Low Birth Volumes and Finances Drive Hospital Obstetric Closures, Study Finds

Across the United States, the number of hospitals offering childbirth services has been shrinking for years, and the pace of that contraction has raised alarms among clinicians, policymakers and expectant parents alike. A new study published in JAMA Health Forum offers one of the most detailed looks yet at why hospitals abandon obstetric care, identifying the specific financial, operational and geographic characteristics that make some facilities far more likely than others to stop delivering babies. The research, led by corresponding author Julia D. Interrante, PhD, MPH, of the Division of Health Policy and Management at the University of Minnesota, finds that lower birth volume, unprofitability, proximity to another obstetric hospital and for-profit ownership status were all associated with the loss of obstetric services. Crucially, the weight of each risk factor differed depending on whether a hospital closed its obstetric unit alone or shut down entirely, and whether the facility was located in a rural or an urban community.

The study’s central conclusion is stark: many hospitals that still maintained obstetric services as of 2023 may be at high risk of losing them in the near future. That projection matters because obstetric care is not a discretionary service. When a hospital stops delivering babies, pregnant patients must travel farther for prenatal visits, labor and delivery, and emergency obstetric interventions, and the consequences of delayed care can be severe. Researchers have long documented that rural communities experience the sharpest effects, with longer travel distances linked to worse outcomes for both mothers and infants. But the new analysis makes clear that urban hospitals are not immune, and that the forces eroding obstetric access operate differently in different settings.

Birth volume emerged as one of the most consequential predictors of obstetric loss. Hospitals that deliver relatively few babies each year face a structural dilemma: maintaining a round-the-clock obstetric team, including physicians, nurses, anesthesiology coverage and surgical capacity for cesarean sections, is expensive regardless of how many patients walk through the door. When deliveries are infrequent, the fixed costs of staffing a labor and delivery unit are spread across fewer cases, driving up the per-birth cost and making the service difficult to sustain. Low-volume units also raise clinical concerns, because clinicians who rarely manage obstetric emergencies may have fewer opportunities to maintain the skills and team coordination that safe childbirth care demands. The study’s finding that lower volume was associated with subsequent obstetric loss fits this economic and clinical logic, and it suggests a self-reinforcing cycle in which declining births push hospitals toward closure, which in turn pushes patients to travel elsewhere, further reducing local volume.

Financial performance was a second major thread in the analysis. Hospitals whose obstetric services were unprofitable were more likely to lose them, a result that underscores the uncomfortable reality that childbirth care often operates on thin or negative margins. Obstetric units generate costs that are not always matched by reimbursement, particularly for facilities serving large shares of patients covered by Medicaid, which typically pays less than private insurance. Payers and administrators frequently describe obstetric care as a loss leader, a service a hospital absorbs because it draws patients and families into its system, or because community need demands it. When overall hospital finances deteriorate, or when ownership priorities shift toward profitability, obstetric services become vulnerable. The finding that unprofitability predicted obstetric loss provides quantitative support for what hospital administrators have long said anecdotally: money, or the lack of it, sits at the heart of many closure decisions.

Geography played a subtler but equally important role. Hospitals located near another hospital offering obstetric care were more likely to lose their own obstetric services. This proximity effect can be read in two ways. From a system-planning perspective, a nearby alternative may make closure seem tolerable, because patients have somewhere else to go, and administrators or health systems may consolidate services to concentrate volume and expertise at one site. From a patient’s perspective, however, even a seemingly short distance can become a meaningful barrier, particularly for people without reliable transportation, for those who go into labor unexpectedly, or for those in areas where weather, road conditions or traffic can turn a short drive into a long one. The study’s attention to proximity highlights that closure decisions are shaped not only by what happens inside a hospital but by the competitive and geographic landscape surrounding it.

Ownership status also mattered. For-profit hospitals were more likely to experience obstetric loss than their not-for-profit counterparts. This association is consistent with a broader body of health services research showing that for-profit facilities face stronger pressure to eliminate services that do not generate returns for shareholders or owners. Childbirth care, with its unpredictable timing, high staffing requirements and frequent reliance on public insurance, fits poorly with that pressure. The finding does not mean that every for-profit hospital will abandon obstetrics, but it flags ownership as a structural risk factor that policymakers and regulators can observe in advance, potentially allowing earlier intervention in communities where access is threatened.

One of the study’s most valuable contributions is its recognition that obstetric loss is not a single phenomenon. The researchers distinguished between hospitals that closed their obstetric units while remaining open for other services and hospitals that shut down entirely, and they found that the importance of specific risk factors varied by type of loss. A hospital that closes its obstetric unit but continues operating is making a service-line decision, often driven by the economics of the obstetric service itself. A hospital that closes entirely removes all inpatient care from a community, and obstetric services disappear as part of a broader collapse. The predictors of these two outcomes are not identical, and treating them as interchangeable risks obscuring the different policy responses each requires. Similarly, the analysis found that risk factors operated differently in rural and urban hospitals, reinforcing that a one-size-fits-all approach to sustaining obstetric care is unlikely to succeed.

The rural-urban distinction deserves particular emphasis. Rural hospitals have faced a well-documented wave of closures and service reductions, driven by low patient volumes, chronic financial strain, workforce shortages and payer mix. In rural areas, the loss of obstetric care often means that the nearest delivery hospital is dozens of miles away, and some counties are left with no local obstetric services at all. Urban hospitals, by contrast, may close obstetric units in the context of dense hospital markets, where consolidation and competition shape service lines, and where patients can usually reach alternative facilities more easily. Yet even in urban settings, closure can concentrate burdens on specific neighborhoods, often those with higher poverty rates and historically limited access to care. By analyzing rural and urban hospitals separately, the study provides a more granular map of vulnerability than earlier work that lumped all closures together.

The policy implications of the findings are significant. If lower birth volume, unprofitability, proximity to alternatives and for-profit status reliably signal elevated risk, then regulators, state health departments and health systems can use these characteristics to identify hospitals that may be approaching an obstetric closure decision, potentially before it happens. Early identification opens the door to interventions ranging from payment reforms that better compensate low-volume obstetric care, to regionalization strategies that pair smaller units with larger referral centers, to workforce programs that ease staffing burdens. The study also suggests that closure decisions should not be evaluated solely on hospital-level finances, since the community consequences of losing childbirth services, including longer travel times and potentially worse maternal and neonatal outcomes, extend well beyond the balance sheet of the facility making the decision.

For the many hospitals that still deliver babies, the study’s warning about future risk lands at a moment when maternal health outcomes in the United States remain a source of national concern and when access to timely obstetric care is increasingly recognized as a determinant of those outcomes. The research by Interrante and colleagues does not predict which specific hospitals will close their doors or their delivery units, but it identifies the characteristics that place facilities on a higher-risk path and shows how those characteristics differ across settings and types of loss. As health systems, insurers and policymakers weigh how to preserve childbirth access in vulnerable communities, the study offers a data-driven starting point: pay attention to volume, margins, geography and ownership, because those are the factors most closely tied to whether a community’s next baby is born nearby or hours away.

Subject of Research: Risk factors associated with the loss of hospital-based obstetric care in rural and urban U.S. hospitals

Article Title: Risk factors for loss of hospital-based obstetric care in rural and urban hospitals

Article References: Risk factors for loss of hospital-based obstetric care in rural and urban hospitals. (n.d.). Original publication

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Keywords: obstetric care, hospital closures, rural health, birth volume, hospital finances, for-profit hospitals, maternal health, health policy, JAMA Health Forum, healthcare access, rural hospitals, urban hospitals