A hospital’s decision to stop offering obstetric care often depends on patient volume. Between 2010 and 2023, rural hospitals with the lowest birth rates had a 36% chance of closing their labor and delivery units—six times higher than the 5% risk for the highest-volume rural hospitals, according to a study published in JAMA Health Forum this month.
The decline has been severe. During that period, 537 U.S. hospitals—nearly half of them rural—eliminated obstetric services entirely, either by shutting down their units or closing permanently. By 2022, 52% of rural hospitals and 36% of urban hospitals no longer provided these services. For communities already facing access barriers, the loss means longer travel distances, fewer prenatal resources, and reduced support for perinatal mental health.
Why some hospitals close obstetric units—and others survive
The study, led by epidemiologist Julia D. Interrante, analyzed 3,108 U.S. hospitals that offered obstetric care in 2010. The research found that birth volume was the strongest predictor of unit closures. Rural hospitals with fewer than 500 births annually faced a 32% chance of losing obstetric services, compared with just 2% for those handling 2,000 or more each year. Urban hospitals with fewer than 500 births a year had a 32% predicted probability of unit closure, compared with 2% for those with 2,000 or more.
Financial performance influenced outcomes, but the effects differed between rural and urban settings. Unprofitable rural hospitals had a 30% probability of closing their obstetric units, 12 percentage points higher than profitable ones. In urban areas, unprofitability raised the unit closure risk by 4 points, though it increased the likelihood of full hospital shutdown by 7 points. For-profit status also played a role: rural for-profit hospitals had probabilities 13 percentage points higher for unit closure and 6 percentage points higher for hospital closure. Urban hospitals with for-profit status were tied only to hospital closure, at 4 percentage points higher, and unprofitable for-profit urban hospitals had a 16-percentage-point higher probability of hospital closure than profitable for-profit ones.
Geographic factors further shaped the risks. Rural hospitals located within 30 miles of another obstetric facility had a 7-point higher probability of closing their units. Urban hospitals faced the same pattern within 10 miles. Critical Access Hospitals (CAHs), rural facilities with fewer than 25 beds, had a 5-point lower chance of full closure in rural areas and a 4-point lower chance in urban areas. However, this designation did not protect their obstetric units from closure.
When multiple risk factors overlapped, the chances of losing obstetric services worsened. The lowest-volume, unprofitable rural hospitals had a 47% chance of closing their units, 15 points higher than their profitable counterparts. Unprofitable rural for-profit hospitals faced a 46% risk. Even among hospitals that retained obstetric services through 2023, 41% still carried high-risk traits for future loss.
Policy and financial initiatives addressing obstetric care access
The study’s authors emphasize that rural and urban hospitals require separate policy approaches due to differing risk factors for obstetric unit closures. They note that existing financial support programs could shape future decisions about maintaining these services. The Centers for Medicare & Medicaid Services (CMS) launched the Transforming Maternal Health Model, a voluntary 10-year initiative running from 2025 to 2034. This program aims to improve maternal care for Medicaid and Children’s Health Insurance Program enrollees in 15 participating states, with each state eligible for up to $17 million in cooperative funding.
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The Rural Health Transformation Program, established under the One Big Beautiful Bill Act, will distribute $50 billion to approved states over fiscal years 2026 through 2030. These programs could provide critical resources to hospitals struggling with financial sustainability while ensuring access to risk-appropriate obstetric care. However, the study’s data from 2010 does not account for later developments, such as Medicaid expansion or pandemic-related disruptions, which may have influenced closure rates.
The findings also highlight limitations in administrative data, as they cannot fully capture factors like local leadership efforts to preserve obstetric services or hospitals operating below viable birth volumes due to community demand. Some closures may have followed earlier unit shutdowns, complicating the distinction between the two outcomes. The authors stress that while the study identifies associations, it does not prove causation between specific factors and unit closures.
Financial pressures and policy challenges
The study reveals a persistent financial imbalance: obstetric care is undervalued in hospital budgets. Payment rates for maternity services rarely cover essential costs like staffing or equipment. By 2023, 35% of rural hospitals that kept obstetric services were operating at a loss, up from 21% in 2010.
Despite these challenges, some hospitals succeeded in retaining their services. Of the 915 facilities deemed high-risk in 2010, nearly all still offered obstetric care by 2023, and many had reduced their risk over time. The study does not specify how these outliers achieved stability, but the authors suggest their strategies could provide useful lessons for others.
The findings highlight the need for targeted policy solutions. Rural and urban hospitals face distinct pressures, and any intervention must address those differences. Existing programs, such as the 10-year Transforming Maternal Health Model, a CMS initiative offering up to $17 million per state for Medicaid-enrolled patients, or the $50 billion Rural Health Transformation Program, could help. However, the study’s authors warn that current financing structures do not match the true costs of delivering obstetric care.
The study’s methodology combined national datasets to track which hospitals retained obstetric services between 2010 and 2023. Researchers cross-referenced American Hospital Association surveys, CMS Provider of Services files, and hospital websites with county-level data on unemployment, nurse staffing, and birth volumes. By comparing 2010 characteristics, such as proximity to another obstetric facility, annual deliveries, and ownership type, to 2023 outcomes, the team isolated factors that predicted closures. Sensitivity tests confirmed the trends held even when excluding hospitals that shut down during the COVID-19 pandemic, indicating these were not pandemic-specific anomalies.
Key differences emerged between rural and urban hospitals in how risk factors interacted. Rural hospitals with fewer than 500 births annually faced a 32% chance of closing their obstetric units, while urban hospitals with the same volume had a nearly identical 30% risk. However, urban hospitals with low volumes and unprofitability saw a sharp rise in full closure risk: 10% for low-volume hospitals alone, jumping to 24% for those that were also unprofitable. Rural hospitals showed less variation in full closure risk tied to unprofitability, though their unit closure rates still climbed significantly when financial strain combined with low birth volumes.
