Loss of Obstetric Care in Rural and Urban Hospitals in the US
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Hello, and welcome to our listeners around the world. This is the JAMA Clinical Reviews Podcast. I am your host, Dr. Linda Brubaker, Deputy Editor at JAMA. And today I'm honored to be joined by Dr. Katie Kosmano, who is in the Division of Health Policy and Management in the University of Minnesota. Welcome, Dr. Kosmano.

Hello. Thank you so much for having me. I wonder if you would introduce your co-authors on this wonderful research letter called Obstetric Care Access at Rural and Urban Hospitals in the United States. I'm so proud of this work that brought together researchers from the University of Minnesota, as well as colleagues at the University of Pennsylvania and at Harvard University with expertise in both rural and urban hospital care and maternity care.

So I think our JAMA readers will be kind of shocked when they see the take-home message of this research letter. And I'm going to just give everybody kind of a bottom line that in 2022, a fair number of hospitals don't

offer obstetric care. Specifically, 52.4% of rural hospitals, more than half of rural hospitals, and 35.7% urban hospitals, more than a third, do not offer obstetric care. I think most doctors, clinicians, and patients will be quite surprised to see such a high proportion of hospitals not offering obstetric care.

So let's rewind to the very beginning. Can you talk a little bit about why you and your team decided to tackle this as a research question?

It originally came from five grandmas in Alabama, actually. Folks in rural Alabama in a predominantly Black community whose daughters were having babies. And they noticed that as they would have one grandchild and then their kids were pregnant with more babies and hospitals were closing around them, their daughters had to travel further to access care. And they wondered if that was isolated to their community. Was it something that was happening more broadly?

And they went to their representative, Representative Terry Seawall, and asked, is this just happening here in Alabama, in our community? Is it happening in other areas? And Representative Seawall's staff contacted the National Rural Health Association, the Federal Office of Rural Health Policy. And I was a researcher at a rural health research center at the time. And

I had a few years of experience doing rural maternity care research, but we were able to shift our research agenda to start to look at that very good and very important question. And one of the things that we found in that original research is that it was communities like theirs that were most frequently losing hospital-based obstetric care. And this was often hospitals closing their obstetric units.

or hospitals closing entirely. We see both of those things happening here. But I think, as you noted, it is maybe counterintuitive to many folks to think that you would go to a hospital and there wouldn't be capacity for patients

supporting labor and delivery at that hospital. And very important to know, both from a patient perspective, a community perspective, and also from a policy perspective, as we engage in much needed efforts nationwide and across states and communities and institutions to address maternal health challenges and maternal mortality and morbidity. Dr.

And as you've described this, there really isn't an easy, transparent way for people to see the proportion of hospitals that are offering obstetric services or to observe the trends of opening or closing in these areas. So that's a bit of a data shortage. You had to kind of dig to be able to find the data to support the research letter findings.

It's so difficult to know whether or not a hospital offers obstetric services. It is difficult for patients, it's difficult for clinicians who are doing referrals, and it's changing all the time. It took more than a year, a lot of time and effort to really get down to the specifics of whether or not a hospital offers obstetric services.

I wish that information were more readily available for folks. And it was extremely important to us and our research team to ensure that we were capturing this information accurately and correctly because there is no one data source where that information is available. And we took time to check that across a variety of data sources. And one of the trickiest parts of this was addressing hospital mergers and acquisitions.

And over this 12-year time period, there was a lot of change in the hospital markets. And it can be difficult to follow hospitals over time and understand the decisions that they are making with different service lines and how that affects the communities that they serve. And in this 12-year time period, 2010 to 2022,

This is all happening against the background of rising maternal mortality, something that's been fairly well documented and really puts the United States as a bit of a shameful outlier with maternal mortality. So this is a particularly important and salient story accompanying the rising maternal mortality. So let's dig into this retrospective cohort study. Tell us a little bit about the design of the study and how you went about doing this analysis.

