Availability of Hospital-Based Childbirth Services and Higher-Level Neonatal Care in Rural and Urban US Counties, 2010-2023.

BACKGROUND: Availability of childbirth services is declining nationally, especially in rural communities, where risks of maternal and infant mortality are elevated. OBJECTIVE: The study aims to describe the availability of hospital-based childbirth services and higher-level neonatal care in rural and urban US counties from 2010 to 2023 and to examine trends in availability. METHODS: Survey, administrative data, and primary sources were used to identify childbirth services (obstetric and basic well-infant services) and higher-level neonatal care (intermediate or intensive care) at short-term acute care hospitals in rural (n=1958) and urban (n=1186) US counties. For each year (2010-2023), counties were categorized into 3 mutually exclusive service categories: having (1) no childbirth services, (2) only childbirth services, or (3) both childbirth services and higher-level neonatal care. We estimated predicted percentages of rural and urban births occurring to residents of counties by service category using multinomial logistic regression models. RESULTS: The predicted percent of urban births occurring to residents of counties with both childbirth services and higher-level neonatal care increased from 87.0% in 2010 to 88.6% in 2023 (P=0.007), while this percent remained statistically stable among rural counties at 17.0% in 2010 and 16.6% in 2023 (P=0.762). In 2023, 83.4% of rural births occurred to residents of counties without higher-level neonatal care, compared with 11.4% of urban births. CONCLUSIONS: In 2023, 88.6% of urban births occurred to residents of counties with both childbirth services and higher-level neonatal care, compared with 16.6% of rural births. From 2010 to 2023, rural-urban differences in the availability of specialized care for high-risk infants widened.