Low birth volume and unprofitability associated with obstetric services losses

A retrospective cohort study assessed which hospital-level characteristics are associated with the loss of obstetric services in the United States, and whether those characteristics differ between obstetric unit closure and full hospital closure, and between rural and urban hospitals.

The analysis, published as an original investigation in JAMA Women’s Health, covered all rural and urban hospitals in the United States that provided obstetric services in 2010, using 2010-2023 data from American Hospital Association Annual Surveys, the Centers for Medicare & Medicaid Services' Provider of Services Files, and primary data from hospital websites and news articles. Data were analyzed from November 2025 to April 2026.

Exposures examined included distance to the nearest obstetric hospital, birth volume, average daily census, nurse staffing, ownership, Critical Access Hospital status, unprofitability, and county unemployment in 2010. Outcomes, assessed using adjusted multinomial logistic regression, included whether each hospital maintained obstetric services through 2023, remained open but closed its obstetric unit, or closed entirely, along with hospital characteristics in 2023. Outcomes are reported as estimated risk-adjusted predicted probabilities and marginal effects as percentage-point (pp) differences.

Key data

• Among 1126 rural obstetric hospitals open in 2010, 239 (21.2%) closed their unit and 42 (3.7%) closed entirely by 2023
• Among urban hospitals (n = 1982), 250 (12.6%) closed their unit and 92 (4.6%) closed entirely by 2023
• Lower birth volume was associated with higher predicted probability of unit closure, ranging from 8 pp (95% CI, 5.4-10.6 pp) higher for the second-highest birth volume quartile to 31 pp (95% CI, 23.2-39.1 pp) higher for the lowest birth volume quartile
• Lower birth volume was associated with higher predicted probability of hospital closure, ranging from 4 pp (95% CI, 0.7-7.1 pp) higher for the second-lowest birth volume quartile to 8 pp (95% CI, 3.3-12.4 pp) higher for the lowest birth volume quartile; birth volume had a larger marginal effect on unit closure than hospital closure
• Unprofitable rural hospitals had a 12-pp (95% CI, 6.8-17.5 pp) higher predicted probability of unit closure than profitable rural hospitals
• Unprofitable urban hospitals had a 4-pp (95% CI, 0.1-7.1 pp) higher predicted probability of unit closure and a 7-pp (95% CI, 3.9-9.7 pp) higher predicted probability of hospital closure than profitable urban hospitals
• Rural and urban hospitals located near another obstetric hospital had more than 7-pp (95% CI, 1.6-12.7 pp) higher predicted probability of unit closure than those farther away
• Rural for-profit hospitals had 13-pp (95% CI, 2.8-22.2 pp) higher predicted probability of unit closure and 6-pp (95% CI, 1.6-10.3 pp) higher predicted probability of hospital closure compared with government-owned hospitals
• In urban areas, for-profit status was associated only with hospital closure (4 pp; 95% CI, 1.2-7.6 pp), not unit closure
• Among hospitals that maintained obstetric services through 2023, 41% had high-risk factors in 2023 for future obstetric loss

Risk factors diverge between unit closure and full hospital closure

The study found that the hospital characteristics associated with losing obstetric services were not uniform across closure types. Birth volume carried a larger marginal effect on the probability of unit closure than on full hospital closure, while for-profit ownership in urban hospitals was linked only to hospital closure and showed no association with unit closure specifically, a distinction the study's authors said points toward the need for separate policy approaches addressing unit-level and facility-level loss.

Among hospitals that maintained obstetric services from 2010 through 2023, 41% carried high-risk factors in 2023 for future obstetric loss. However, among the 915 hospitals identified as high risk in 2010 that were able to maintain services, risk levels were either reduced or held steady rather than worsening over the study period.

Reference:

Interrante JD, Carroll C, O’Hanlon K, Sheffield EC, Kozhimannil KB. Risk Factors for Loss of Hospital-Based Obstetric Care in Rural and Urban Hospitals. JAMA Health Forum. 2026;7(9):e263122. doi:10.1001/jamahealthforum.2026.3122