Nearly all states saw declines in the number of acute care hospitals offering obstetric services between 2010 through 2022, with seven states seeing a quarter or more of their hospitals dropping obstetric care, according to new analysis.
The shutdowns were spread across urban and rural hospitals alike, but more pronounced in the latter. Twelve states lost obstetric services among a quarter or more of their hospitals, and by 2022, there were eight states in which more than two-thirds of all rural hospitals did not offer obstetric care, researchers found.
“Access to hospital-based obstetric care is eroding in rural and urban communities across many U.S. states,” Katy Backes Kozhimannil, a professor at the University of Minnesota School of Public Health and the study’s lead author, said in a statement. “This is occurring alongside a maternal health crisis and in a rapidly evolving state health policy environment.”
Writing in Health Affairs, Kozhimannil and colleagues noted that the service line closures come despite targeted maternal health policy efforts and other obstetric care access efforts from provider and professional organizations.
The analysis, published Tuesday, reviewed data on nearly 5,000 hospitals collected from American Hospital Association annual surveys and Centers for Medicare and Medicaid Services data files. Researchers looked for changes in hospitals’ service lines over the study period, but noted that some states already had “very few” hospitals offering obstetrics due to closures preceding 2010.
Their work underscored state-to-state differences in obstetrics care access, which were often more pronounced in rural regions and highly rural states. For instance, by 2022, most rural hospitals in North Dakota (73%), Oklahoma (63%) and West Virginia (62%) did not offer obstetric services. Iowa (33.3%) and West Virginia (30%) led the way with the largest portion of rural and urban hospitals that ended obstetrics during the study window.
Rural hospital obstetrics closures exceeded more than 40% in Pennsylvania (46.2%), South Carolina (46.2%), West Virginia (42.9%) and Florida (40%) between 2010 and 2022. Urban hospital closure percentages were less pronounced among individual states, with Rhode Island (28.6%), Oklahoma (27.6%) and Hawaii (25%) leading the way.
Three states—Delaware, Utah and Vermont—had no hospital obstetric service losses during the study window, as opposed to the seven (Iowa; Oklahoma; Pennsylvania; Rhode Island; South Carolina; Washington, D.C.; and West Virginia) that saw cuts among a quarter or more of their hospitals. Rural-urban divides were also spotted within individual states, such as New Hampshire, where 36.4% of rural hospitals lost obstetrics as opposed to zero urban hospitals.
Access to obstetric care is a key determinant of health outcomes among mothers and infants, the researchers wrote. The study’s findings could be a resource for policymakers and others to craft targeted, state-level interventions addressing access disparity.
“Obstetric unit closures can increase distance to care and put pregnant patients and newborns at risk,” Kozhimannil said. “Our analysis revealed wide variability across states in obstetric care losses, and highlighted the growing access challenges faced by people living in rural communities and highly rural states.”
Researchers and hospital leaders have pointed to tough demographic issues, such as declining birth rates, for rural obstetric service line closures that appear to be continuing beyond the study’s 2022 end date. Another wrinkle is that births among hospital obstetric units fielding fewer births per year have been shown to have a higher risk of severe maternal morbidity.
All the while, hundreds of rural hospitals are weathering tight operating margins and are at risk of closure, which would further limit access to care services. Opponents of the recently passed “big, beautiful bill” warned that more rural unit closures and full hospital shutdowns will accompany the package’s Medicaid funding cuts.