Heart of America Medical Center in rural Rugby, N.D., shuttered its obstetrics program about 10 years ago. Patrick Branco, who came on board as CEO in 2015, is determined to resuscitate the program.

“Obstetrics is needed in this community because we are gaining a much younger, childbearing-age population,” Branco says. “It is a critical piece of health care that is unserved in my community, and I can't live with that.”

The plight facing Heart of America has affected rural hospitals throughout the United States. According to an April 2017 policy brief titled “Closure of Hospital Obstetric Services Disproportionately Affects Less-Populated Rural Counties,” issued by the University of Minnesota Rural Health Research Center, 179 rural counties lost access to in-county hospital obstetric services between 2004 and 2014.

The policy brief highlights difficulties in staffing obstetric units and financial concerns among the challenges facing rural hospital obstetric care.

Peiyin Hung, a researcher and doctoral candidate who co-wrote the policy brief, recalls the case of a rural Minnesota woman who went into labor two days before her due date. Unable to reach a hospital with an obstetric unit 2 1/2 hours away, the woman gave birth in an ordinary patient room at her local hospital.

The mother and baby came through the experience in good health, but Hung says the incident demonstrates the hurdles faced by rural women who cannot obtain OB care at their local hospitals.

“Hospitals cut obstetrical care first when they face financial difficulties,” Hung says, “but doing so creates a health risk for local families.”

Rural hospital obstetric programs frequently fall prey to low patient volume, which leads to higher malpractice insurance rates. Such a predicament nearly killed the OB program at St. Mary's Clearwater Valley Hospitals and Clinics in Idaho when Branco was the CEO there in 2013.

In response, Branco says that he convinced the state of Idaho to launch a computer simulation mannequin program. Using the mannequin enabled his staff to perform more than 40 simulated deliveries in three days, which prompted the hospital's insurer to hold the line on premiums

Branco now wants to obtain a computer simulation mannequin to help re-establish OB competency at Heart of America Medical Center. He also is recruiting a couple of family medicine doctors who have expressed interest in providing OB care.

Branco says he will begin recruiting certified nurse midwives once he has at least one family medicine doctor signed up. He hopes to restore OB care by next summer.

“It's a journey of the heart,” Branco says. “There's an economic element, but it isn't my primary motivator. It's to give a full-service benefit to this rural community.”

Hung says one solution to the difficulties facing rural obstetric care could be regionalized perinatal care. “That kind of systematic approach should involve transportation and information exchange, so that women can have continuity of care throughout their time of pregnancy,” she says.

The American Hospital Association strongly advocates on behalf of obstetric care for rural areas. In a Nov. 29, 2016, report, the AHA's Task Force on Ensuring Access in Vulnerable Communities cited prenatal care and primary care as essential health care services.

“When you combine primary with prenatal, you get issues that are going to circulate around women's health services and obstetrics,” says John Supplitt, senior director of the AHA's Section for Small or Rural Hospitals. “As an association, we want to find strategies that will help vulnerable populations access these essential health care services.”

Supplitt says the health care barriers facing rural communities should be looked at from a holistic standpoint and should address issues like transportation.

“If one doesn't have access to transportation, then 60 minutes might as well be 90 minutes or four hours,” he says. “If you can't get there from here, it's not going to do much good to have the service available 60 minutes away.”

In addition, Supplitt notes that rural Americans are less likely to be insured and more likely to depend on Medicaid than Americans who live in non-rural areas. As such, he says the American Health Care Act passed by the U.S. House of Representatives threatens to further undermine rural health care.

“I don't know that our lawmakers fully understand the repercussions of these decisions to rural America and vulnerable communities and moms and babies,” Supplitt says. “But the reality is if you cut Medicaid, if you eliminate Medicaid expansion in rural states, there will be less access and the problems will only become bigger.”