Revealing the scope of rural OB unit closures

By: National Rural Health Association | 12/06/17

Carrie Henning-Smith

Peiyin Hung

Katy Kozhimannil

Brock Slabach

Closures of rural obstetrics units and entire hospitals have affected access to care for more than 28 million women of reproductive age living in rural America. With many hospitals closing OB units, women in rural areas are traveling many miles for treatment and delivery.

“In the broader discussions around health policy, most of the evidence is generated from an urban setting, and most of the decision-makers live in urban areas,” says Katy Kozhimannil, PhD, University of Minnesota School of Public Health associate professor and University of Minnesota Rural Health Research Center director of research. “Rural voices are not always part of the conversation, and we see our work as an effort to bring attention to rural voices and experiences.”

The National Rural Health Association (NRHA), together with its partners at the University of Minnesota Rural Health Research Center and grant funding by the Federal Office of Rural Health Policy, took a deep dive into researching the developing rural maternity crisis.

Risks of closing rural OB services

“The problem of OB services closing in rural communities has been a glacial movement for decades,” says Brock Slabach, NRHA senior vice president for member services. “Over time we’ve seen the disintegration of rural hospital maternity programs due to a number of factors. At NRHA, we wanted to look closely at this issue and better understand the effects on women in rural areas. The research team at the University of Minnesota put together an effective set of studies that documents the extent to which OB deserts are forming across the U.S.”

“Each community felt the experience in isolation, and our process was born out of that — drawing connections between numerous rural communities struggling with loss of access to maternity services,” Kozhimannil says. “We wanted to look at concerns at the community level and better understand what’s driving those closures.”

Kozhimannil and her team, including University of Minnesota research associate Carrie Henning-Smith, PhD, and Yale School of Public Health postdoctoral associate Peiyin Hung, PhD, found a dramatic decline in the number of rural counties that have hospital-based obstetrics units.

“In addition, we discovered that some communities, particularly those in rural areas with a higher percentage of black residents and lower incomes, were more vulnerable to losing or not having OB services. The groups that already suffer the worst health burdens were most likely to lose hospital-based obstetric care,” Kozhimannil explains.

The loss of OB services is troubling for a number of reasons, in large part because access to quality care is essential for healthy mothers and babies. “We are studying what happens to prenatal care and infant outcomes after communities lose hospital-based OB care,” Kozhimannil notes. “Data from other countries show that losing obstetric care in rural communities adds risk to pregnancies and deliveries by increasing travel distances.”

Henning-Smith adds, “We don’t have all of the answers yet. Anecdotally, we’ve talked to providers and they are seeing consequences for women in rural areas who are burdened by the economic ramifications of traveling 100 or 200 miles for OB services — taking time off from work and traveling great distances takes a toll, especially for those who are economically vulnerable.”

According to Slabach, distance not only affects deliveries; it can also inhibit effective prenatal care. “If a community is 60 miles from the nearest location for OB services, it can be difficult to travel for prenatal appointments,” Slabach says. “Patients may show up at delivery with little or no prenatal care due to the distance, adding to the risk of delivery.”

Factors contributing to loss of OB services

Henning-Smith, NRHA Rural Health Fellow and Journal of Rural Health editorial board member, outlined a number of reasons why rural hospitals are struggling to keep OB units open:

• Cost — Rising costs in health care, especially in the labor and delivery space, make it difficult for rural hospitals to get the reimbursements they need to provide OB services.
• Medicaid reimbursements — Half of all births in rural hospitals are funded by Medicaid, and the reimbursement rate tends to be lower. Discussions around reductions in Medicaid funding could further impact hospitals’ services and the ability to provide OB services.
• Demographic shifts — Changing demographics in rural areas impact the services offered by hospitals. As rural populations are getting older, hospitals need to put more energy into health services for an aging population, which can take away from resources for maternity care.
• Workforce challenges — Rural areas struggle across the board with having enough health care providers, and OB services can be staff-intensive.
• Requirements for rural hospitals — American Congress of Obstetricians and Gynecologists guidelines require that a hospital providing OB services be within 30 miles of another facility that can perform an emergency cesarean section, and there’s no flexibility for rural settings.
• Role of insurance — Malpractice insurers want to make sure they are comfortable with the setting, and in some cases they do not want to insure OB providers in rural hospitals.
• Patient choice — Some women may prefer to have their baby in a more urban setting if they have the means to do so.

