MHA e-Briefing: Obstetric Services and Quality Among Critical Access, Rural and Urban Hospitals in Nine States

									Charlie Plain |
																			October 27, 2014

Katy Kozhimannil, PhD, MPA, Assistant Professor
Peiyin Hung, MSPH, HSRP&A PhD student
Maeve McClellan, BS, MPH-PHAP student
Michelle Casey, MS, Deputy Director, Rural Health Research Center
Shailendra Prasad, MBBS, MPH, Associate Pprofessor, Dept. of Family Medicine & Community Health
Ira Moscovice, PhD, Mayo Professor and Director, Upper Midwest Rural Health Research Center


Motivated by concerns about the clo­sure of obstetric units in rural hospi­tals and limited availability of obstet­ric care providers in rural areas, much contemporary research on rural obstetric care has focused on access and workforce issues. Increasingly, health policy is focused on measure­ment and improvement of obstetric care quality in U.S. hospitals, includ­ing an obstetric care patient safety initiative by the National Partnership for Patients. The Joint Commission adopted a new set of perinatal care measures in 2011, and the National Quality Forum endorsed 14 perina­tal measures in 2012. State interest in obstetric care quality measure­ment is growing as the percentage of births covered by Medicaid (cur­rently 47 percent) continues to rise.Despite these trends, questions about the quality of childbirth-related care in different types of hospital settings (e.g., development of maternity care quality measures, reducing primary cesarean rates, and increasing access to vaginal birth after cesarean) have remained unexamined. Under­standing how obstetric care is cur­rently provided in Critical Access Hospitals (CAHs) and other rural hospitals is important for assess­ing the quality of maternity services and quantifying implications for ma­ternal and child health.


The goal of this research was to assess and compare the characteristics and quality of obstetric care in CAHs, other rural hospitals, and their urban counterparts.


The study measured obstetric care quality related to delivery mode, elec­tive procedures, and perinatal safety in CAHs, other rural hospitals, and their urban counterparts using 2010 discharge data from Colorado, Iowa, Kentucky, New York, North Caro­lina, Oregon, Vermont, Washing­ton, and Wisconsin State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. The data set included all births occurring in 623 hospitals in the nine states (N=686,703 births). These hospitals comprise a census of all rural hospitals providing obstetric services in the nine states we studied.

These nine states were chosen based on the size of their rural population, number of rural hospitals (including CAHs) providing obstetric care, U.S. regional distribution, and because they permitted linkage with Ameri­can Hospital Association (AHA) An­nual Survey data on hospital charac­teristics and location.

Outcomes measured were the low-risk cesarean rate (among full term, vertex, singleton pregnancies with no prior cesarean deliveries), labor in­duction without medical indication, cesarean delivery without medical in­dication, episiotomy, and 3rd- or 4th-degree perianal laceration. Medical indications used in the calculation of non-indicated induction and cesarean delivery outcomes were defined based on the Joint Commission National Quality Measure, “Perinatal Care Measure PC-01: Elective Delivery.”

Key findings

The major results of the study include the following:

  • Women who gave birth in CAHs and other rural hospitals in 2010 were younger on average and had lower rates of clinical complications than those who gave birth in urban hospitals.
  • CAHs compared favorably with other rural and urban hospitals on obstetric care quality measures including cesarean delivery among low-risk women, those who had cesarean deliveries without medical indication, and those whose labor was induced with medical indication.
  • Medicaid covered 49 percent of births in CAHs and 56 percent of births in other rural hospitals, compared to 41 percent of births in urban hospitals.
  • The percentages of CAHs, other rural hospitals, and urban hospitals providing obstetric services in 2010 varied significantly across states, with the greatest variation among CAHs.
  • Half of the CAHs in this study’s sample provided obstetric services in 2010, likely a higher rate than all CAHs nationwide due to the selection criteria for the sample.

Policy implications

This analysis revealed that obstetric care quality in CAHs and other ru­ral hospitals compares favorably with urban hospitals. This finding is im­portant in the context of decreases in the number of rural hospitals that are providing obstetric services, and implies that the CAHs that have cho­sen to keep an obstetric service line within their hospital are providing care that is, on average, largely con­sistent with or better than the care provided in other rural and urban hospitals. At the same time, obstetric care quality in all hospitals requires improvement to be consistent with professional recommendations and clinical guidelines.

Our analysis reveals that payer mix differs across hospital settings, with Medicaid financing a greater percent­age of births in CAHs and other ru­ral hospitals, compared with urban hospitals. This has important impli­cations as Medicaid adopts strategies designed to improve maternity care, which may not account for differ­ences in the rural hospital context. It is also important to the financial sol­vency of rural hospitals, as Medicaid pays less for childbirth-related ser­vices than private insurers. Rural hos­pital administrators often cite payer mix as a financial concern regarding the provision of obstetric care, but if payment systems can reward high-quality care, CAHs may benefit from the type of childbirth-related care they are currently providing, espe­cially with respect to management of cesarean deliveries and episiotomies.


(Note: More information on this topic is available online at and in Kozhimannil K, Hung, Prasad S, Casey M, McClellan M, Moscovice S. Birth Volume and the Quality of Obstetric Care in Rural Hospitals. Journal of Rural Health 30(2014)335-343. doi: 10.1111/jrh.12061.)

~Post by Mona Rath

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