In recent decades, hundreds of obstetric units at hospitals across the United States have closed, forcing mothers in many rural and vulnerable communities to travel significantly farther for care during pregnancy and for delivery. Over the same period, rates of infant mortality in rural counties have gotten worse compared to urban counties, leading many to worry that the two trends are directly connected.

In a paper in the American Economic Journal: Applied Economics, authors Stefanie Fischer, Heather Royer, and Corey White show that hospital-based obstetric unit closures had little to no impact on maternal and infant health outcomes, but they did lead women to deliver in higher-quality hospitals.

The findings come from analyzing the National Vital Statistics System’s natality and mortality files between 1989 and 2019. Using a difference-in-differences research design, the authors compared health outcomes and delivery hospital quality in counties that had an obstetric unit closure to those that didn’t, before and after a closure event.

Panels A and B of figure 8 from the authors’ paper shows what happened to the quality of hospitals where women gave birth.

Panels A and B of figure 8 from Fischer et al. (2024)

In the chart, the black series and the red series represent average estimates based on a two-way fixed effects estimator (TWFE) and de Chaisemartin and D’Haultfoeuille difference-in-differences estimator (dCDH), respectively. The vertical bars are 95 percent confidence intervals.

Panel A shows the change in the z-score—the number of standard deviations from the average—of a composite measure of hospital quality. It shows that closures led women to give birth in counties with quality scores 0.1 standard deviations higher than their counterparts. Panel B shows the change in the share of births that occurred in counties with a neonatal intensive care unit (NICU)—an indicator of a hospital's obstetric resources. The chart shows that mothers in counties that experienced a closure were 4 percentage points more likely to give birth in a county with a NICU. 

Looking at several measures of maternal or infant health, the authors found no indication that the health of mothers and newborns had deteriorated because of closures. In fact, the evidence suggests that maternal health outcomes may have improved slightly. Overall, the findings indicate that many mothers—especially in rural communities—must travel farther for care, but they appear to be receiving better care than they otherwise would have.