A rural hospital in the Midwest is weighing whether it can continue to care for pregnant women in its community.
The hospital performs 80 deliveries per year, about half of which are for Medicaid beneficiaries. Rural hospital obstetrics units need either obstetricians-gynecologists who nationally earn an average of $300,000 to $400,000 annnually or family physicians who specialize in obstetrics. The latter would typically require on-call anesthesiologists, general surgeons and specialized nurses.
The hospital loses money on deliveries as Medicaid reimbursement falls well below costs and salaries, and wages for nurses, surgeons and anesthesiologists skyrocket, said Eric Shell, a principal at the consultancy Stroudwater Associates who works with rural hospitals across the country.
The next closest hospital-based obstetrics unit is more than 40 miles away.
“The CEO is saying, ‘I am losing my darn shirt here—do we give up the program or give up the entire hospital?’ That’s the question that many rural hospitals providing obstetrics services are asking,” he said. “If it is low-volume and going to lose money, they have to decide whether there are enough ‘mission’ dollars available.”
Many rural hospitals throughout the country are grappling with the same dilemma. They need to perform at least 200 births a year to maintain patient safety and financial viability, a recent study from the University of Minnesota published in JAMA Health Forum found. Around 42% of rural hospitals with maternity care surveyed for the study did not perform enough deliveries in 2021 for their units to be profitable.
Maternity care deserts are growing as more hospitals cut obstetrics services. Not enough OB-GYNs are entering the medical field to meet demand, as providers are deterred by legal threats and the growing uncertainty around obstetrics since the U.S. Supreme Court overturned Roe v. Wade, the federal law protecting abortion rights. Health inequity and maternity care quality will suffer as access wanes, experts said.
“Now that Roe has been overturned and abortion restrictions and bans are littering the country, we likely will be facing even greater workforce challenges in certain areas, particularly if obstetrician-gynecologists are unable to live and work in states with restrictive abortion laws,” said Dr. Jen Villavicencio, an OB-GYN who leads equity transformation at the American College of Obstetricians and Gynecologists. “This is an untenable situation for all people living in rural areas, but particularly for the Black and indigenous people who account for a significant proportion of the residents living in these areas.”
Some rural providers are asking for help from academic medical centers, which are sending OB-GYNs to their hospitals or offering virtual consultations. Many rural providers that weren’t able to form those partnerships cut obstetric services.
Nearly 200 rural hospitals eliminated obstetrics care from 2011 through 2019, amounting to nearly 20% of all rural hospitals that previously offered such care, according to a 2022 report from the Chartis Center for Rural Health.
Most rural counties do not have an OB-GYN in their area, according to a policy brief from the University of Kentucky’s Center for Economic Analysis on Rural Health. Residents of those counties have to travel farther for care or hospitals have to hire them on a temporary basis, compromising care quality and increasing costs.
The New Orleans-based not-for-profit health system Ochsner Health recently closed its labor and delivery department at Ochsner Medical Center in Bay St. Luis, Mississippi. A relatively low number of births in the area and the departure of the local obstetrician made it hard to sustain, a spokesperson said. Two rural hospitals in Iowa also closed their birthing units this year amid staffing shortages.
“The problem is in a small rural facility, you are just one resignation away from disaster,” said Brock Slabach, chief operations officer for the National Rural Health Association. “The economics, staffing shortages and low reimbursement are reinforcing the downward spiral of women of reproductive age not being able to access care.”
Counties without obstetrics care have higher rates of poverty and more uninsured residents, according to the University of Kentucky research. Rural hospitals were more likely to close after cutting obstetrics care. Those that did cut those services saw their workforces shrink, the brief found.
“We are seeing an erosion of OB access in rural America. The political aspect of all this is adding tension to a situation that has already been in significant decline,” said Michael Topchik, national leader for Chartis. “Young women in OB deserts have to travel great distances for care.”
Between 2011 and 2019, closures of rural obstetrics lines have affected at least 450,000 women of reproductive age, requiring women in around half of these communities to drive at least 30 minutes to the nearest facility offering those services, according to Chartis data.
As for the around 1,000 rural hospitals that still provide obstetrics care, around 40% have negative margins, Chartis data show.
As access declines, more women will likely give birth in emergency departments and en route to hospitals. The U.S. already has the highest maternal mortality rate among industrialized nations. Access gaps will increase maternal mortality and health complications, experts said.
“The reality is that babies are being born in cars or ambulances and, at best, in EDs in rural America,” Topchik said.
The U.S. maternal mortality rate has increased from 17.4 deaths per 100,000 live births in 2018 to 23.8 deaths in 2020, according to the latest data from the Centers for Disease Control and Prevention. Black mothers are more than twice as likely to die than white mothers, CDC data show.
Staffing shortages have buffeted maternal care. Legal concerns may deter medical students from pursuing obstetrics, experts said.
OB-GYNs tend to have the highest malpractice insurance premiums. Their legal liability is expected to increase as states restrict or ban abortion services in the absence of Roe v. Wade.
“If one thing goes wrong, it puts the entire hospital at risk,” Topchik said.
The U.S. will have an estimated shortage of 5,170 OB-GYNs by 2030, HHS’ Health Resources and Services Administration data show. The South and West are projected to have the biggest supply-demand mismatches.
While an estimated 18,880 OB-GYNs are expected to enter the workforce from 2018 to 2030, 22,240 are projected to retire or leave the profession, according to HRSA. Only 19% of the nation’s OB-GYNs were younger than 40 years old as of 2017, data from the digital health software company Doximity show.
Midwives and doulas can help fill some of the gaps outside of the hospital setting, but they are limited by scope-of-practice laws, experts said.
“Imagine thinking about going into the profession that has this growing legal liability,” said Dr. Laurie Zephryin, senior vice president of advancing health equity at the Commonwealth Fund, a research institute. “We already have a crisis of staffing and capacity and we are at risk of not being able to refresh the pipeline of workers.”
More hospitals are partnering with academic medical centers to bolster that pipeline and try to maintain services. Tertiary teaching hospitals are providing video consultations to help guide caregivers at rural facilities through more complicated procedures in cardiology, neurology, nephrology, pulmonology and obstetrics.
But not all deliveries need to happen in a hospital, Zephryin said. The federal government could expand the National Health Services Corps funding for midwives, a program that incentivizes tuition reimbursement for caregivers entering underserved areas, she said. Policymakers could expand scope-of-practice laws for nurses and midwives, Zephryin said.
“There is an opportunity to rebuild the capacity of community birth infrastructure and support a culturally competent and diverse workforce of midwives,” she said.
Another option is adjusting reimbursement to patient volumes, experts said. Payers should provide higher reimbursement rates to low-volume obstetrics units that are more expensive to maintain, Slabach said.
“If that was addressed, I think more programs would survive,” he said.