So the study design is a fairly straightforward and descriptive approach where the lion's share of the work on this was in merging data and doing a very careful process to understand whether or not in every year, each short-term acute care hospital that was operating in the United States operated

obstetrics or not, and then to identify where closures occurred, whether that was, again, closure of the entire hospital or the closure of just an obstetric unit. We also looked at hospitals that added or gained obstetrics or hospitals that opened

that had an operating obstetric unit. So when you think about it, it's almost factorial when you start to look at every hospital and every transition they could make in each year, but it was our intention to do that. So to do so, we used as a basis, the American Hospital Association Annual Survey and the Centers for Medicare and Medicaid Services Provider of Services files. And in addition to that, we went through an enhanced algorithm that we have developed

in order to identify and go back and do some hand checking, including phone calls and including website checks where needed to really validate whether a hospital had obstetric services or if it closed and which year that happened.

And then we looked at hospitals separately that were in metropolitan counties. So we termed those urban hospitals and hospitals that are located in non-metropolitan counties that are rural hospitals and simply described these transitions as clearly as we could and in a way that we hope is useful.

So you ended up with just shy of 5,000 short-term acute care hospitals, 1,982 rural, and 2,982 in urban counties. So what did you find in these hospitals?

We found that there were quite a lot of hospitals that closed their obstetric units during this time. And I'm going to give the actual numbers because I think that's very important to actual people, but 537 hospitals closed.

lost obstetrics. They either closed their unit or closed entirely during this time period. That was split fairly evenly between rural hospitals. So there were 238 hospitals that closed their obstetric units and urban hospitals. That was 299 hospitals closed obstetrics. And there were also 138 hospitals that gained obstetrics, either opened unit or opened a hospital that had obstetrics.

but those were heavily leaning toward urban areas. So 112 of those were in urban hospitals and only 26 were in rural hospitals. All of this adds up to a steady decline in a

obstetric care access at hospitals across the United States in both rural and urban areas. But in rural areas, we started off with fewer hospitals providing obstetrics, and the decline was steeper. And fewer hospitals are gaining obstetrics. It's quite rare in rural communities for that to be happening. Also, about 98% of all births in the U.S. happen in hospitals. And so

It's very important that we consider our hospital infrastructure for birthing people, especially, as you mentioned earlier, in the context of an ongoing maternal health crisis that disproportionately affects rural people and also racially minoritized folks, especially those living in rural communities. It was important to us to quantify and clarify how this is happening. So would you just reiterate at the end of the study in 2022, what

What were the proportions of hospitals that did not offer obstetric care? So in 2022, more than half, 52.4% of rural hospitals did not offer obstetrics. More than half of all rural hospitals were not places that were prepared to support labor and delivery or a birthing person.

I just want to emphasize that because there have been so many rural hospital closures. These are of the hospitals that were open in 2022. And also more than a third of our urban hospitals closed.

Thank you.

And that's not something that our research letter looked into specifically here, but it's something that we know from prior research is a pattern and also a pattern that we see playing out in maternal health outcomes and maternal mortality and morbidity. Would you go through briefly some of the limitations on this analysis? Sure.

No data are perfect. Some are useful, we hope. We only used data on hospitals. So we're really focusing, again, on those hospital-based births. And as I mentioned, about 2% of births happen outside of hospitals, sometimes planned, sometimes unplanned. There is a growing number of out-of-hospital births that are happening at freestanding birth centers, and that was not included as a part of this analysis, but is a very important part of maternity care access in the United States.

Also, the denominators for the study outcomes, the number of hospitals declined each year as hospitals closed. And we started with a baseline year of 2010 and all of the hospitals that were operating in 2010 declined.

There were many, many communities that lost hospitals prior to 2010 and were not capturing all of the cumulative effects of closures that predated the study period here. So I think that's really important information.

We also use just a dichotomous measure of rurality, rural versus urban, and obviously there's a continuum there. There's diversity among rural places and among urban places. We also used a county-based measurement, and counties vary tremendously in their size, in the way that they are defined by the Census Bureau. So those are some important limitations to keep in mind as folks think about these results.

Dr. Kazamanal, we are very grateful for you and your research team highlighting this evidence for our JAMA readers and our JAMA listeners. And we hope you will continue to monitor this situation as women's health becomes more of an issue in the coming years. This trend will need to be monitored. So thank you very much.

Thank you so much. And I am so glad to be able to keep focus on these questions. Well, thank you for putting focus on this. It's a very important topic. A link to this research letter can be found in this episode's show notes. This episode was produced by Shelley Steffens at the JAMA Network. To follow this and other JAMA Network podcasts, please visit us online at jamanetworkaudio.com. And thanks for listening.

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