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Access to Maternal Healthcare

Rural hospitals experience many challenges. Maternity care is expensive. Rural hospitals have lower birth volumes than urban hospitals. There are high fixed costs with having around-the-clock staffing of providers able to support childbirth or administer anesthesia if needed. Medicaid pays for about 51% of all births in rural areas. Medicaid's reimbursement rates vary by state, and sometimes the reimbursement rates for obstetric services are extremely low, making it unprofitable for hospitals to cover the operating costs of a labor and delivery unit.

Losing hospital-based obstetric services puts rural communities — especially those far from urban areas — at risk of greater rates of emergency room births and preterm births. Facilities attending a higher number of births may provide higher quality maternity care, though it is unclear how many births is too few to provide high quality care.

More than half of rural counties across the U.S. have no hospitals with obstetric services. Financial and workforce shortages sometimes result in the complicated decision to close an entire rural hospital. In other cases, hospitals decided to close only the obstetric unit. Safety guidelines set forth by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend birthing facilities be equipped to begin cesarean birth within 30 minutes. This guideline affects many rural hospitals, given there is considerable distance between pregnant women and the nearest hospital with obstetric care, should surgery become necessary. Closing obstetric units has resulted in pregnant women not receiving comprehensive prenatal care, increased rates of preterm births, out-of-hospital births, and births in hospitals without obstetric units.

To increase access to a hospital, some women and families must take time off of work and relocate to the town where the hospital is located prior to the pregnant woman's due date. However, not all rural residents have the benefit of paid leave, and for those struggling financially, renting a hotel room can be expensive. In addition, as birth is unpredictable, rural residents may not be able to estimate the correct duration or timing of their stay. Maternal Waiting Homes (MWHs) are housing facilities that provide residence near the birthing facility to expectant women in the weeks and months leading up to birth. MWHs typically provide housing for high-risk women, but may also be considered for rural pregnant women who are facing barriers accessing maternal healthcare due to transportation.

Barriers to transportation in rural areas include lack of infrastructure, quality of roads and bridges, and long distance to access obstetric services. Some communities have increased their reliance on perinatal telehealth in response to chronic transportation barriers. Even when some prenatal visits are provided virtually, pregnant women may need to travel to a facility to get diagnostic imaging and lab tests. They will also need to travel to a hospital or birth center for labor and delivery. In the case of emergency obstetric situations, pregnant women who are in labor may rely on an ambulance to transport them to the hospital. However, in rural areas, the continued existence of ambulance services are threatened due to declining populations, drops in volunteer emergency medical services (EMS) personnel, and minimal cost reimbursements. More information on rural transportation can be found in the Rural Transportation Toolkit.

Resources to Learn More

CDC Levels of Care Assessment Tool (CDC LOCATe)
Map/Mapping System
A web-based tool based on the guidelines of several national health organizations allowing states to develop standardized assessments for levels of maternal and neonatal care by facility, distribution of staff, and services offered.
Organization(s): Centers for Disease Control and Prevention (CDC)

Dwindling Maternal Care in Rural Areas Has Feds Seeking Fixes
Document
Discusses the loss of access to obstetric services in rural community hospitals. Highlights an effective maternal care program at Kearny County Hospital in rural Kansas.
Author(s): Stein, S.
Organization(s): Bloomberg Law
Date: 4/2019

Improving Access to Maternal Health Care in Rural Communities
Document
Provides background information on accessing maternal care before, during, and after pregnancy. Gives examples on how to improve access to maternal healthcare in rural communities.
Organization(s): Center for Medicare and Medicaid Services
Date: 9/2019