How low can they go? Rural hospitals weigh keeping obstetric units when births decline

As rural hospitals struggle to stay financially stable, their leaders watch other small facilities close obstetrics units to cut costs. They face a no-win dilemma: Can we continue operating delivery units safely if there are few births? But if we close, do we risk the health and lives of babies and mothers?

The other question this debate hangs on: How few is too few births?

Consider the 11-bed Providence Valdez Medical Center, which brings 40 to 60 newborns into the world each year, according to Dr. John Cullen, one of several family physicians who deliver babies at the Valdez, Alaska, hospital. The next nearest obstetrics unit is a six- to seven-hour drive away, if ice and snow don't make the roads treacherous, he said.

The hospital cross-trains its nurses so they can care for trauma and general medicine patients along with women in labor, and it invests in simulation training to keep their skills up, Cullen said. He typically stays on-site, checking regularly as labor progresses, just a few steps away if concerns arise.

If the measure is the number of deliveries, "I do think that obviously there's too small and we're probably at that limit of low volume," Cullen said. "I don't think that we really have a choice. So, we just have to be really good at what we do."

Some researchers have raised concerns based on their findings that hospitals with few deliveries are more likely to experience problems with those births. Meanwhile, "maternity deserts" are becoming more common. From 2004 to 2014, 9% of rural U.S. counties lost all hospital obstetric services, leaving slightly more than half of rural counties without any, according to a study published in 2017 in the journal Health Affairs. Yet shutting down the obstetrics unit doesn't stop babies from arriving, either in the emergency room or en route to the next closest hospital. In addition, women may have to travel farther for prenatal care if there's no local maternity unit.

Clinician skills and confidence suffer without sufficient practice, said Dr. Nancy Dickey, a family physician and executive director of the Texas A&M [University] Rural and Community Health Institute in College Station. So, what is that minimum threshold for baby deliveries? "I don't have a number for you," she said.

Dickey and Cullen are not alone in their reluctance to set a metric. For instance, the American College of Obstetricians and Gynecologists has published a position statement about steps that rural and other low-volume facilities can take to maintain clinician skills and patient safety, including conducting frequent drills and periodically rotating health providers to higher-volume facilities to gain experience. But when asked to define "low volume," a spokesperson wrote in an email: "We intentionally don't define a specific number for low-volume because we do not want to create an inaccurate misperception that less volume equals less quality."

Neither does the American Academy of Family Physicians provide guidance on what constitutes too few deliveries for safe operation. The academy "has not specified a minimum of deliveries required to maintain high quality obstetrical care in rural and underserved communities due to the unique and multifaceted nature of each case in each community," according to a written comment from the group's president, Dr. Sterling Ransone Jr.

One challenge in sorting out any connection between the number of deliveries and safety is that the researchers use differing cutoffs for what qualifies as a hospital with a low number of births, said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health who studies rural maternal health. Plus, such data-driven analyses don't reflect local circumstances, she said. The income level of local women, their health risk factors, the distance to the closest hospital with an obstetrics unit, hospitals' ability to keep trained doctors and nurses — hospital leaders must consider these and other factors as they watch their birth numbers fall due to declining local population or pregnant women opting to deliver at more urban high-tech hospitals, she said.

Research on birth volumes and outcomes has been mixed, but the "more consistent" finding is that hospitals with fewer deliveries are more likely to have complications, largely because of a lack of dedicated obstetric doctors and nurses, as well as potentially fewer resources for emergencies, such as blood banks, according to the authors of a 2019 federal report on improving rural maternity care. A study cited in the report, published in 2015 in the American Journal of Obstetrics & Gynecology, found that women are three times as likely to hemorrhage after delivery in rural hospitals with the lowest number of deliveries — defined as between 50 and 599 annually — as in those with 1,700 or more.

Just 7.4% of U.S. babies are born at hospitals that handle 10 to 500 births annually, according to a geographic analysis published last month in JAMA Network Open. But those hospitals, which researchers described as low volume, are 37% of all U.S. hospitals that deliver babies.

Finances also influence these decisions, given that half of all rural births are paid for by Medicaid, which generally reimburses providers less than private insurance. Obstetrics is "referred to as a loss leader by hospital administrators," Kozhimannil said. As births dwindle, it can become daunting to pay for clinicians and other resources to support a service that must be available 24/7, she said. "Most hospitals will operate in the red in their obstetrics for a very long time, but at some point it can become really difficult."

If a hospital closes its unit, most likely fewer local women will get prenatal care, and conditions like a mother's severe anemia or a baby's breech position will be missed, Dickey said. "Not getting prenatal care increases the risks, wherever this patient delivers."

One Texas A&M initiative will enable its family medicine residency program to use telemedicine and periodic in-person visits to get more prenatal care to pregnant women in rural Texas, Dickey said. "What we really want are healthy mamas and healthy babies," she said.

The rural institute Dickey leads also plans to use a mobile unit to provide maternal simulation training to emergency room clinicians at 11 rural Texas hospitals, only three of which provide obstetrics. "But all of them catch babies now and then in their ER," said Dickey.

In Valdez, Alaska, keeping the hospital's unit open has paid off for residents in other ways, Cullen said. Since the hospital delivers babies, including by cesarean section, there's work to support a nurse anesthetist in the community of slightly more than 4,000 people. That enables the hospital to handle trauma calls and, more recently, the complexities of treating covid-19 patients, he said.

In her ongoing research, Kozhimannil remains committed to nailing down a range at which deliveries have dropped low enough to signal that a hospital needs "either more resources or more training because safety could be at risk." Not to shutter the obstetrics unit, she stressed. But rather to automatically qualify that hospital for more support, including extra financing through state and federal programs given that it's taxpayers that foot the bill for delivery complications, she said.

Because women will keep getting pregnant, Kozhimannil said, even if a hospital or a doctor decides to stop providing obstetric services. "That risk does not go away," she said. "It stays in the community. It stays with the people, especially those that are too poor to go other places."