The rash of hospital closures in rural counties across the country has led to an ever-widening gap in maternal care services, leaving more than 2.4 million women with no hospital-based obstetric services in 2014, according to a new study.
The analysis, published Tuesday in Health Affairs, found that 9% of rural counties lost all hospital obstetric services between 2004 and 2014 with the closure of maternity wards in 179 counties.
All in all, 45% of rural U.S. counties had no hospital obstetric services at all during those years, according to the researchers.
"It's a trend that does not affect all communities in the same way," said study co-author Katy B. Kozhimannil, associate professor of health policy and management at the University of Minnesota's School of Public Health.
Rural counties with lower median household incomes, higher populations of black women, and those located in states with lower Medicaid income eligibility limits for pregnant women were the most likely to lose or have no obstetric services, the study found.
Gaps in healthcare coverage have increased in most rural areas over the past decade as providers in those areas have either shut their doors or cut back on costly services, such as obstetrics, due to financial strain. Since 2010, more than 80 rural hospitals have closed, according to the National Rural Health Association, and more than 600 are at risk of closing.
More than half of births in rural areas are paid for by Medicaid, which has reimbursement rates that either barely cover or fail to completely offset the cost of obstetric care, according to Diane Calmus, government affairs and policy manager at the NHRA.
Losing obstetric care in one location adds strain to surrounding healthcare providers as their patient volume increases, but they lose money for the services they provide to each Medicaid patient, she said.
"Ultimately, when hospitals are operating in the red, they have to make the decision to cut services and that's when obstetric services often get targeted," Calmus said.
The closure of maternity services helps precipitate a continuous cycle that could lead to more rural hospital closures and service cuts and even wider disparities in health outcomes for women in rural communities, according to Calmus.
Studies have found women who must travel longer distances to receive obstetric care often have lower rates of participation in prenatal care during the first trimester of pregnancy compared to women in more urban areas.
Women living in small rural counties experience rates of infant mortality during the post-neonatal period of up to one year of life that are 27% higher compared to women living in urban counties, according to the U.S. Health Resources and Services Administration. Other evidence has shown higher rates of maternal deaths occurring in rural areas compared to metropolitan communities.
According to the American College of Obstetricians and Gynecologists, women living in more rural areas have higher rates of hospitalizations due to complications from their pregnancy compared with women in urban areas.
