Research Brief

Rural maternity care losses lead to childbirth risks

Pregnant woman standing in field.
Photo courtesy of David Salafia,

Access to obstetric care in rural communities is critical to ensuring good maternal and child health outcomes. Eighteen million reproductive-age women live in America’s rural counties, but over half of these counties have no hospital where people who are pregnant can give birth. The past decade has been marked by a decline in maternity care access, as hospitals and obstetric units across rural America shutter their doors.

Now, the consequences of these closures are becoming clear. A new study from the University of Minnesota Rural Health Research Center published today in the Journal of the American Medical Association examined how birth outcomes change after losing obstetric services, focusing on two categories of rural counties - those located next to an urban area (urban-adjacent) and the more remote rural areas not located near an urban area (non-adjacent).

The research, led by Katy Kozhimannil, Ph.D., director of the University of Minnesota Rural Health Research Center, found that families living in non-urban-adjacent rural counties faced increased risk of out-of-hospital birth, birth in a hospital that does not provide obstetric care (possibly in an emergency department), and preterm birth, after losing hospital-based obstetric services.

“Preterm birth is the leading cause of infant mortality, and infant mortality is higher in rural versus urban communities,” said Kozhimannil. “Loss of hospital-based obstetric services has immediate and significant impacts on rural families, and may exacerbate the challenges rural mothers and families already face.”

Starting with all rural U.S. counties that had at least one hospital that provided maternity services in 2004 (1,086 counties), the study looked at the births in counties that lost services entirely (either through closures of obstetric units or whole hospitals) over the next ten years. Outcomes for births in counties with services loss were compared with outcomes for births in counties with continual services to see whether there were immediate changes or changes over time.

The researchers focused on three main challenges that rural communities might face following loss of hospital-based obstetric care:

  • Out-of-hospital birth (planned or unplanned)

  • Birth in a hospital without obstetric services

  • Preterm birth, before 37 weeks gestation

The findings revealed the biggest effects of the loss of hospital-based obstetric care were seen in the most remote rural counties (i.e., those that were not adjacent to urban areas). Before services loss, approximately one percent of births occurred out of the hospital, less than half a percent of births occurred in hospitals without obstetric services, and 12 percent of babies were born preterm. After losing hospital-based obstetric care, residents of rural counties not adjacent to urban areas experienced an increase in out-of-hospital births (0.70 percentage points), births in hospitals without obstetric units (3.06 percentage points), and preterm births (0.67 percentage points), compared to counties with continual obstetric services.

“These findings should raise concern about immediate and long-term health impacts for mothers and babies, especially in the most remote rural areas, which already experience disproportionate economic and health challenges,” said Carrie Henning-Smith, Ph.D., deputy director of the University of Minnesota Rural Health Research Center and co-author of the study.

In urban-adjacent rural counties, there was an increase in births in hospitals without obstetric services (1.80 percentage points), followed by a decline over time.

“After local hospitals stopped doing obstetrics or closed entirely, rural communities far from urban areas saw a rise in conditions that may put moms and babies at risk - including birth in a hospital with no obstetric capacity as well as preterm birth,” said Kozhimannil. “Knowing the consequences of services loss, policymakers, clinicians, and families can make informed choices to help ensure the safety and well-being of rural moms and babies.”

“The Health Resources and Services Administration and the Federal Office of Rural Health Policy are happy to support this research,” said HRSA Administrator George Sigounas, MS, Ph.D. “These findings have important implications for many of the populations served by HRSA such as rural residents, patients served by our community health centers, the many mothers and children who receive services through the Maternal and Child Health Block grant as well as the health professional schools we support to provide that next generation of primary care providers.”

Funding support for this research came from the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services (Cooperative Agreement No. U1CRH03717-13-00).

The University of Minnesota Rural Health Research Center, within the University of Minnesota School of Public Health, conducts high quality, empirically driven, policy-relevant research that can be disseminated in an effective and timely manner to help improve the quality and fiscal viability of rural healthcare.

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