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. 2018 Mar 27;319(12):1239-1247.
doi: 10.1001/jama.2018.1830.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States

Katy B Kozhimannil  1 , Peiyin Hung  2 , Carrie Henning-Smith  1 , Michelle M Casey  1 , Shailendra Prasad  1   3
Affiliations

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States

Katy B Kozhimannil et al. JAMA. .

Abstract

Importance: Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown.

Objective: To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties.

Design, setting, and participants: A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004.

Exposures: Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas.

Main outcomes and measures: Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks' gestation).

Results: Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric services, and this was followed by a decreasing trend (-0.19 percentage points per year [95% CI, -0.25 to -0.14]).

Conclusions and relevance: In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kozhimannil reported receiving grants from the Federal Office of Rural Health Policy, Health Resources and Services Administration, Department of Health and Human Services. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Trends in Birth Location in Rural US Counties That Lost Hospital-Based Obstetric Services in the Years Prior to and Following Services Loss
The graphs show the trend lines for mean unadjusted values of out-of-hospital births and births in a hospital without obstetric units in rural US counties that lost hospital-based obstetric services as well as 95% CIs in the years prior to and following services loss. The graphs do not include data from rural US counties with continual obstetric services over the study period.
Figure 2.
Figure 2.. Trend in Preterm Births in Rural US Counties That Lost Hospital-Based Obstetric Services in the Years Prior to and Following Services Loss
The graph shows the trend lines for mean unadjusted values of preterm births (<37 weeks’ gestation) in rural US counties that lost hospital-based obstetric services as well as 95% CIs in the years prior to and following services loss. The graph does not include data from rural US counties with continual obstetric services over the study period.
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References

    1. US Census Bureau American Community Survey 5-year estimates: table DP05. American FactFinder website. http://factfinder2.census.gov. Accessed February 24, 2018.
    1. Hung P, Kozhimannil K, Casey M, Henning-Smith C State variability in access to hospital-based obstetric services in rural US counties. University of Minnesota Rural Health Research Center. http://rhrc.umn.edu/wp-content/files_mf/1491503846UMRHRCOBstatevariabili.... Published April 2017. Accessed January 29, 2018.
    1. Hung P, Henning-Smith CE, Casey MM, Kozhimannil KB. Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14. Health Aff (Millwood). 2017;36(9):1663-1671. - PubMed
    1. Hung P, Kozhimannil K, Henning-Smith C, Casey M Closure of hospital obstetric services disproportionately affects less-populated rural counties. University of Minnesota Rural Health Research Center. http://rhrc.umn.edu/wp-content/files_mf/1491501904UMRHRCOBclosuresPolicy.... Published April 2017. Accessed January 29, 2018.
    1. American College of Obstetricians and Gynecologists ACOG committee opinion No. 586: health disparities in rural women. Obstet Gynecol. 2014;123(2 pt 1):384-388. - PubMed

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