Declining Access to Hospital-based Obstetric Services in Rural Areas: Causes and Impact

Research center:
Lead researcher:
Project funded:
September 2004
Project completed:
September 2006
A steady decline in the number of hospitals and a significant drop in the fraction of hospitals providing obstetric services led to reduced availability of hospital-based obstetric services in rural communities from the mid-1980s to the early 2000s. Policy-makers and public health researchers are concerned that this may reduce access to obstetric services in some rural communities and may thereby adversely impact maternal and infant health. While a variety of demand- and supply-side variables could have contributed to the decline of hospital-based obstetric services in rural counties, health-care providers often identify increasing malpractice liability pressure as a particularly important factor. Since the mid-1970s, many state legislatures have enacted tort reforms covering numerous aspects of medical malpractice litigation. This study examines the impact of various factors on the availability of hospital-based obstetric services in rural counties, with a focus on five types of malpractice reforms - caps on total, non-economic and punitive damages, the mandatory offset of collateral source rule, and rules mandating periodic payment arrangements for damages.

Data for this analysis were extracted from multiple sources, including the Annual Hospital Survey from the American Hospital Association, the Area Resource File from the Health Resources and Services Administration, the Census Bureau, the Bureau of Economic Analysis and the natality data files from the National Center for Health Statistics. Our study covers the years 1985, 1990, 1995 and 2000, and uses both bivariate and multivariate analysis techniques to control for differences in counties' socioeconomic characteristics and time trends. We find limited evidence on the influence of direct tort reforms on the presence of county hospital-based obstetric services. However, estimates of the effects of tort reforms lack sufficient precision for us to draw firm conclusions.

In addition to the quantitative analyses, an informal survey of hospital administrators was conducted to capture local perceptions of the impact of the loss of hospital-based obstetric services. Among 28 completed telephone interviews, the most frequently-cited reasons for closing obstetric units are low volumes of deliveries in rural communities, financial vulnerabilities due to high proportions of patients on Medicaid, and difficulties in staffing obstetric units. Reasons for difficulties in staffing obstetric units include malpractice burdens for OB/GYNs and family practitioners, changes in physicians' attitudes toward work and quality of life, and the costs involved in recruiting supporting specialists such as anesthesiologists and surgeons. Survey responses also show that more than 60 percent hospitals that closed their obstetric units are within a 30-minute drive to another hospital that provided at least basic obstetric services, suggesting that, in most cases, closures of hospital obstetric units may not have caused serious access-to-care problem. However, women at high risk for complications during labor and delivery may have had to travel longer distances to obtain specialized care.


  • Why Are Fewer Hospitals in the Delivery Business?
    NORC Walsh Center for Rural Health Analysis
    Date: 04/2007
    This study examines the declining availability of hospital-based obstetric services in rural areas from the mid-1980s to the early 2000s. It looks at potential causes for this trend and explores the effects of medical malpractice reforms.