Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States
Open accessAbstract
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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Cited by
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Stone, B., Amiri, A., Zhao, S., Hamidi, S., Johnson, P., & Bruns, D. (2025) · Healthcare · doi:10.3390/healthcare13192407
- Authors
- Kozhimannil, K. B., Hung, P., Henning-Smith, C., Casey, M. M., & Prasad, S.
- Affiliations
- University of Minnesota (US)
- Yale University (US)
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
- Corresponding author
- Kozhimannil, Katy B.
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2018-03-27
- Volume
- 319
- Issue
- 12
- Pages
- 1239
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC5885848
- OpenAlex
- W2793794978
- Cited by
- 325
- References
- 32
- Citations by year
- 2026: 40 · 2025: 51 · 2024: 31 · 2023: 43 · 2022: 42 · 2021: 46 · 2020: 41 · 2019: 21 · 2018: 9 · 2016: 1
- FWCI
- 44.67
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Health Professions › General Health Professions › Maternal and Neonatal Healthcare
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Keywords
- rural counties, out-of-hospital birth, birthplace, preterm birth, birth outcomes, maternity ward, rural healthcare access, urban-rural differences, rural-urban migration, rural-urban return migration, rural-urban health disparities
- MeSH terms
- Adult, Female, Health Services Accessibility, Home Childbirth, Hospitals, Rural, Humans, Infant, Newborn, Obstetrics and Gynecology Department, Hospital, Pregnancy, Pregnancy Outcome, Prenatal Care, Retrospective Studies, United States, Birthing Centers, Premature Birth, Interrupted Time Series Analysis
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