Access to obstetric care is declining across the United States, a trend coinciding with a rise in maternal mortality rates. This decline is particularly pronounced in rural areas, where fewer than half of rural hospitals offered obstetric care as of . The challenges faced by rural communities in accessing adequate maternal care are multifaceted, extending beyond geographical distance to encompass socioeconomic factors and systemic barriers.
Recent research, including a study led by LDI Senior Fellow Sara C. Handley, highlights the disparities in care received by high-risk pregnant individuals in rural areas. The study, published on in JAMA Health Forum, found that distance was the strongest barrier to receiving risk-appropriate obstetric care in four states – Oregon, Michigan, Pennsylvania, and South Carolina. However, other factors also played a significant role, including younger age, Hispanic ancestry, lower educational attainment, and lack of insurance.
“People who live in rural areas experience a higher burden of pre-existing and pregnancy-related conditions,” explains Dr. Handley, a neonatologist at the Children’s Hospital of Philadelphia. “For example, high blood pressure can complicate pregnancy and benefits from regular visits for diagnosis, monitoring, and treatment. In our study, almost half of rural residents had some indication of higher medical or obstetric risk warranting a specific level of obstetric care.”
The decline in hospital-based obstetric services isn’t simply a rural phenomenon, but the impact is disproportionately felt in these communities. Between and , the percentage of rural hospitals offering obstetric services decreased from approximately 57% to 48%. A study led by the University of Minnesota School of Public Health, published in Health Affairs on , revealed that seven states experienced at least a 25% closure rate of hospital obstetric units during this period. By , eight states had more than two-thirds of their rural hospitals without obstetric services.
The consequences of these closures extend beyond access to delivery services. The loss of obstetric units can adversely affect the quality of perinatal care and outcomes, particularly for vulnerable populations. Maternal and infant morbidity and mortality rates are elevated for rural residents and racially minoritized people, exacerbating existing health inequities.
Dr. Handley emphasizes the need for a systemic approach to address these challenges. “There are real, structural barriers for rural residents to reach risk-appropriate obstetric care at the time of childbirth,” she states. “These highlight opportunities to improve the organization of our health care systems.” She advocates for the creation of regional care networks capable of delivering high-risk care more widely, expansion of reimbursement for maternal transport, and incentives for hospitals to transfer patients to facilities equipped to handle complex cases when their own capabilities are limited.
The potential of telehealth to bridge the gap in access is often discussed, but Dr. Handley cautions against assuming its universal availability. “Many assume that telehealth is usable everywhere, but that’s untrue in many parts of the U.S.” She points to the Arkansas High-Risk Pregnancy Program as a successful model, demonstrating the effectiveness of coupling improved broadband access with a telehealth initiative focused on high-risk care.
The study also identified key inequities in access to high-risk obstetric care within rural areas. Residents who identified as American Indian or Alaska Native, as well as those with missing race data, had higher odds of not receiving risk-appropriate care. This underscores the importance of addressing social determinants of health and systemic biases that contribute to disparities in maternal health outcomes.
While current maternal level of care guidelines are largely consensus-based, emerging evidence suggests a strong correlation between higher levels of care and improved outcomes, mirroring established evidence in neonatal care. Data from Massachusetts indicates that high-risk patients who deliver at hospitals lacking appropriate maternal care levels face a significantly increased risk of severe complications. Further research is anticipated to solidify this link.
Looking ahead, Dr. Handley and her team plan to investigate the long-term impact of rural obstetric unit and hospital closures on access to risk-appropriate care and subsequent maternal and infant outcomes. This ongoing research aims to inform policy decisions and guide the development of effective strategies to improve maternal health equity in rural communities.
The study, “Risk-Appropriate Childbirth Care Among Higher-Risk Pregnant Rural Residents,” was authored by Sara C. Handley, Brielle Formanowski, Molly Passarella, Maggie L. Thorsen, Julia D. Interrante, Clara E. Busse, Scott A. Lorch, and Katy B. Kozhimannil.
