1. Sofer, Dalia


Isolated counties with low populations are most affected.


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Between 2004 and 2014, an additional 9% of rural counties in the United States lost their hospital obstetric services, exacerbating a trend that already had 45% of rural counties lacking such services, according to a University of Minnesota study.

Figure. A certified ... - Click to enlarge in new window A certified nurse midwife looks after a client in rural North Carolina. Photo by Thomas Goldsmith.

The loss of services primarily occurred in sparsely populated counties with low birth volume. Some 2.4 million women of reproductive age (15 to 44 years) out of an estimated 28 million such women throughout rural America live in these counties. The study focused on county-by-county hospital-based services, and did not measure residents' potential access to obstetric care at hospitals in adjacent counties. The authors also acknowledged the complexities in this trend, including the difficulty of finding a balance between providing obstetric services close to home and having sufficient birth volume for clinical proficiency.


Still, the closure of obstetric units and financial pressures on rural hospitals generally is worrisome (see AJN Reports, September), as is the potential for this trend to exacerbate racial and ethnic disparities in maternal and infant health care.


The researchers found that the odds of never having a hospital with obstetric services were higher in counties with a higher proportion of non-Hispanic black women of reproductive age, lower birth volume, and lower median household incomes, and in states with more restrictive Medicaid eligibility requirements. The most vulnerable counties were isolated and had fewer than 10,000 residents; 59% of these lacked hospital obstetric services in 2004 and an additional 10% lost services over the next decade.


Among reasons for the closures are difficulties in recruiting clinical staff, low reimbursement rates for obstetric care, low birth volume, and the expense of malpractice insurance, according to Angeline Bushy, a professor at the University of Central Florida College of Nursing, in Orlando, whose research focuses on rural health. Recruitment and retention are challenging, she told AJN, because many clinicians-especially those educated in urban settings-are not attracted to a rural lifestyle. Consequently, if a rural obstetrics provider retires or leaves, the entire hospital unit may have to shut down. Comparatively low salaries exacerbate the situation, because rural hospitals must compete with urban ones for the same pool of applicants. Moreover, the low birth volume in sparsely populated rural counties not only limits revenue potential for providers of obstetric services but also has implications for clinical proficiency. "It's fine to do simulations," said Bushy. "But you need to practice in order to maintain skills." Lack of proficiency in managing the wide range of maternal conditions and births, in turn, raises the risk of malpractice lawsuits.


There are a number of national and state-level initiatives aimed at ensuring access to maternity care for women living in rural areas. For example, in Arkansas-where 73 of the 75 counties are designated as medically underserved-a telemedicine program called ANGELS (Antenatal and Neonatal Guidelines, Education and Learning System) links rural clinicians with experts at the University of Arkansas for Medical Sciences. The university also disseminates best practice guidelines, provides continuing education programs for physicians and nurses, offers a 24-hour call center staffed by RNs, and provides home care for families of high-risk infants. At the federal level, the National Health Service Corps offers education loan repayment to clinicians who serve for at least two years in an underserved area.


Nurses in rural settings play an important role in maternal and infant health care through education and care management, according to Bushy. "They can teach women about responsible sexuality and family planning, conduct prenatal classes, and get involved with discharge planning and home visits."


The future of rural obstetric care remains uncertain in light of efforts by Congress to repeal the Affordable Care Act and restructure Medicaid, and recent executive action by President Trump to eliminate ACA premium subsidies. As the University of Minnesota researchers note, "The implications could be particularly acute in rural areas, where a greater proportion of births are Medicaid-funded."-Dalia Sofer




Hung P, et al. Health Aff (Millwood) 2017;36(9):1663-71.