Less than half of the rural hospitals in America offer labor and delivery services, contributing to a range of problems that can endanger the health and lives of rural mothers and newborns.
According to a report from the Center for Healthcare Quality & Payment Reform (CHQPR), 46% of rural hospitals across the country offer labor and delivery services. Nearly 200 rural hospitals have stopped delivering babies altogether over the past 10 years, primarily to cut costs.
Closing maternity services may save money for the hospital, the report says, but it puts women at higher risk of mortality, said Harold Miller, president and CEO of CHQPR. The causes of this higher risk stem from the additional time it takes to get to obstetric services, less access to prenatal care, and the potential for pre- or post-natal complications to turn into emergencies.
In communities where women have no local maternity care, driving to the nearest obstetrics unit puts the mother’s life at risk. While women in urban areas can reach a hospital with maternity services in under 20 minutes, the study found, women in rural areas are likely to be traveling 30 minutes or more. In 40% of rural communities without maternity care, women have to drive more than 40 minutes to reach those services.
“If you have to travel for your delivery, the rate of complications and potential death is higher,” Miller said in an interview with the Daily Yonder. “If you’re on the road, you may be delivering on the road, or you may not leave in time, so the narrow issue of childbirth becomes more dangerous because of that.”
According to the Centers for Disease Control and Prevention (CDC), rural women have nearly twice the rate of severe maternal morbidity and mortality (SMM) than their urban counterparts. In studies of maternal morbidity rates by population density, pregnant women in rural counties (with populations of 50,000 or fewer) died at a rate of 23.8 deaths per 100,000 live births, compared to 14.6 deaths in large metropolitan counties. For Black women in rural counties, the SMM is 59.3 deaths per 100,000 births.
Traveling to another hospital for labor and delivery is just one cause of higher maternal mortality rates in rural women, said Julia D. Interrante, Ph.D., a research fellow with the Rural Health Research Center at the University of Minnesota.
“The reasons for higher SMM for birthing people in rural areas are many and likely include disparities related directly to the health care system and broader socioeconomic factors (i.e., the social determinants of health),” Interrante said in an email interview with the Daily Yonder. “Health-care-system related factors include workforce shortages, maternity unit closures leading to longer travel times to the nearest maternity unit, and low patient volume (which means hospital staff might not be as well practiced at higher risk or unexpected birth situations).”
Miller said the lack of maternity care extends beyond labor and delivery. When hospitals don’t provide labor and delivery services locally, he said, it’s less likely for a woman to get good maternity care in general.
“Women (in rural communities that lack maternal care) are not as likely to get prenatal care,” he said. “Even if the hospital claims it’s offering prenatal care, pregnant women are less likely to get enough prenatal care because the hospital is probably not staffed enough to be able to deliver adequate prenatal care to everybody who needs it.”
Additionally, women run the risk of dying from complications after delivery, he said.
“It’s not just in the process of delivering the baby, it’s both before and after that,” he said. “So if you end up all of a sudden having an obstetric hemorrhage before you were due or after you go home from the hospital… If the community doesn’t have skilled people and the appropriate level of education, monitoring, and postpartum follow-up, you’re more likely to have that problem because it won’t necessarily be diagnosed properly or treated quickly.”
Miller said the reason rural hospitals close maternity departments is financial. Because maternity departments lose money, he said, it’s one of the specialties hospitals close first.
“These hospitals in particular are losing money on private payments, which is kind of one of the myths about rural hospitals,” he said. “People think they have no privately insured patients and that everything is Medicare and Medicaid, which is not true. About half of their patients overall are privately insured patients and those are actually, in most cases for small rural hospitals, the biggest loser that they have in terms of payment.”
Staffing a maternity department means healthcare providers are on standby waiting for someone to give birth, he said, something private insurers don’t necessarily pay for. Hospitals include that in the cost of the service they bill to Medicare and Medicaid. But they can’t do that with private insurers.
“Insurers say to the hospital, ‘That’s all we’re going to pay, take it or leave it,’” he said.
Miller proposes that private insurers should pay rural hospitals a standby capacity payment, or a flat fee that pays for them to staff for things like maternity services.
“The notion of the standby capacity payment is a way to pay for that service,” Miller said. “This is a better way to pay for it because it’s a predictable payment specifically designed to support the minimum capacity for that service.”
In the meantime, researchers said, emergency departments need to be trained to provide maternal services.
“There are multiple proposed policy solutions around increasing access to maternity care in rural areas, including providing government funding to financially support rural hospitals in keeping their maternity units open and well-staffed,” Interrante said. “In hospitals where there is no labor and delivery unit, it is important that emergency department staff be trained in emergency births as people will still come there to give birth if they can’t travel to a hospital with a maternity unit.”