Rural obstetric care continues to operate at financial loss


Local community needs for obstetric care trump financial viability and staffing challenges at rural hospitals, according to a national survey in JAMA Health Forum.

Lindsay Admon, MD

Lindsay Admon, MD

Local community needs for obstetric care trump financial viability and staffing challenges at rural hospitals, according to a national survey in JAMA Health Forum.

“Rural hospitals and rural obstetric units have been closing at alarming rates over the last decade,” said study team member Lindsay Admon, MD, MSc, an assistant professor of ob-gyn at the University of Michigan in Ann Arbor. “Rural communities that have lost local access to obstetric care face reduced access to prenatal care and higher rates of preterm birth.”

Safely maintaining access to obstetric care is a clinical and policy priority, according to Admon. “We sought to understand rural hospital perspectives on criteria for maintaining safe provision of obstetric care,” she said of her work on the survey.

The investigators used the American Hospital Association Annual Survey to identify a national sample of rural hospitals that provided obstetric services in 2021. Obstetric unit managers or administrators at 93 rural hospitals with obstetric services were surveyed between March and August of 2021.

Of the hospitals in the study sample, 35.5% were critical access hospitals and 64.5% were located in micropolitan rural counties.

Overall, the hospitals had a median average daily census of 22 total inpatients. Half (52.2%) of hospitals reported a decline in births over the past 3 years and a median of 274 births in 2019.

Respondents reported that the minimum number of annual births needed to safely provide obstetric care was 200, which was the same number of births needed to ensure financial stability.

“A full 40% of participants reported they did not have enough births annually to breakeven financially, yet they continue to offer obstetric services,” Admon told Contemporary OB/GYN®.

When making decisions about maintaining obstetric care, 64.6% of hospitals cited meeting local community needs as their highest priority, compared to 16.5% that listed financial considerations and 12.7% that considered staffing as the most important factor.

Overall, 25% of hospitals were unsure they would continue providing obstetrics, or they expected to stop offering the service.

“Many rural hospitals continue to operate obstetric units, despite operating at a financial loss,” Admon said. “It is likely that the availability of rural obstetric care will continue to decline in coming years, and that this will exacerbate longstanding rural maternal and child health disparities.”

Rural hospitals that lack obstetric units often have births that occur in their emergency departments—along with unanticipated adverse birth outcomes, delays in urgent transport—and report the need for additional resources for emergency obstetrics.

Admon noted that urgent policy solutions are needed to continue the safe provision of obstetric care in rural America.

“To support rural hospitals in continuing to safely provide obstetric services, attention to financing of maternity care ought to include discussion of low-volume adjustments,” she said.

Medicaid is a major lever for policy change because its programs fund more than half of rural births. “Hence, Medicaid payment policies and reimbursement rates play a key role in the financial viability of rural obstetric care,” Admon said. “However, Medicaid pays substantially lower rates for childbirth than commercial insurance.”

Furthermore, pregnant Medicaid beneficiaries living in rural areas are less likely than those who are privately insured to give birth at an urban hospital or at a hospital with neonatal intensive care.

Rural representation in policy decision-making bodies is crucial for providing the distinct perspective of rural residents, communities and healthcare delivery systems, according to Admon. “This will help ensure that policy changes and safety resources are relevant and useful in rural settings,” she said.


  1. Kozhimannil KB, Interrante JD, Admon LK, et al. Rural hospital administrators’ beliefs about safety, financial viability, and community need for offering obstetric care. JAMA Health Forum. Published online March 25, 2022. doi:10.1001/jamahealthforum.2022.0204
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