Loss of Hospital Obstetric Services in the United States

Abstract

The loss of obstetric services has been a pressing concern in urban and rural areas nationwide. The first chapter used discrete-time multinomial logit model to identify urban-rural differences and factors associated with obstetric unit or hospital closures. During 2003-2013, 632 of 3,551 nationwide hospitals with obstetric services in 2002 stopped their obstetric services- through closures of hospitals or obstetric units. Loss of obstetric services has disproportionately affected areas served by low-volume hospitals, rural noncore, non-white and low-income communities, and counties with fewer family physicians, signaling a need to address maternity care access in these communities. The second chapter used generalized logistic regression models to examine associations of maternal residence rurality and insurance type with whether a woman lived in a zip code area where the nearest hospital obstetric unit and advanced neonatal care units were farther than 30 miles away in 2002 and 2013. The uneven geographic distribution of hospital obstetric care increased and varied by maternal residential rurality and insurance type. Women in rural noncore areas, with Medicaid or no insurance, and living in counties with lower income and educational attainment levels, had to travel farther to the nearest hospital with obstetric services or neonatal care than their counterparts.

The third chapter employed propensity score matching to estimate the associations between service loss at the nearest hospital during 2003-2013 and outcomes, stratifying by maternal residence rurality and residential proximity to care prior to the services loss. Hospital obstetric service loss increased an average of 12 miles (10.6 minutes) to the nearest hospital obstetric unit for rural women. Service loss was not significantly associated with postpartum hemorrhage and prolonged lengths of stay for women who had access to hospital obstetric services within 30 miles, which accounted for nearly 98% of women with childbirth hospitalizations. Loss of nearby hospital obstetric services increased distances to care for rural women, and was also associated with a higher risk of non-indicated cesarean and postpartum hemorrhage for women living more than 30 miles from hospital-based obstetric services, highlighting the need to address efforts to improve maternal health in rural isolated populations