Kozhimannil adds, “Small hospitals have different financial risks. When you run a maternity unit, you need a team of health care providers trained and ready to deliver a baby at any time. In a small or remote rural area, it becomes hard to pay for having that service available. Rural hospitals want to provide this care, but at some point it becomes untenable financially or clinically.”

According to Hung, the shortage of family physicians is another challenge. “Rural hospitals rely heavily on family physicians to provide obstetric care, but the number of family physicians is decreasing, and many do not keep up their labor and delivery skills because of low volume,” says Hung.

Low patient volume also makes it difficult to keep an OB unit open. “When you have to divide the cost of running a maternity department over a smaller number of patients, the unit cost is a lot higher,” Slabach explains. “And if your contracts for services are being pushed downward by payers, it’s difficult to cover the cost of the service in that lower-volume operation. As a result, the drive toward efficiency by all payers of care has reduced the financial viability for small-volume hospitals to be able to cover the costs of providing maternity services.”

Providers need to maintain the skill set to provide safe care. “We’ve looked closely at nurse staffing, and for hospitals with fewer than 350 births per year, nurses work on different units — they are not dedicated to labor and delivery,” Kozhimannil explains. “They have to keep up training in all of those areas, which can be timeconsuming and expensive.”

Paving the way for solutions

“There’s not one silver bullet solution, and there’s a lot of room for creativity,” Henning-Smith says. “Promising solutions involve more effort to incentivize providers to work in rural areas and sharing resources across systems and settings by regionalizing care. Ultimately, we need to address the Medicaid reimbursement rate, the cost of labor and delivery in general.”

Slabach agrees that solutions need to address the costs of maternity care. “We need to be advocating for payments to providers of obstetrical services based on the actual cost of care. We need to educate payers about differences between rural providers in OB and those in urban areas and insist on differentiating pricing based on volume to keep the units that are open viable,” he says.

On the national level, legislation has been proposed via the Improving Access to Maternity Care Act to designate health professional shortage areas for maternity care and extend some of the benefits to address provider shortages in rural areas. “There are some promising models looking at medical residency programs and how to make family practice or OBGYN attractive to medical students, introducing medical students, nurses and midwives to a rural setting context, and incentivizing them to practice in rural areas,” Henning-Smith says.

Kozhimannil adds, “We have to look for examples from states like Alaska where women travel great distances to give birth. Alaska has programs to help women give birth safely and to support travel at the end of pregnancy with subsidies for transportation and housing. In rural communities, when you’re about to have a baby, there are many expenses. Pre-maternity homes provide a place where women can stay as they near the end of pregnancy.”

Advances in technology and telemedicine can also help improve access to OB services in some cases. “Technology helps if you’re able to simulate delivery situations for training purposes or bring in experts via technology. For example, you could bring in a specialist to consult for high-risk pregnancy,” Henning-Smith explains.

Hung adds, “Consolidation among health systems could present an opportunity to break the negative impact of access to care. Consolidation leads to coordinated care through technology and information exchange between rural hospitals and their parent health systems. Local hospitals can take care of mothers so they don’t have to travel, and those who need high-risk care need to be identified.”

Currently, regionalization of health care is more focused on neonatal care than maternity care, which means there are networks of care set up for high-risk infants but not for high-risk mothers. “Providing access to neonatal care is critical for infant outcomes, but there should be a way to take care of both mothers and babies,” Hung says.

“We need a model of care for providing prenatal care to women closer to home,” Slabach adds. “This care could be provided through nurse practitioners, nurse midwives and family practice physicians trained to provide prenatal care, with care in the last month transferred to place of delivery. The evidence is clear that consistent and high-quality prenatal care definitely reduces mortality.”

Birth is important in every community

As a country, we all benefit from having new babies born healthy and well. “Half a million babies are born in rural areas each year. We need that next generation to be healthy and ensure babies are born safely,” Henning-Smith says. “We need to figure out how to best support new moms, babies and families so that rural areas can remain vibrant areas.” Kozhimannil adds, “Birth is important in communities, and a growing number of rural communities are fighting for their vitality. Providing OB services, and doing it well, can attract and keep families in these areas.”

If rural communities are going to maintain economic viability going forward, they must have access to maternity services. “Making sure that patients of childbearing age living in rural areas have equal access to care is vitally important,” Slabach says. “At NRHA, we’ll continue to raise awareness about this important topic so policymakers can help us with solutions. We want to make the voices of these expectant mothers louder so policymakers hear the call for attention to this problem.”

Image © iStock.com/shironosov