Rural America's maternity care crisis is worsening.
More than 57% of U.S. rural hospitals do not offer labor and delivery services, and in 10 states, fewer than 33% do, according to the Center for Healthcare Quality and Payment Reform. Since 2010, more than 500 hospitals have closed their labor and delivery departments, according to a Dec. 4 study published in JAMA Network. This is despite such facilities delivering nearly 1 in 10 babies in the U.S., according to the American Hospital Association.
Florida has 22 rural hospitals, 20 of which lack obstetric services. Texas has 164 rural hospitals, 97 of which do not offer obstetric services. Of the 967 rural hospitals that provide labor and delivery services, nearly 40% lost money on patient services overall in 2023, putting their ability to continue delivering maternity care at risk.
Low Medicaid reimbursements, rising costs, and ongoing staff shortages have led many rural hospitals to shutter labor and delivery units. This has resulted in a higher number of maternity care deserts — counties without a hospital or birth center offering obstetric care and without any obstetric providers.
Areas with low or no access affect up to 6.9 million women and almost 500,000 births across the U.S. annually, according to the March of Dimes, a nonprofit focused on improving maternal and child health. In maternity care deserts alone, about 2.2 million women of childbearing age and nearly 150,000 babies are affected.
Coupled with the rise in rural hospital closures — 38 facilities have closed since 2020 — rural America faces a serious problem.
"Low Medicaid reimbursement is our greatest challenge, especially in Indiana, where rates paid to hospitals have not been raised in over 30 years. This is especially detrimental in rural areas, where a higher number of births are covered by Medicaid," Eric Fish, MD, president and CEO of Schneck Medical Center in Seymour, Indiana, told Becker's. "In Indiana, over half of babies born annually are covered by Medicaid, which pays 57 cents on the dollar of the cost of providing care. This means hospitals, particularly in rural areas, are experiencing significant financial losses. Increasing Medicaid reimbursement is imperative to keep these services open and preserve access in the future."
Many rural communities are at risk of losing maternity care due to the financial challenges rural hospitals face. Rural hospitals typically lose money on obstetric care. If a hospital cannot generate enough revenue from other services to offset those losses, it may be forced to eliminate maternity care to prevent the hospital from closing entirely.
Another challenge for rural communities is recruiting and retaining healthcare providers — especially obstetricians.
"In Indiana, 87% of rural residents live in areas with a primary care shortage. Across the country, rural hospitals have been creative in forming strategic regional partnerships, including working with larger hospitals and health systems for care coordination, provider training, and other resources," Dr. Fish said. "Such partnerships help rural patients receive care in their communities while a specialist from a larger system can manage high-risk patients as necessary and support the rural provider in planning for delivery locally. Solutions are needed to increase the pipeline of healthcare workers, including incentives for providers who choose to serve rural communities, student loan repayment, and more."
The lack of an obstetrics workforce and expertise is a growing issue in rural America, affecting both providers and obstetric nurses.
"We have spent upwards of $3 million annually for traveling obstetric nurses to keep our unit staffed 24/7/365, but it is the right thing to do for southwest Iowans to reduce the excessive mileage required to reach the nearest obstetrics unit," Brett Altman, DPT, CEO of Cass Health in Atlantic, Iowa, told Becker's. "Low-volume obstetrics is not profitable and is one of the key drivers for why so many obstetric units have closed in rural areas as hospitals face financial headwinds in addition to concerns about competency."
With 50% of deliveries in rural areas funded by Medicaid, improved Medicaid reimbursement for maternal care services would have the most significant impact, according to Dr. Altman.
"To help cover the losses associated with obstetrics, perhaps rural hospitals offering obstetrics could qualify for a special exception through Medicaid with an add-on payment program or an annual lump-sum payment, similar to [prospective payment system] hospitals that have received disproportionate numbers of low-income patients, based on the hospital's disproportionate OB patient percentage," he said.
Rural hospitals are especially feeling the financial pinch coming out of the pandemic, but federal financial support or an add-on payment program could go a long way toward ensuring their long-term sustainability.
Another significant issue rural communities face is population decline and fewer younger people having children in rural areas. However, some hospital leaders have found effective strategies to combat these trends.
"Our strategy has been to expand our footprint using a hub-and-spoke model to keep our delivery numbers high enough to maintain competency," Dr. Altman said. "Over the past three years, we've been doing outreach with one of our OB-GYNs to three smaller rural hospitals in southwest Iowa, which has increased the number of our deliveries by roughly 50%. It is a win for those outreach communities to have maternal health services available, making them more viable places for young people to live, a win for Cass Health, and most importantly, a win for young moms in underserved rural areas by creating local access to maternal health services."