Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one?



To quantify drive distances to hospital obstetric services and advanced neonatal care and to examine such disparities by residential rurality and insurance type.

Study design

Data for all-payer maternal childbirth hospitalizations in 2002 (N = 661,240) and 2013 (N = 634,807) from nine geographically dispersed states were linked with the American Hospital Association annual surveys to identify maternal residence zip codes and the addresses of hospitals with obstetric services or advanced neonatal care.


The uneven geographic distribution of hospital obstetric and advanced neonatal care increased between 2002 and 2013, varying by maternal residential rurality and insurance type. Women in rural non-core areas, with Medicaid or no insurance, and living in counties with lower income and educational attainment, had to travel farther to the nearest hospital with obstetric services or neonatal care than their counterparts.


Women in communities that are already socioeconomically disadvantaged face increasing and substantial travel distances to access perinatal care.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1
Fig. 2


  1. 1.

    Rayburn WF, Richards ME, Elwell EC. Drive times to hospitals with perinatal care in the United States. Obstet Gynecol. 2012;119:611–6.

    Article  PubMed  Google Scholar 

  2. 2.

    Cook NL, Hicks LS, O’Malley AJ, Keegan T, Guadagnoli E, Landon BE. Access to specialty care and medical services in community health centers. Health Aff. 2007;26:1459–68.

    Article  Google Scholar 

  3. 3.

    Kozhimannil KB, Hung P, Casey MM, Lorch SA. Factors associated with high-risk rural women giving birth in non-NICU hospital settings. J Perinatol. 2016;36:510–5.

    Article  PubMed  CAS  Google Scholar 

  4. 4.

    Attar MA, Hanrahan K, Lang SW, Gates MR, Bratton SL. Pregnant mothers out of the perinatal regionalization’s reach. J Perinatol. 2006;26:210–14.

    Article  PubMed  CAS  Google Scholar 

  5. 5.

    Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38:976–93.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Serv Res. 2011;11:147–54.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Clark EAS, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol. 2011;205(6 Suppl):S2–10.

    Article  PubMed  Google Scholar 

  8. 8.

    Vollers AC. Many Alabama women drive 50+ miles to deliver their babies as more hospitals shutter L&D departments. Alabama Media Group. 01 Feb 2016; Available at

  9. 9.

    Kozhimannil KB, Hung P, Prasad S, Casey M, Moscovice I. Rural-urban differences in obstetric care, 2002-10, and implications for the future. Med Care. 2014;52:4–9.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    American Hospital Association. Table 2.1: Number of community hospitals, 1992-2013. Trendwatch Chartbook 2014. American Hospital Association: Chicago, IL.

  11. 11.

    Office of Management and Budget. Revised Delineations of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, and Guidance on Uses of the Delineations of These Areas [data online]. OMB Bulletin No. 15-01. United States Department of Agriculture Economic Research Service: Washington, DC; 2015. Available at Accessed 25 March 2017.

  12. 12.

    Zdeb M. The Basics of Map Creation with SAS/GRAPH® [web site]. SAS Institute Inc., Rensselaer, NY; 2004. Available at

  13. 13.

    Hung P, Kozhimannil KB, Casey MM, Moscovice IS. Why are obstetric units in rural hospitals closing their doors? Health Serv Res. 2016;51:1546–60.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    U.S. Census Bureau. Health Insurance Coverage Status by Sex by Age by Geographic Areas among Civilians in All Metropolitan and Micropolitan Statistical Areas within United States. 2010 American Community Survey 1-Year Estimates. 2014 [cited 17 December 2017]. p. B27001. Available at

  15. 15.

    Kozhimannil KB, Thao V, Hung P, Tilden E, Caughey AB, Snowden JM. Association between hospital birth volume and maternal morbidity among low-risk pregnancies in rural, urban, and teaching hospitals in the United States. Am J Perinatol. 2016;33:590–9.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg. 2010;110:1368–73.

    Article  PubMed  Google Scholar 

  17. 17.

    Powers BW, Rinefort S, Jain SH. Nonemergency medical transportation: delivering care in the era of Lyft and Uber. JAMA. 2016;316:921–22.

    Article  PubMed  Google Scholar 

  18. 18.

    Cohen D, Coco A. Declining trends in the provision of prenatal care visits by family physicians. Ann Fam Med. 2009;7:128–33.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Women’s Health USA 2013. Department of Health and Human Services: Rockville, Maryland; 2013.

  20. 20.

    Pathman DE, Goldberg L, Konrad TR, Morgan JC. State repayment programs for health care education loans. JAMA. 2013;310:1982–84.

    Article  PubMed  CAS  Google Scholar 

  21. 21.

    Pathman DE, Konrad TR. Growth and changes in the National Health Service Corps (NHSC) workforce with the American Recovery and Reinvestment Act. J Am Board Fam Med. 2012;25:723–33.

    Article  PubMed  Google Scholar 

  22. 22.

    Fryer GE, McCann JL, Dodoo MS, Green LA, Miyoshi T, Phillips RL. Access, health, and wealth: the impact of the National Health Service Corps in rural America, 1970-2000. Robert Graham Center: Washington, DC; 2006.

  23. 23.

    Dunne T, Klimek SD, Roberts MJ, Xu DY. Entry, exit, and the determinants of market structure. Rand J Econ. 2013;44:462–87.

    Article  Google Scholar 

  24. 24.

    Noble A. Insurance carriers and access to healthcare providers: network adequacy [web site]. National Conference of State Legislatures. 2015. Available at Accessed 27 August 2017.

  25. 25.

    Association of State and Territorial Health Officials. Fact Sheet: Perinatal Regionalization [web site]. Arlington, VA; 2014. Available from: Accessed 27 August 2017.

Download references


The authors wish to acknowledge the State Inpatient Databases, Healthcare Cost, and Utilization Project, Agency for Healthcare Research and Quality; the University of Minnesota Rural Health Research Center for data assistance.

Author information



Corresponding author

Correspondence to Peiyin Hung.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

This work was presented at the 2017 AcademyHealth Interest Groups Meeting in New Orleans, LA

Electronic supplementary material


Supplementary Table 1. Distribution of Driving Distance to Nearest Hospital Providing Obstetric Care by Maternal Characteristics in 2002 and 2013 (N=1,296,047 Women)


Supplementary Table 2. Distribution of Driving Distance to Nearest Hospital with Neonatal Intensive/Intermediate Care Capacity by Maternal Characteristics in 2002 and 2013 (N=1,296,047 Women)


Supplementary Table 3. Adjusted Marginal Effects of Residential Proximity to Nearest Hospitals Providing Obstetric Services or Advanced Neonatal Care >30 Miles Drive


Supplementary Table 4. Adjusted Marginal Effects of Residential Proximity to Nearest Hospitals Providing Obstetric Services>30 Miles Drive by Mode of Delivery

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hung, P., Casey, M.M., Kozhimannil, K.B. et al. Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one?. J Perinatol 38, 645–652 (2018).

Download citation

Further reading


Quick links