Timely access to care, including cesarean delivery, is critical for optimizing obstetric and neonatal outcomes. The Lancet Commission on Global Surgery defines access to timely essential surgery as the population proportion living within 2 hours of a facility that performs cesarean delivery, laparotomy, and open fracture repair.1 Although the American College of Obstetricians and Gynecologists (ACOG) proposes a 30-minute capability for within-hospital decision-to-incision time for emergency cesarean delivery,2 no benchmark exists for timely access to a facility for obstetric care. Studies measuring access to obstetric and perinatal care in the United States have used a 30- and 60-minute drive time based on thresholds used in trauma, burns, and stroke3 or a 50-mile driving distance based on the furthest distance most people are willing to travel for specialized care.4 Recent closures of rural obstetric units in the United States and rising numbers of high-risk pregnancies have raised concerns about access to intrapartum care.5,6 These concerns, along with disparities in care, have led to the standardization of a regionalized system of perinatal care and emphasize the need to establish benchmarks for timely access.7 The objectives of this study are to map and compare U.S. travel times to obstetric and neonatal intensive care using the global 2-hour benchmark for access to emergency surgery and a 30-minute benchmark for access to emergency cesarean delivery.
The 2016 American Hospital Association Annual Survey8 was used to identify facilities providing obstetric care. The American Hospital Association defines levels of care as follows:
- Level 1: services for uncomplicated maternity and newborn cases
- Level 2: services for most complicated cases and special neonatal services (resuscitation and intravenous and oxygen therapy)
- Level 3: services for all serious illnesses and abnormalities, with full-time supervision by a maternal–fetal medicine specialist.
Facilities that provide neonatal intensive care unit (NICU) care were also identified, because there is evidence that discordance between access to obstetric and neonatal care may affect the delivery of appropriate care for both women and neonates.4 We used Redivis to geospatially estimate road travel time to access the nearest facility that provides obstetric and NICU care based on road network information from OpenStreetMap and population estimates from WorldPop,9 using the same methodology used to measure global access to surgical care.10–12
In 2016, 2,399 facilities provided obstetric care, including 930 level 1, 836 level 2, 577 level 3, and 479 level 3 with NICU; 56 obstetric hospitals lacked American Hospital Association designation and were excluded. Nearly all (99.6%) of the U.S. population resided within 2 hours of any facility that provides obstetric care, 88.4% resided within 2 hours of a level 3 facility, and 87.5% resided within 2 hours of level 3 facility with NICU (Table 1). Only 61.6% of the population had 30-minute access to any obstetric care, 23.4% had 30-minute access to a level 3 facility, and only 20.7% had 30-minute access to a level 3 facility with NICU (Fig. 1).