Rural hospitals weigh keeping obstetric units

comment from the group’s president, Dr. Sterling Ransone Jr.

One challenge in sorting out any connection between the number of deliveries and safety is that the researchers use differing cutoffs for what qualifies as a hospital with a low number of births, said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health who studies rural maternal health. Plus, such data-driven analyses don’t reflect local circumstances, she said. The income level of local women, their health risk factors, the distance to the closest hospital with an obstetrics unit, hospitals’ ability to keep trained doctors and nurses — hospital leaders must consider these and other factors as they watch their birth numbers fall due to declining local population or pregnant women opting to deliver at more urban high-tech hospitals, she said.

Research on birth volumes and outcomes has been mixed, but the “more consistent” finding is that hospitals with fewer deliveries are more likely to have complications, largely because of a lack of dedicated obstetric doctors and nurses, as well as potentially fewer resources for emergencies, such as blood banks, according to the authors of a 2019 federal report on improving rural maternity care.

Just 7.4% of U.S. babies are born at hospitals that handle 10 to 500 births annually, according to a geographic analysis recently published in JAMA Network Open.

But those hospitals, which researchers described as low volume, are 37% of all U.S. hospitals that deliver babies.

Finances also influence these decisions, given that half of all rural births are paid for by Medicaid, which generally reimburses providers less than private insurance. Obstetrics is “referred to as a loss leader by hospital administrators,” Kozhimannil said. As births dwindle, it can become daunting to pay for clinicians and other resources to support a service that must be available 24/7, she said.

If a hospital closes its unit, most likely fewer local women will get prenatal care, and conditions like a mother’s severe anemia or a baby’s breech position will be missed, Dickey said.

In Valdez, Alaska, keeping the hospital’s unit open has paid off for residents in other ways, Cullen said. Since the hospital delivers babies, including by cesarean section, there’s work to support a nurse anesthetist in the community of slightly more than 4,000 people. That enables the hospital to handle trauma calls and, more recently, the complexities of treating COVID-19 patients, he said.

In her research, Kozhimannil remains committed to nailing down a range at which deliveries have dropped low enough to signal that a hospital needs “either more resources or more training because safety could be at risk.”

Not to shutter the obstetrics unit, she stressed. But rather to automatically qualify that hospital for more support, including extra financing through state and federal programs, she said.

Because women will keep getting pregnant, Kozhimannil said, even if a hospital or a doctor decides to stop providing obstetric services. “That risk does not go away,” she said. “It stays in the community. It stays with the people, especially those that are too poor to go other places.”