Access to obstetric services in rural US communities continues to decline

By Benjamin Mateus
3 October 2017

According to a study published in September in the journal Health Affairs, nine percent of rural counties in the United States lost all access to hospital-based obstetric services from 2004-2014. As 45 percent of rural counties already lacked these services during the period in which the study was conducted, this means that more than half of rural counties have no access to this kind of medical care, despite being home to more than 28 million women of reproductive age.

This reduction in childbirth medical services has occurred parallel to an increase in US maternal mortality rates. Research published in 2016 in Obstetrics and Gynecology found that maternal mortality rates had increased from 18.8 per 100,000 live births in 2000 to 23.8 in 2014, a rise of 26.6 percent. By contrast, the World Health Organization reported in 2014 that 157 of 183 countries had seen a decrease in maternal mortality. The United States now ranks thirtieth among all OECD countries on this metric, ahead of only Mexico.

The decline in obstetric services has occurred over several decades. In 1985, 24 percent of non-metropolitan counties lacked hospital services while 50 percent of childbearing-aged women in these regions had access to obstetric services. By the early 2000s, more than 44 percent of these counties lacked hospital services, and only 20 percent of women of childbearing age living in the most rural counties had access to obstetric services.

According to the Health Affairs study, of the more than 28 million women of reproductive age who live in these areas, nearly a half million give birth each year. These rural facilities also serve a higher proportion of low and moderate-income families. Medicaid finances approximately half of all births in the US, with a greater proportion, 59 percent, in rural areas.

Counties are categorized as metropolitan (an urban core of more than 50,000 residents), micropolitan (an urban core of 10 to 50,000 residents) and noncore (all other rural counties). There are 1,984 rural US counties comprising 646 micropolitan and 1,338 noncore areas. For the year 2004, the Health Affairs study identified 1,249 rural hospitals located in 1,086 rural counties, of which 158 counties had multiple hospitals. Glaringly, 898 rural counties (45 percent) did not have hospitals.

According to the Office of Management and Budget, rural (micropolitan and noncore) areas account for 72 percent of the nation’s land area and are home to 46.2 million people, which is 15 percent of the total population. The median age of the rural population is 51, making these counties older by comparison to urban counties, whose median age is 45. Rural communities have higher poverty rates, and significant health disparities exist when compared to urban centers.

During the 2004-2014 period, 179 counties (9 percent) experienced the loss of all in-county hospitals providing hospital obstetric services. This affected 600,000 women of reproductive age, bringing the total number of women without access to these services from 1.8 million in 2004 to 2.4 million in 2014, an increase of 25 percent.

Noncore counties were more likely to not have obstetric services (58.6 percent) compared to micropolitan counties (17.6 percent), and were more likely to lose these services during the study period (n=150, 11.2 percent) in comparison to micropolitan counties (n=29, 4.5 percent). A full 59 percent of the most isolated noncore counties, those not adjacent to an urban area, had no obstetric services in 2004, a figure which increased to 69 percent in 2014.

While the study notes that almost all counties with full closures were adjacent to at least one county with continual services, the impact of these closures on maternal and neonatal outcomes is not addressed.

Childbirth-related hospitalizations totaled $27.6 billion in hospital costs in 2009, with 45 percent of these costs billed to Medicaid and 47 percent to private insurers. Medicaid pays hospitals about 50 percent less than private insurers for the same services, further straining hospital finances and contributing to closures in rural areas with higher proportions of Medicaid births.

Over the last decade, the US has seen severe maternal morbidity and postpartum hospitalization increase by 75 percent and 114 percent, respectively. The rates of blood transfusion, acute renal failure, shock and respiratory distress, as well as heart failure during deliveries, have doubled, while overall mortality has increased considerably. Currently, maternal mortality in large metropolitan areas is approximately 18.2 per 100,000 live births, while in rural areas it is as high as 29.4.

According to the American College of Obstetrics and Gynecology, women in rural areas of the United States have lower prenatal care initiation in the first trimester. Many cite distance as a major factor. Less than half of pregnant women in rural areas live within 30 minutes of a facility that offers obstetric services. They also experience higher rates of hospitalization due to pregnancy complications. Infant mortality rates in 1,041 (51 percent) rural counties exceeded the US rate. Some 128 rural counties had infant mortality rates that were twice the national rate.

Adding to these problems are the decreasing numbers of physicians practicing in rural settings. In 2008, only 6.4 percent of obstetricians practiced in rural settings, and in 2010, 49 percent of counties, home to 10.1 million women, lacked an obstetrician. However, according to the American Association of Medical Colleges, AAMC, demand for residency graduates is projected to account for only two percent of the projected demand.

The AAMC projects that by 2025 there will be a shortage of approximately 46,000 to 90,000 physicians. The shortfall for primary care physicians will be between 12,500 and 31,000, with shortages expected to persist under every scenario health care policymakers currently envision. With physician training taking a decade to complete, the shortfall is essentially already in effect and will become more apparent with each year.

Since the financial crisis of 2007-2008, critical access hospitals and other rural hospitals that have subsequently closed their doors have been closed primarily for financial reasons, and not due to declining demand for their services. The financial pressures show no sign of abating, leaving rural communities in continued distress.

Giving birth remains the most common reason for hospitalization, accounting for 10 percent of all hospital stays—nearly four times higher than the next leading causes for admission, such as pneumonia, septicemia or congestive heart failure.

With the already inadequate health care system under constant bipartisan attack by the American ruling class, the only way to address the shortage of health services in rural counties is through the fight for socialism, which alone can guarantee the resources necessary to address these needs and ensure everyone the right to the highest quality health care.