When Bonner General Health stopped providing labor and delivery services in 2023, the families of Sandpoint, Idaho, were devastated. Jen Jackson Quintano told me that back in 2014 she had planned on a home birth, but it was not progressing, and her midwife took her to Bonner General, where she had a C-section. It went so well, she became friends with her obstetrician.
If you’re a pregnant woman in Bonner County, in the northern panhandle of the state, your options for receiving prenatal and postpartum care and giving birth are quite limited. If you want to get an ultrasound, you are probably driving nearly an hour to Coeur d’Alene, or over an hour to Spokane, Wash. That’s in good weather. But try navigating a bumpy dirt road and mountain passes, which sometimes close, in an ice storm, while in labor.
As a result, many pregnant women in the area are either opting for planned home births with midwives, or, if it’s possible, they are booking short-term rentals or staying with family near hospitals with obstetric units. If a planned home birth goes sideways, fast, some of these women may end up in Bonner’s emergency room, which no longer has obstetricians nor pediatricians to manage neonatal resuscitations. Some of them are buying helicopter insurance in case they need to be airlifted.
Quintano, who is a progressive activist, gathered birthing stories from other community members when Bonner closed its labor and delivery unit three years ago. Without having Bonner’s obstetric care available, “I likely never would have tried to start a family knowing that all my prenatal appointments were over an hour away,” a woman named Jonell said as part of the collected stories.
The closure of rural labor and delivery units is not just a northern Idaho problem. According to a 2024 report on maternity care deserts from the March of Dimes, “In 1,104 U.S. counties, there is not a single birthing facility or obstetric clinician.” This is also not solely a recent problem, though it will be worsened by cuts to Medicaid by the Trump administration. The federal Rural Health Fund, which seeks to modernize ailing country hospitals, among other improvements, will not offset these cuts by much.
I’d describe it more as a slow-rolling disaster that is picking up speed across the country.
Over 130 rural labor and delivery units have closed since 2020, per the Center for Healthcare Quality and Payment Reform, a nonpartisan policy organization. Women who live in rural areas (that are not adjacent to urban areas) without hospital-based obstetric care are more likely to have preterm births and less likely to receive adequate prenatal care, according to a 2018 investigation published in The Journal of the American Medical Association. They are more likely to give birth in emergency rooms that are not set up for obstetric emergencies.
I have now heard stories from across the country of women giving birth on the side of the road or in their cars because they did not make the long journey to the hospital in time.
The existential pain of losing birth services
As I was reporting this article, I heard from mothers, physicians, nurses, midwives and doulas living in rural areas from Maine to Oregon. They described the same interwoven set of dynamics making it hard to keep rural labor and delivery units open. The first issue is the aging population of rural America, which means fewer babies, and less revenue. Rural hospital administrators say that if a labor and delivery unit drops below 200 births a year, its financial viability is endangered, and it may no longer be able to guarantee the safety of its maternity care.
Maternity care tends to be a financial loser at urban hospitals, too, because insurance reimbursement rates for it are not great. But higher-volume procedures compensate for the losses. And if a city hospital ends labor and delivery services, a prospective patient’s travel time to another hospital tends to be far shorter and less perilous.
Still, when any hospital loses obstetric services, it puts pressure on the closest hospitals. Patients now wait longer to see providers, and I heard anecdotes about women having to give birth in the hallways of hospitals because there was no bed for them.
Richard Leidinger is the medical director of surgical specialists at Northern Light Health in Presque Isle, Maine, part of Aroostook County. Half of the county’s obstetrics departments have closed in the past 10 years. So Leidinger’s hospital, which has one of the two remaining units in a county larger than Connecticut, is seeing women who “have had no prenatal care and arrive in active labor on our doorstep with no warning.”
Keeping staff at rural hospitals is a huge problem in many medical specialties, because doctors and nurses often prefer to be closer to the amenities of more populous areas. Elizabeth Khan, a primary care physician who was formerly based in sparsely populated Mendocino County, Calif., and also gave birth while living there, said that the closest obstetrician to her hospital “was an hour and a half drive through the mountains from us” while some of her patients have to drive four hours to San Francisco, where she now lives, to see a neurologist.
Katy Backes Kozhimannil, a co-director of the Rural Health Research Center at the University of Minnesota, told me that when a community loses its labor and delivery unit, that loss is about so much more than just some medical procedures — it becomes existential. We all have a story of where we were born, she told me.
