Joy Baker is an OB-GYN who practices in rural Georgia. Her patients travel 40 miles on average to see her, reports Atlanta magazine. She's one of only two doctors offering obstetric services in an area that spans eight counties and more than 2,700 square miles. What's more alarming is that more than half of Georgia's counties do not have a single practicing obstetric provider.
And according to a new study published in the journal Health Affairs, if trends continue, it's only going to get harder for women who live in rural counties to access maternal care.
In light of the challenges rural Americans face gaining access to health care—and recent findings that pit the US as the worst developed country for maternal mortality rates—researchers from the Rural Health Research Center at the University of Minnesota were interested in getting a better understanding of the scope of hospital obstetric service closures, and what these impacted communities looked like. They analyzed five sources of national data to figure out just how many hospitals and obstetric units closed between 2004 and 2014; survey county-level characteristics; and identify other variables, such as Medicaid income eligibility thresholds for pregnant women.
Researchers found that 45 percent of all rural counties in the US had no hospital-based obstetric services during the 10-year period studied. The most common cause of hospitalization in the US, the study also notes, is childbirth. For context, the study's authors point out that nearly two million women of reproductive age lived in these 898 rural counties in 2004. They also found that another nine percent of counties actually lost access to obstetric services during the same time period—leaving more than half of all rural US counties without obstetric services.
"This highlights the disproportionate barriers that rural women in vulnerable communities face in gaining access to hospital obstetric services."
As far as who exactly is being impacted by these closures, the study's authors discovered that counties with higher proportions of black women and lower-income households had higher odds of closures. "This highlights the disproportionate barriers that rural women in vulnerable communities face in gaining access to hospital obstetric services," they write. "Indeed, black women and Medicaid beneficiaries in rural areas have less access to nonlocal high-acuity obstetric care than do white or privately insured rural women—even when black women and those on Medicare have high-risk clinical conditions (such as preterm or multiple births) that may warrant advanced care in urban hospitals."
Peiyin Hung is a postdoctoral associate at Yale School of Public Health and lead author of the study. She says that planning is key for women seeking maternal care who live in underserved areas. "Labor and delivery involves many uncertainties," she tells Broadly. "Patients' needs in obstetrics may change rapidly and without warning, leaving rural women without immediate access to needed care. The farther a hospital-based obstetric care is from home, the more planning measures are needed for a rural family. Previous studies have showed psychological burdens from traveling for childbirths."
Historically, the study states, obstetric services are usually the first to go when a hospital is making cuts based on financial issues. "Rural women's access to obstetric care services is an issue of clinical, community, and personal relevance," Hung says. "This study quantifies the trend of losing hospital obstetric services in rural counties, and mapped the vulnerable communities that face this situation. This is the time to start thinking about potential interventions."
That's why the study suggests lawmakers re-evaluate their state Medicaid policies: "Greater access to Medicaid coverage during pregnancy may contribute to the financial viability of obstetric services provision in rural areas." Recognizing how difficult it would be to maintain high, and expensive, levels of care in an area where few children are being born, the authors also note the importance of expanding other options, such as programs that focus on referral and transfer services and what role nurse practitioners and midwives can play in each state.
Baker, the OB-GYN in Georgia, told Atlanta magazine she wished she had access to more resources. "You have to be a very tenacious person to survive out here," she said. "You can't take no for an answer. Because these women are phenomenal, and they deserve a voice. They deserve the same level of care as anybody else."