challenging context. When a rural hospital stops providing obstetric care or closes entirely, the risks associated with the clinical management of child birth shift from the hospital to local clinics and staff that may not be equipped to provide obstetric services or to distant communities with whom rural residents may have little connection.”

Celebrating one of the founders of rural health care

In examining the state of rural obstetric care in the United States, it seems appropriate to honor one of the seminal figures in worldwide rural health care, Hawa Abdi Dhiblawe, born on May 17, 1947, in Mogadishu, Somalia.

In 1983, Dr. Abdi, a physician and activist, opened the Rural Health Development Organization (RHDO) on land owned by her family. The RHDO began as a one-room clinic that provided free obstetrician services to roughly 24 rural women per day. It has since become a 400-bed hospital. In 2007, after surviving a siege by insurgents in southern Somalia, the RHDO was renamed the Dr. Hawa Abdi Foundation (DHAF).

To date, the DHAF has served roughly 2 million people, providing water, shelter, and medical care, mostly to women and children. The DHAF is run by Dr. Abdi and her two daughters, who are also physicians, and includes a hospital, school, and nutritional center.

The research reported in this article was supported by the Federal Office of Rural Health Policy, Health Resources and Services Administration, Department of Health and Human Services.


  1. Hung P, Kozhimannil K, Henning-Smith C, Casey M. Closure of hospital obstetric services disproportionately affects less-populated rural counties. University of Minnesota Rural Health Research Center. Published April 2017. Accessed January 29, 2018.
  2. Ely DM, Driscoll AK, Mathews TJ. NCHS data brief, No. 285: Infant mortality rates in rural and urban areas in the United States, 2014. Published September 2017. Accessed February 19, 2018.
  3. Itkowitz C. Closure of two DC maternity wards hurts low-income women most. The Washington Post. Published October 28, 2017. Accessed February 19, 2018.
  4. Hung P, Henning-Smith CE, Casey MM, Kozhimannil KB. Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004–14. Health Aff (Millwood). 2017;36 (9):1663-1671.
  5. Kozhimannil KB, Hung P, Henning-Smith C, et al. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA. doi:10.1001/jama.2018.1830.
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