“What does it mean to live a good life in a place?” Kozhimannil mused. “It feels like there is a deep loss in a community if you can’t be born there — you can only die.”
Cutting red tape, increasing reimbursements
The good news is that there are many common-sense, bipartisan policy solutions to this problem, and there is both state and federal legislation in the works aimed at some of the obstacles to rural woman getting quality care.
“The simplest solution is for health insurance plans (both commercial insurance and Medicaid) to pay adequately for labor and delivery services. ‘Adequately’ means enough to cover the lowest feasible cost of delivering high quality care in that community, not some amount that might be adequate, on average, for large hospitals,” said Harold Miller, the president and chief executive of the Center for Healthcare Quality and Payment Reform. Because there are fewer deliveries at small hospitals, there needs to be a higher payment per delivery to keep them afloat.
Miller also explained that ideally hospitals should be receiving what’s called a standby capacity payment from each health insurance plan, a payment that would “support the minimum fixed costs of maintaining labor and delivery staffing in that community regardless of how many births there are.” After all, he said, we don’t fund fire departments based on how many fires there are every year.
There is a bill sitting in Congress called the Rural Obstetrics Readiness Act that would provide grants to rural hospitals for equipment and emergency obstetric training for physicians. I heard from many family medicine doctors who said that it would be useful to have additional obstetrics training, since they are providing cradle-to-grave care in many hospitals in rural America. This doesn’t fix the problem of keeping staff in rural areas, but it’s something.
Another policy solution, which some states have already taken steps to institute, is unbundling Medicaid payments for prenatal, birth and postpartum care. In many states, Medicaid reimbursement is a one-time payment for everything. In practice this can result in a delay in reimbursement or in hospitals potentially seeing no money at all if someone receives prenatal care from their obstetricians but delivers in another setting. By reimbursing on a fee-for-service plan, small rural hospitals can see more funding for what they are providing.
There also needs to be better reimbursement for and easier access to midwives and doulas, who are providing essential care to rural women. I spoke to Sara Fichtenbauer, who is planning a home birth for her third child in Chippewa Falls, Wis. She told me she is paying $6,000 out of pocket for midwife care, and she isn’t sure she’s going to get reimbursed — she’s still filling out paperwork. California recently passed a law that cut some of the red tape for midwife-run birthing centers to help ease the burden of maternity deserts. This isn’t a cure-all, though, because midwives cannot perform C-sections, and sometimes infants really need a NICU, and fast.
The babies are going to keep coming whether there’s a labor and delivery unit to care for them. There is no shortage of ideas, nor of passion for fixing this problem. The issue is the political will and the slow pace of legislative solutions.
Leidinger, the hospital medical director in Presque Isle, told me that he served at a combat surgical hospital in Iraq, and he also treated patients in rural Guatemala. What he is seeing now in Maine makes him think that we’re headed in the direction of those levels of medical care.
This shouldn’t happen in the richest country in the world, Leidinger said. And I couldn’t agree more.
End Notes
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I didn’t even have space to get into the way abortion bans are part of the rural maternity care story in red states. Jen Jackson Quintano told me that her obstetrician in Idaho was Amelia Huntsberger, who left the state to practice in Oregon. In the wake of the Supreme Court’s Dobbs decision overturning Roe v. Wade, all four of Sandpoint hospital’s obstetricians left because they felt they could no longer safely practice in Idaho, Huntsberger told Oregon Public Broadcasting last year. From August 2022 to December 2024, Idaho lost nearly 35 percent of its obstetricians.
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Foreign physicians are a vital piece of the rural medical work force, and the Trump administration’s travel ban prevented many of them from coming to this country. As of last week, that ban has been reversed for doctors. But foreign physicians who are practicing here have already suffered. According to Miriam Jordan in The Times: “Ezequiel Veliz, a family doctor from Venezuela who fell out of legal status and whose new visa had not been processed, was detained by federal agents on April 6 at a checkpoint in Texas. He was released 10 days later.” I would imagine this kind of thing has a chilling effect on doctors who would have otherwise been excited to come to the United States.
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I’m not usually into romance novels but I decided to try “An Academic Affair” by Jodi McAlister after I saw it recommended in the very fun newsletter “Links I Would Gchat You if We Were Friends.” It is a totally delightful and low-stakes book about two academics jockeying for jobs in a dying industry, with an archetypal enemies-to-lovers plot.
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The post You Can’t Be Born Here. You Can Only Die. appeared first on New York Times.
