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Delivering Rural Babies: Maternity Care Shortages in Rural America

Rural Hospitals Are Closing – And Pregnant Women are Paying the Price

We’ve seen this title over and over, from the original Politico article by Lisa Rab, to our session at the 2018 Policy Institute. The number of rural hospitals without an obstetrics unit or any obstetrics care is growing at an alarming rate, placing expecting mothers at risk. 18 million reproductive-age women live in rural communities across the United States, and half a million babies are born in rural hospitals every year. Still, from 1985 to 2002, the number of rural hospitals without obstetric services grew from 24% to 44%. Today, more than half of rural counties have no hospital-based obstetrics services, and the most vulnerable communities – those who are low-income, minority, remote – experience the most damaging impact. When distance to maternity care is directly correlated with outcomes, this care shortage has a devastating effect on the health of both the mother and the infant. Rural babies are being born outside of hospitals or in hospitals without obstetrics care, and infant mortality rates are rising. The loss of maternity care in rural America is the result of multiple factors including: workforce shortages, low birth volumes, and stingy Medicaid programs.

The most vulnerable communities are the most likely to be without maternity care: low-income, health care shortage areas, minority populations, and the most remote locations. Rural counties with higher percentages of African American women were more than 10 times as likely as rural counties with higher percentages of white women to have never had hospital-based obstetric services and more than 4 times as likely to have lost obstetric services between 2004-2014. More than half of rural women in rural communities live more than the recommended 30 minutes from a hospital offering maternity services. Even worse, 88% of women in rural towns live within 60 minutes of a hospital offering these services and in the most isolated areas that number drops to 79%.

Causes of Closures
There are a variety of reasons why we continue to see more and more rural obstetrics units closing across our country, leaving a growing number of expecting mothers in rural communities without timely, local care:
  • Declining Birth Rates: Though more than half a million babies are born in rural area annually, rural populations are overall experiencing a decline. As a result, there are a declining number of births in rural areas.
  • Costly Service: More than half of rural births are services that are covered under Medicaid, and reimbursement rates for rural hospitals are a continuing issue.
  • Hospital Closure: Obstetrics units are high-cost, low-volume units at a hospital. In efforts to keep a hospital open, administrators will often choose to first close their obsetrics care.

Workforce Shortages
As obstetrics units close and hospitals continue to struggle, rural communities are also grappling with a shortage of maternity care providers. Hospitals with obstetrics care are struggling to retain maternity care providers:
  • Hospitals with lower birth volume (less than 240 births per year) are more likely to have family physicians and general surgeons attending deliveries, whereas hospitals with a higher birth volume more frequently have obstetricians and midwives attending deliveries.
  • More than three-quarters of rural hospitals with less than 300 births a year have shared nurse staff, and midwives attend deliveries in 1/3 of rural hospitals.
  • Workforce retention challenges reported by surveyed hospitals are related to their rural location and low birth volume.

The Improving Access to Maternity Care Act
Geographic maldistribution of health care providers has resulted in a relative shortage of maternity care providers in rural America. S. 783, the Improving Access to Maternity Care Act would improve the geographic distribution of maternity care providers by creating maternity health professional target areas.

NRHA is joining with the American College of Nurse-Midwives (ACNM), the American College of Obstetricians and Gynecologists (ACOG), Every Mother Counts (EMC) to host a lunch briefing on this legislation on Thursday, March 8 from 12:30 to 1:30 p.m. We are excited to join our colleagues to discuss the impact of maternity workforce shortages on maternal mortality and health. During this briefing, we will learn how S. 783 can help alleviate the significant pressures on many rural communities and health systems.

Maternity care is disappearing in rural America, but together we can take a step forward to close this growing gap. Please follow along with us on social media @NRHA_Advocacy for live Tweets from the briefing.

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