Rural Hospital Administrators’ Beliefs About Safety, Financial Viability, and Community Need for Offering Obstetric Care

IMPORTANCE: Rural obstetric unit closures are associated with adverse maternal and infant health outcomes and are most common among low–birth volume facilities located in remote areas. Declining access to obstetric care is a concern in rural communities in the US. OBJECTIVE: To assess rural hospital administrators’ beliefs about safety, financial viability, and community need for offering obstetric care. DESIGN, SETTING, AND PARTICIPANTS: Using the American Hospital Association Annual Survey to identify rural hospitals with obstetric units, we developed and conducted a national survey of a sample of rural hospitals that provided obstetric services in 2021. Obstetric unit managers or administrators at 292 rural hospitals providing obstetric services were surveyed from March to August 2021. EXPOSURES: Local factors, clinical safety, workforce, and financial considerations for obstetric services at participating hospitals. MAIN OUTCOMES AND MEASURES: Hospital-level decisions on maintaining obstetric care. RESULTS: Of the 93 total responding hospitals (32% response rate), 33 (35.5%) were critical access hospitals, 60 (64.5%) were located in micropolitan rural counties; they had a median (IQR) average daily census of 22 (10-53) patients, and 48 (52.2%) had experienced a recent decline in births, with a median (IQR) of 274 (120-446) births in 2019. Respondents reported that the minimum number of annual births needed to safely provide obstetric care was 200 (IQR, 100-350). From a financial perspective, the minimum number of annual births needed was also 200 (IQR, 120-360). When making decisions about maintaining obstetric care, 51 (64.6%) responding hospitals listed their highest priority as meeting local community needs, 13 (16.5%) listed financial considerations, and 10 (12.7%) listed staffing. Overall, 23 (25%) responding hospitals were not sure they would continue providing obstetrics, or they expected to stop offering this service. CONCLUSIONS AND RELEVANCE: In this survey of US rural hospitals that offer obstetric services, many administrators indicated prioritizing local community needs for obstetric care over concerns about financial viability and staffing.