Low birth volume, finances tied to hospital obstetric unit closures

Rural hospitals that delivered the fewest babies had a 36% predicted probability of closing their obstetric units between 2010 and 2023, compared with 5% for the highest-volume rural hospitals, according to a study published Sept. 11, 2026, in JAMA Health Forum.

Access to hospital-based obstetric care has been becoming scarcer across the U.S. Between 2010 and 2022, 537 hospitals stopped offering obstetric services, either by closing their labor and delivery units or by shutting down entirely, according to study authors of the University of Minnesota School of Public Health. By 2022, 52% of rural hospitals and 36% of urban hospitals did not offer these services.

When rural communities lose obstetric care, residents can have a harder time getting prenatal care, doula services and perinatal mental health care. Urban residents also face longer travel times and fewer options.

Earlier research associated rural losses to smaller, for-profit hospitals and urban losses to hospitals serving many publicly insured or uninsured patients. However, it wasn’t known whether risk factors differ when a hospital closes only its obstetric unit versus closing altogether or between rural and urban hospitals.

How the study was conducted

Led by Julia D. Interrante, Ph.D., MPH, epidemiologist and research fellow at the University of Minnesota School of Public Health, the study looked at all 3,108 U.S. hospitals that provided obstetric services in 2010, including 1,126 rural and 1,982 urban hospitals. Interrante and her team used American Hospital Association surveys, CMS Provider of Services files, hospital websites and news articles, linked to hospital cost reports and county data.

Each hospital was sorted by its 2023 status, including keeping obstetric services, closing its unit but staying open or closing entirely. The team measured 2010 traits, such as distance to the nearest obstetric hospital, annual births, patient census, nurse staffing, ownership, Critical Access Hospital (CAH) status, profitability and county unemployment. Rural and urban hospitals were analyzed separately, with each estimate adjusted for the other factors.

What drove closures

By 2023, 239 rural hospitals (21.2%) had closed their obstetric units and 42 (3.7%) had closed entirely. Among urban hospitals, it was found that 250 (12.6%) closed their units and 92 (4.6%) closed entirely. 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.

Unprofitable rural hospitals had a 30% probability of unit closure, 12 percentage points higher than profitable ones, though unprofitability was not a significant independent factor in rural hospitals closing entirely. Unprofitable urban hospitals had probabilities 4 percentage points higher for unit closure and 7 percentage points higher for hospital closure.

Hospitals near another obstetric hospital—within 30 miles for rural and 10 miles for urban—had unit closure probabilities more than 7 percentage points higher. Compared with government-owned hospitals, rural for-profit hospitals had probabilities 13 percentage points higher for unit closure and 6 percentage points higher for hospital closure.

Some factors played out differently in rural and urban areas. Overall, rural hospitals had a 6-percentage-point higher predicted probability of unit closure and a 3-percentage-point higher probability of hospital closure than urban hospitals. Urban hospitals with fewer than 500 births a year had a 10% probability of closing entirely, rising to 24% for those that were also unprofitable.

In urban areas, for-profit status was 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. CAH status was linked to a 5-percentage-point lower probability of hospital closure in rural areas and a 4-percentage-point lower probability in urban areas, though it was not tied to unit closure.

Many remaining units at risk

Study results also revealed that risks increased when factors overlapped. For example, among the lowest-volume rural hospitals, unprofitable ones had a 47% probability of closing their obstetric unit, compared with 32% for profitable ones. Unprofitable rural for-profit hospitals had a 46% probability of unit closure.

Out of the hospitals that kept obstetric services through 2023, 41% had high-risk traits for future loss. The share of those rural hospitals that were unprofitable rose from 21% in 2010 to 35% in 2023, and 28% of urban hospitals that kept services were unprofitable by 2023. The authors noted that obstetric payment rates are lower than for other clinical services and often do not cover the fixed costs of care.

“While it is not realistic or appropriate to have a hospital in every community or for every hospital to have obstetric services, access to risk-appropriate care is essential to efforts to reduce maternal morbidity and mortality,” the authors wrote.

Limitations and next steps

The study's strengths include its national scope and a validated method for identifying obstetric service status. Results held in sensitivity tests, including one measuring outcomes in 2019, before the COVID-19 pandemic. However, the findings show associations, not proof that any one factor caused a closure. Administrative data can’t capture some drivers, such as leaders who champion keeping services or rural hospitals that operate below financially viable birth volumes because of community need.

Because traits were measured in 2010, the researchers could not adjust for later events such as Medicaid expansion and the pandemic. Some hospital closures may also have followed earlier unit closures, which blurs the line between the two outcomes.

The authors wrote that because risk factors differ by closure type and location, the findings suggest a need for distinct rural and urban policy approaches. They added that financing efforts such as the Transforming Maternal Health Model and the Rural Health Transformation Program could influence future decisions about operating obstetric units.

The CMS Transforming Maternal Health Model, a voluntary 10-year model running from 2025 through 2034, can improve maternal care for women enrolled in Medicaid and the Children's Health Insurance Program in 15 states, each eligible for up to $17 million in cooperative agreement funding. In addition, the Rural Health Transformation Program, created under the One Big Beautiful Bill Act, will allocate $50 billion to approved states over fiscal years 2026 through 2030.

The authors pointed to 915 hospitals that were high risk in 2010 but kept their obstetric services and held steady or lowered their risk by 2023.

“Understanding what these hospitals did to maintain services may be important to developing strategies to ensure access to obstetric care,” they wrote.