Addressing the Impact of Rural Hospital Closures on Maternal and Infant Health
June 20, 2023 | Lexa Giragosian
Nearly 200 rural area hospitals have closed since 2005, leaving more than 50% of all rural counties without access to hospital obstetric services. There are limited rural hospitals, and when even a few hospitals are closed, it greatly impacts community access to care. Rural hospital closures exacerbate poor socioeconomic conditions, job loss, cost of health services, transportation times and barriers, and inequitable access to quality care, all of which contribute to unfavorable maternal and infant health outcomes.
Hospital closures and financial challenges directly correlate as hospital profitability is an indicator of the likelihood of closure. Typically, hospitals that serve populations with high rates of poverty, uninsurance, or public insurance underperform profit-wise due to the populations’ financial barriers to care and the resulting low patient volume common for rural hospitals, and further exacerbated by the COVID-19 pandemic’s impact on routine services. Rural hospitals are also at risk of closure due to the present and ongoing physician shortage. This blog post will address rural hospital closures, while a related brief addresses the financial challenges of accessing care in rural areas.
Strategies to Address Hospital Closures
Risk appropriate care strategies ensure that pregnant people and infants receive care at facilities that best match their level of health risk. The provision of risk appropriate care is supported through integrated perinatal care coordination and standardized classification of levels of care. Supporting the usage of birth centers, coordinating “hub-and-spoke” models, and promoting telehealth are strategies that can address rural hospital closures’ negative impact on maternal and infant populations.
Birthing Centers
Promoting alternative lower levels of care, such as birthing centers, can address the high prevalence of hospital closures in rural areas. Birth centers meet many pregnant people’s needs, and establishing birth centers in rural areas allows pregnant people to access the care they require without needing a hospital. Reports indicate that birth centers are an effective and safe option for low-risk pregnant people. The Affordable Care Act requires Medicaid to give birthing centers a facility fee and reimburse midwives within these facilities, contributing to the success and future growth of birth centers in rural areas.
New York state recently passed legislation expanding access to care for pregnant people by alleviating cumbersome licensure requirements for midwife-led birthing centers, which inhibited the opening of centers despite being allowed since 2016. Supporting policies that allow for easier development and utilization of birth centers can limit the impact of rural hospital closures; compared to hospitals, birth centers are more easily implemented in rural areas and act as a cost-effective alternative pathway to accessing care for low-risk patients.
“Hub-and-Spoke” Models
Establishing “hub-and-spoke” models can address hospital closures in rural areas while achieving equitable risk appropriate care. These models create a perinatal regionalization system by organizing care networks within states to connect facilities with more limited services—spokes—to facilities that can provide a higher level of care with a full range of services—hubs.
Partnership and collaboration within “hub-and-spoke” models allow pregnant people in rural areas to receive care at the appropriate level facility through formal facility relationships, referrals, and transport coordination. These networks create an accessible avenue to receive risk appropriate care despite the geographic barriers exacerbated by hospital closures. South Dakota utilized this model with the "Maternal Health Compact," which links a Level III care center with two lower-level rural facilities using labor analysis software to foster care coordination.
Telehealth
Telehealth can alleviate barriers to care, such as the negative impacts of hospital closures; coordinated telehealth systems between providers and hospitals allow for distance-based care through consultations, diagnosis, and treatment and are an effective strategy for improving access to risk appropriate care. States have introduced policies solidifying telehealth, such as expanding Medicaid reimbursement or increasing access to broadband internet. However, the specific inclusion of perinatal risk appropriate care in future telehealth state policy can improve access to maternal and infant care in rural areas.
Equitable implementation of telehealth can be supported by ensuring coverage of telehealth care, reimbursement parity for services, patient access to technology, and allowability of providers to practice across state lines.
Telehealth Innovations during the COVID-19 Pandemic
During the pandemic, the North Carolina Department of Health and Human Services temporarily expanded Medicaid coverage of perinatal care via telehealth. Specifically, the Medicaid program authorized eligible providers to deliver antepartum and postpartum care via telemedicine to new and established patients, thus expanding access to care.
The University of North Carolina introduced telehealth booths in public buildings at the county level to improve equitable access to telehealth. Public telehealth booths located in communities with geographic or technology barriers allow for easier access to care and create an opportunity to provide equitable risk appropriate care for maternal and infant populations.
The University of Arkansas for Medical Science developed the ANGELS program, which focuses on creating equitable access to care for pregnant patients despite rural hospital closures. The program provides education, training, and consultations for clinicians and creates a telemedicine network for high-risk pregnant patients to improve access to prenatal care and obstetric services. This program required partnership, collaboration, and effective collaboration between stakeholders to improve rural access to care for pregnant people.
State health officials and their staff can adopt risk appropriate care strategies by fostering engagement and collaboration between hospitals and facilities to establish better avenues to care and alleviate the negative impacts of rural hospital closures. Including community health partners and providers in the decision-making process is also necessary for taking a comprehensive, equitable, and sustainable approach to developing a solution to this ongoing public health issue.
Thank you to the ASTHO Clinical to Community Connections team for their contributions to this blog post.
This publication was prepared with funding support from the Centers for Disease Control & Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.