Access and Coverage · Workforce and Availability
Kozhimannil KB et al., 2025 · JAMA
Plain Language This study quantifies losses and gains of obstetric care services at US rural and urban short-term acute care hospitals between 2010 and 2022.
Birth Setting and Provider · Hospital Birth
Kozhimannil KB et al., 2020 · JAMA
This study describes hospital-based obstetric service losses in rural US counties between 2014 and 2018 overall and by county population and urban adjacency.
Birth Setting and Provider · Hospital Birth
Kozhimannil KB et al., 2018 · JAMA
Comment in
JAMA. 2018 Mar 27;319(12):1203-1204. doi: 10.1001/jama.2018.1646. 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.
To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties.
DESIGN, SETTING, 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.
Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas.
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).
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]).
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.
Guidelines by Clinical Area · Fertility and Infertility Guidelines
Practice Committee of the American Society for Reproductive Medicine, 2025 · Fertility and sterility
It has been estimated that only a quarter of persons with infertility in the United States can sufficiently access infertility care. Against this backdrop of disparity, specific populations, including persons of color, sexual and gender minorities, immigrants, and lower-income persons, face barriers that further constrain access to care. This document outlines these communities' barriers and reviews best practice recommendations to extend inclusive access to care for marginalized populations. This reference is intended to support health professionals with knowledge of barriers that limit access to care and to provide practical strategies to improve access and optimize healthcare delivery.