TOPLINE

Hospital obstetric unit closures are associated with a significant increase of approximately 14 minutes in travel time to the nearest obstetric service. Rural areas experience greater increases in travel time (approximately 17 minutes) than urban areas (approximately 10 minutes) after all in-county obstetric services are lost.

METHODOLOGY

• Researchers used data from the 2010-2021 American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services Provider of Services files to determine hospital-based obstetric service availability in the US.
• A total of 60,516 census tracts (726,192 tract-years) across 3033 continental US counties were included, with 208 counties losing all obstetric services, 1512 counties maintaining continual services, and 1313 counties never having obstetric services between 2010 and 2021.
• The primary outcome was one-way estimated travel time by car in minutes from census tract centroids to the nearest hospital-based obstetric services, calculated using network analysis in ArcGIS accounting for road networks and posted speed limits.
• Investigators used a staggered difference-in-differences study design using the Callaway and Sant’Anna difference-in-differences model to evaluate changes in travel time after obstetric unit closures, comparing counties that lost all services with counties that had continual services.
• Analysis was stratified by rurality using the Rural-Urban Continuum Code, with counties categorized as urban (codes 1-3) or rural (codes 4-9), and adjusted models controlled for county socioeconomic characteristics and healthcare supply and demand variables from 2010.

TAKEAWAY

• Overall, 2.7% of tracts were in counties that lost all hospital-based obstetric services between 2010 and 2021, while 89.2% were in counties with continual services and 8.2% were in counties that never had services.
• In both unadjusted and adjusted models, obstetric unit closures were associated with a significant increase of 13.8 minutes (95% CI, 13.1-14.4) in estimated travel time to the nearest obstetric hospital.
• Travel time increased significantly more in rural areas than in urban areas, with increases of 16.9 minutes (95% CI, 15.9-17.8) vs 10.3 minutes (95% CI, 9.4-11.1), respectively.
• Event study estimates showed that preclosure period coefficients were small and mostly not statistically significant from zero, supporting the parallel trends assumption, while postclosure coefficients were positive and statistically significant, indicating increased travel time for closure counties.

IN PRACTICE

“After hospital obstetric unit closures, travel time to the nearest obstetric services increased, especially in rural areas. The increased travel time presents a barrier to obstetric care because almost all US births occur in hospitals,” the authors of the study wrote.

SOURCE

The study was led by Brittany L. Ranchoff, PhD, MPH, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston. It was published online in O&G Open.

LIMITATIONS

The study has several limitations. First, the data did not contain patient-level information as this was a population-level analysis using tract-level travel times, though the tract level provides excellent geographic granularity. Second, researchers could not account for intended birth location or risk-appropriate care for high-risk individuals and pregnancies, which might not be the nearest obstetric unit, and the American Hospital Association data have limited accuracy about maternal care-level variables. Third, obstetric service availability is measured at the county level, though this measure is commonly used to describe obstetric service access. Lastly, there is potential for measurement error with travel time because variations in traffic patterns or alternative transportation modes such as public transit or ferries could not be accounted for, though travel time was based on road networks and posted speed limits consistent with prior healthcare access research.

DISCLOSURES

This research was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number R01NR020859. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors reported no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.