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Maternal Health: Availability of Hospital-Based Obstetric Care in Rural Areas

GAO-23-105515 Published: Oct 19, 2022. Publicly Released: Oct 19, 2022.
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Fast Facts

The number of hospitals providing obstetric services in rural areas has declined since 2014. Over half of rural counties didn't have a hospital that provided these services, as of 2018. This is particularly prevalent in low-income areas, and is associated with problems such as premature births.

Experts and other stakeholders said it is difficult for hospitals in rural areas to recruit and retain maternal health providers. Also, a higher proportion of rural patients rely on Medicaid, which doesn't fully cover obstetric services. Increasing Medicaid reimbursement rates that states set could help rural hospital obstetric services stay open.

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What GAO Found

Research indicates that the number of rural hospitals providing obstetric services declined from 2004 through 2018, and more than half of rural counties did not have such services in 2018, according to the most recent data available. Studies showed that closures were focused in rural counties that were sparsely populated, had a majority of Black or African American residents, and were considered low income. Studies also showed differences in the type of clinicians delivering babies in rural and urban areas. Specifically, family physicians were more common in rural areas than in urban areas, while obstetrician-gynecologists and midwives were more common in urban areas, though the prevalence and types of clinicians varied by state.

Stakeholders GAO interviewed most often ranked two factors as most important among a list of seven factors potentially affecting the availability of obstetric care in rural areas. Specifically, stakeholders said:

  • Medicaid reimbursement rates set by states do not cover the full cost of providing obstetric services. This may mean particular financial losses for hospitals providing these services in rural areas, where a higher proportion of births are covered by Medicaid. Medicaid covered 50 percent of rural births in 2018, compared to 43 percent of births for the United States as a whole, according to the most recent analysis from the Medicaid and CHIP Payment and Access Commission.
  • Recruiting and retaining providers is particularly challenging for rural areas, as they must compete with urban areas for a limited pool of providers to staff obstetric units that require a full range of maternal health providers, such as physicians and nurses, as well as anesthesiologists.

Stakeholders GAO interviewed most often cited the following efforts federal agencies, states, and others could take to increase the availability of obstetric care in rural areas. Specifically, stakeholders said:

  • Increasing Medicaid reimbursement would help to keep obstetric services open, as Medicaid covers a higher proportion of births in rural areas than urban areas.
  • Increasing remote consultations, such as through videoconferencing or phone calls, between clinicians could help ensure that rural patients who live longer distances from higher levels of obstetric care have access to such care through their own clinicians in their communities.
  • Establishing regional partnerships—such as a hub-and-spoke model where a larger hospital (hub) partners with smaller rural hospitals (spokes) for care coordination and to provide training and other resources—could help ensure rural patients receive risk-appropriate care in their communities. For example, a specialist from the hub hospital could help manage a rural patient's high-risk condition as needed and support the rural clinician for planning delivery at the local hospital.

Why GAO Did This Study

Access to obstetric care is a growing concern in rural U.S. communities, given recent closures of hospitals in rural areas. The loss of hospital-based obstetric services in rural areas is associated with increases in out-of-hospital births and pre-term births, which may contribute to poor maternal and infant outcomes. These have been more prevalent in rural areas and non-White racial and ethnic groups.

House Report 116-450 directed GAO to report on ways to improve access to obstetrics care in rural areas. This report is focused on the hospitals and clinicians that provide delivery services, and describes (1) the availability of hospital-based obstetric services in rural areas, (2) stakeholder perspectives on factors that affect such availability, and (3) stakeholder perspectives on efforts federal agencies, states, and others could take to increase such availability.

GAO reviewed literature published from 2011 through 2022, interviewed researchers and provider associations, and conducted semi-structured interviews with 19 selected stakeholders to obtain their perspectives on factors that affect the availability of care and efforts to address such factors. Stakeholders, comprised of provider associations, patient advocacy groups, researchers, and federal agencies, were selected to represent diverse perspectives, including various obstetric clinicians and organizations representing different racial and ethnic groups.

GAO provided a draft of this report to HHS. HHS provided technical comments, which GAO incorporated as appropriate.

For more information, contact Alyssa M. Hundrup at (202) 512-7114 or

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Access to health careGynecologyHealth careHospitalsObstetricsPatient careQuality of careRural healthRural hospitalsWomen