Birth and Delivery Birth Setting and Provider
RRM Academy Synopsis
Obstetric Service Loss Linked to Preterm Birth in Non–Urban-Adjacent Counties
A national cohort study of 4 941 387 births found that non–urban-adjacent rural counties had more preterm births after obstetric services closed than counties that kept services. In the year after closure, these counties also had more out-of-hospital births and more births in hospitals without obstetric units. Urban-adjacent counties had more of the latter.
Key Findings
- A total of 179 rural counties lost every in-county hospital obstetric service during 2004 to 2014. Of these, 103 were urban-adjacent and 76 were non–urban-adjacent.
- In non–urban-adjacent counties, preterm births rose 0.67 percentage points (95% CI, 0.02 to 1.33) in the year after loss, compared with counties with continual services.
- In those counties, out-of-hospital births rose 0.70 percentage points (95% CI, 0.30 to 1.10) in the year after loss, compared with counties with continual services.
- In the same counties, births in a hospital without an obstetric unit rose 3.06 percentage points (95% CI, 2.66 to 3.46) in the year after loss, compared with counties with continual services.
- In urban-adjacent counties, births in a hospital without obstetric services rose 1.80 percentage points (95% CI, 1.55 to 2.05), then trended at −0.19 percentage points per year (95% CI, −0.25 to −0.14).
Interpretation
This cohort study compared county birth records before and after obstetric service closures against counties that kept services continuously. A county counts as urban-adjacent when it borders a metropolitan county and at least 2% of its working residents commute to one. The authors note that unmeasured confounding remains possible. The findings support further research into how losing local obstetric services affects birth outcomes in rural communities.
RRM Context
Restorative reproductive medicine seeks the causes of reproductive problems, and its care continues through pregnancy. The authors suggest the preterm association may come partly from fewer prenatal visits and the stress of lacking local childbirth services. Local maternity access is part of the setting for pregnancy care.
Abstract
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.
