Pregnant people in Minnesota and nationwide have lost access to hospital birthing care

NINA MOINI: A recent study by the University of Minnesota School of Public Health looks at obstetric care in all 50 states, and it found that there has been a widespread loss of care for pregnant people, and it's disproportionately impacting rural communities here and everywhere.

Joining me now to dig in to the findings of this study is lead author Katy Backes Kozhimannil. She's a distinguished McKnight University professor and co-director of the Rural Health Research Center at the University of Minnesota.

Thanks so much for being with us, Katy.

KATY BACKES KOZHIMANNIL: I'm happy to speak with you, Nina.

NINA MOINI: Can you start by telling us, just for people who may not know, exactly what obstetric care entails and why it's so important for you to track this?

KATY BACKES KOZHIMANNIL: Absolutely. So when folks are pregnant and ready to give birth, almost all, 99% of all births in the US happen in hospitals. And to be ready to take care of someone who is giving birth in a hospital, they need to have the folks that are the clinicians that are there to help take care of someone in labor.

And as they give birth, both for taking care of the mama and the baby, need to have people that are available to provide pain relief, if that's something that's needed, and Cesarean delivery, if that's something that's needed. We also need to have the right equipment and also sources of backup and even, in extreme cases, transfer, if the mom or baby need more care than is available at the particular hospital where birth is occurring.

NINA MOINI: Sure. Sure. So talking about this study and the research that you're doing, give us an idea for just how many hospitals you looked at and over what scope of time, what did you find?

KATY BACKES KOZHIMANNIL: Sure. The analysis that we just completed looks at all of the short-term acute care hospitals in the United States that, from 2010 to 2022, that were providing obstetric services in 2010. So we know that there were losses of hospitals and obstetric care prior to 2010. But our study really started at that time period.

And over the 12 years, between 2010 and 2022, there have been a lot of changes in health care delivery and a lot of increasing attention to maternal health, recognition of the maternal mortality crisis in this country and of declining access to maternity care. And in spite of that attention, we saw a pretty steady decline overall, in both rural and urban areas, in terms of whether or not hospitals provide obstetrics.

So we looked at whether those hospitals that had obstetrics in 2010 stopped providing it and by 2022, what percentage of all hospitals in each of the 50 states were places that provided obstetric care.

NINA MOINI: OK. And so that's interesting that the care is decreasing both in rural and urban hospitals and areas. Would you tell us a little bit about some of the different or unique challenges perhaps rural hospitals face, and then urban hospitals?

KATY BACKES KOZHIMANNIL: Yes. Rural and urban hospitals-- pregnant folks in rural and urban communities all need access to care when they're having their babies. But hospitals in those areas face different kinds of constraints, as do the patients in those communities.

In rural areas, which I know very well, and where we've seen a concentration of hospital closures and hospital obstetric unit closures, there are some real challenges with offering obstetric services in rural hospitals. I mentioned at the beginning all of the things that a hospital needs to have available 24 hours a day, 7 days a week, to be able to take care of a person in labor.

And there's pretty high cost associated with having all the equipment and the clinicians and everyone available all the time. The revenues to cover those costs come with each birth that happens in the hospital. And in some of our rural communities and less heavily populated areas, birth volume is just lower. There are fewer people in the community, and so there are fewer births and therefore fewer resources to cover each of those births.

NINA MOINI: That's interesting.

KATY BACKES KOZHIMANNIL: Additionally, something that affects both rural and urban hospitals is the total amount that is paid for labor and delivery, it differs based on whether the patient has private insurance or is covered by Medicaid. Medicaid generally pays less than private insurers, so hospitals in rural areas or urban areas that take care of a lot of patients with Medicaid coverage, Medicaid pays about half of what private health plans do on average. And so you need about twice as many Medicaid patients as privately insured patients, again, to just make the math work on those resources.

NINA MOINI: So facing some decreases in funding across the different areas, it seems like, and then perhaps workforce shortages, other types of finances for a clinic. So all of these challenges. Would you give us an idea of if you zoom in on Minnesota, on our state, which has one of the higher rates, I guess, of decline in obstetrics in the country-- I was shocked to learn that, I must admit-- what's happening there?

