“Most of the rural hospitals around us, at one time or another delivered babies over the last eight to nine years. Two hospitals have closed. The three remaining hospitals that had maternity wards ceased their women's services and stopped delivering babies,” Kent said. “We're seeing an increase in women who deliver with no prenatal care.”
A new study in the journal Health Affairs quantifies the trend. In 2004, 45 percent of rural counties lacked a hospital with obstetrics services. About one in 10 rural counties lost those services over the next decade, and by 2014, 54 percent of communities lacked those services. That leaves 2.4 million women of childbearing age living in counties without hospitals that deliver babies.
There are already a slew of well-known health disparities between rural women and those who live in urban settings. Women from rural areas are more likely to report having fair or poor health, be obese, smoke cigarettes, commit suicide and have cervical cancer than their urban counterparts. But the recent trend could exacerbate disparities in reproductive health, too. One recent study found that rural areas had made far fewer gains in improving infant mortality compared with the rest of the country.
“A lot of discussion has been focusing on the closures of rural hospitals entirely,” said Peiyin Hung, a postdoctoral associate at Yale School of Public Health, who led the study. “We found that even among surviving hospitals in rural communities, a lot of obstetric services in these areas are disappearing.”
What was concerning to Hung was that the most geographically isolated communities were more likely to not have had obstetrics services to begin with — and were more likely to lose them over the decade they studied. There were also patterns of inequality: Rural counties that had lower median incomes and higher percentages of African American women of reproductive age were also more likely to not have hospitals with maternity wards.
The reduction in obstetrics services stems from many factors. When hospitals are struggling financially, as many rural hospitals are, obstetrics services are often first on the chopping board because they generally don't generate a lot of money, Kent said. In some communities, there may be such a low volume of births that there is simply not enough care to support an obstetrician. The lifestyle of an obstetrician in a remote area might also be a hard one, if the doctor is permanently on call as the only doctor who delivers babies.
Megan Evans, an obstetrician and gynecologist at Tufts Medical Center in Boston, has been working with the American Congress of Obstetricians and Gynecologists to push forward a solution to some of the workforce issues. Through a federal program called the National Health Service Corps, medical students can have their school paid for as long as they commit to practicing in an underserved community for a given period of time.
But the way the communities are defined isn't specific to the type of care in shortage, and she and others would like to see communities defined by categories, such as maternity care shortage.
Right now, an underserved community might have no pediatricians but several obstetricians. More narrowly defining categories of need could help young physicians have the biggest impact. A bill to identify areas of maternity care need passed the House and has been introduced in the Senate.
But she acknowledged that other barriers exist: Many young physicians may not want to relocate to remote rural areas where they may feel isolated, not have many mentors or could be the only obstetrician at the hospital.