55% of Rural Orgs Lack Labor & Delivery, Cause Maternity Deserts

January 24, 2024 - Maternity deserts are a growing problem in the United States, especially for rural hospitals that have to shutter labor and delivery departments at higher rates than their urban counterparts, according to a new report from the Center for Healthcare Quality & Payment Reform (CHQPR).

The report, which began by outlining the maternity desert problem in the US, contended that rural healthcare’s staffing and reimbursement models need rethinking in order to sustain patient access to maternity care.

Right now, 55 percent of rural hospitals in the US do not offer labor and delivery services, and in ten states, more than two-thirds of rural hospitals do not offer labor and delivery services, CHQPR reported.

In the past ten years, more than 200 rural hospitals have shuttered their labor and delivery services.

This is creating a care access problem, the report authors said. With fewer hospitals offering labor and delivery services, patients are left facing greater travel distances to access care. As data has shown, the longer the travel distance, the less likely a patient can safely access timely healthcare.

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In urban areas, the travel time to a hospital with labor and delivery services is typically 20 minutes or less, CHQPR noted. In rural communities, the typical travel time is between 30 and 40 minutes, and it can often be greater than 40 minutes.

This is also a problem before a pregnant person needs labor and delivery services. Longer travel distances to prenatal care can have consequences for infant and maternal health outcomes.

“There is a higher risk of complications and death for both mothers and babies in communities that do not have local maternity care services,” CHQPR wrote. “Women are less likely to obtain adequate prenatal and postpartum care when it is not available locally.”

This problem is only slated to get worse, the report continued, largely because labor and delivery, as well as other types of maternity care, are expensive to keep open.

“Safe, high-quality maternity care requires having physicians and nurses available on a 24/7 basis, and rural hospitals are experiencing dramatically higher costs to maintain adequate staffing,” CHQPR explained. “Payments from many private insurance and Medicaid plans are not adequate to cover these costs, so hospital losses on these services are increasing.”

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Many rural hospitals can’t keep labor and delivery departments open because they are losing money on other kinds of patient care. A third of the rural hospitals that still have labor and delivery have been losing money on overall patient services, which jeopardizes their ability to keep their maternity care departments open.

This is a greater risk in smaller rural communities, the report added. More than half of small rural maternity care hospitals lost money on patient services overall in 2022.

The solutions to the nation’s maternity desert problems are twofold: supporting a rural workforce and designing adequate payment models.

Foremost, the US needs to create training designed for rural maternity care, including tailored clinician recruitment in rural areas. The existing rural workforce can be supported by remote consults from maternal-fetal specialists and experienced OB nurses, CHQPR advised, as well as staffing models that promote a more sustainable on-call model.

In terms of adequate payment models, CHQPR started by asserting a need for bigger payments for maternity care as a whole. In small, rural hospitals, maternity patient volumes are smaller, but the resources needed to meet patient demand remain static due to the unpredictability of patient visits. In turn, reimbursements need to be bigger to sustain staffing levels.

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Employers need to start by requiring that their health insurance plans demonstrate that they pay enough to cover the cost of maternity care services. States should also require Medicaid plans to pay enough to cover maternity care services.

But it’s not just reimbursement for maternity care that needs rethinking, CHQPR added. Part of the issue is that rural hospitals do not make enough from other patient services to cover the costs of labor and delivery departments; in fact, many lose money on other patient services.

This problem is most pronounced when looking at reimbursements from private payers. The report authors asserted that employers in rural areas should only select payers that reimburse adequately for all hospital services.

Finally, CHQPR introduced the idea of capacity payments.

Right now, rural hospitals only get paid when they actually provide a service. Capacity payments may help rural hospitals be prepared to provide the service.

“A small hospital must be staffed and ready to deliver a baby at all times, even though there will be no deliveries at all on many days,” CHQPR wrote in the report. “As a result, when there are fewer pregnancies than expected, the hospital will lose money, even if payments would have been adequate for a larger number of births.”

Capacity payments from private insurers and Medicaid issued on an annual basis would allow rural hospitals to have predictable revenue for the fixed costs of having a labor and delivery department.

“It is not an exaggeration to say that rural maternity care is in a state of crisis, and a crisis demands immediate action,” the report authors concluded. “Every day that steps are not taken to implement the changes in workforce recruitment and payments described above increases the likelihood that more women and babies will die unnecessarily.”