KATY BACKES KOZHIMANNIL: Sure. We have heard-- I'm born and raised in Minnesota, so I'm from here. And conducting this work nationally, it was striking to me as well. If you look at the maps that we produced in our research, Minnesota does stand out. And there are a couple of reasons for this.

One, Minnesota is a place that has worked hard to retain hospital care and hospital-based obstetric care specifically, and didn't see as many losses as some other areas before 2010. So Minnesota actually started with a higher number of hospitals overall, and a higher percentage of those hospitals that were providing obstetrics.

Between 2010 and 2022, 22 hospitals in Minnesota lost obstetric services. That was 21% of all of the hospitals that had obstetrics in 2010. And by 2022, 38.2% of our hospitals in the state did not offer obstetric services.

Now, that's pretty high. But if we look at our neighbors, a state like Iowa, which also saw quite a few closures, they saw 27 closures in the same time period, by 2022, 55% of all hospitals didn't offer obstetrics. And in a place like North Dakota, fewer than 5 hospitals stopped providing obstetric services during this time period. But very few hospitals in North Dakota had those services in 2010. And by the end of 2022, almost 75% of all hospitals in North Dakota do not provide obstetric services. So even though we have experienced quite a bit of loss, we still have, in Minnesota, a higher percentage than many of our neighboring states of hospitals that do offer obstetrics.

And there are also rural-urban differences within Minnesota that are important. We've seen closures in both urban communities as well as in our rural areas.

NINA MOINI: Yeah. Wow, this is just such good context. I'm curious to know, before I let you go, Katy, is this something that is happening-- I know your research focuses on obstetrics-- are there other areas of care that are also being cut back over time, or do you sense that obstetrics is one of the most impacted?

KATY BACKES KOZHIMANNIL: Obstetrics is unique in many ways. It's very different than other things that happen in a hospital, because it's, frankly, the happiest thing that happens in a hospital. People who are pregnant are not sick. And generally, our hospital systems are designed to help clinicians take care of sick folks and people with illnesses.

And so, reimbursement and the finances of health care are often focused on that. So obstetrics is really different and is therefore sometimes more vulnerable, oddly, because it's a happy thing generally. But that also means that rural communities and rural hospital administrators tend to try to fight pretty hard to keep obstetrics when they can, because it's something that people see as important to a community.

Those of us here in Minnesota, all of us have these stories about where we were born and it becomes part of our families and our identities. And it means a lot to be born in your community. And I know it's a difficult thing when a community is a place where you can no longer be born locally in your hometown.

NINA MOINI: So what are any possible solutions, Katy, or anything that you're hoping that people will look into to try to perhaps keep this from getting even worse?

KATY BACKES KOZHIMANNIL: Yeah. There are so many things that we can do. I mentioned that the time period we're looking at in this analysis is a time of a lot of care and attention to maternal health and to maternity care access. But the things that we have been doing weren't working. And I think that's important to think about doing things differently as we move forward.

I think fundamentally thinking about financing and resources is very important. One of the ways that rural communities have been able to maintain basic care and services is through specific programs that offer different kinds of financing in those rural communities, like critical access hospitals, for example.

So there may be ways to look specifically at maternity care financing in rural areas, giving standby capacity payments to those hospitals in rural areas with fewer births, recognizing that they really have some higher fixed costs that aren't going to be covered by the patient volume that they have. So I think there are-- or low volume payment adjustments. There are many different financial strategies that can be used.

NINA MOINI: Yeah. It sounds like what you're saying is it's time for folks to get creative, Katy.

Thank you very much for your time and sharing your work with us, Professor. Really appreciate your time.

KATY BACKES KOZHIMANNIL: Absolutely. I'm glad to have talked with you about this.

NINA MOINI: Thank you.

That was Professor Katy Backes Kozhimannil with the University of Minnesota School of Public Health.