If you’re pregnant near Sandpoint, Idaho, the nearest labor and delivery unit is 50 minutes away. In Laurium, Michigan, it’s about two hours. From Glennallen, Alaska, expect to drive at least three hours.
Having a baby at a hospital isn’t a given in much of rural America. Access to hospital-based obstetric care has declined in recent years, with many hospitals closing their maternity wards to save money or shutting down altogether. Hospitals are increasingly under stress with dwindling federal funding, aging facilities, and high healthcare costs.
For infants and pregnant patients, the consequences can be devastating.
“In places that have lost their obstetric units, there’s higher rates of pre-term births and more out-of-hospital births,” said Julia Interrante, researcher and statistical lead at the University of Minnesota Rural Health Research Center. “Sometimes those are planned home births, but a lot of those are births that are happening on the side of the road as people are trying to get to the hospital where they had planned to deliver.”
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Over 500 hospitals have dropped labor and delivery services in the last 10 years
Researchers at the University of Minnesota have monitored hospital-based obstetric access across the US since 2010, and their newly published report shows that 60% of rural counties offered no labor and delivery services in 2023. That’s compared to 38% in urban counties.
States like Kentucky, South Dakota, Florida, and Iowa have been hit hardest. In North Dakota, 79% of counties — most of which are rural— have no hospital care for pregnant patients.
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Counties without obstetric units may or may not have a local hospital. Data from The University of North Carolina at Chapel Hill show that 110 of America’s rural hospitals have closed since 2010, and another 85 have been downsized from full hospitals to outpatient-only centers, such as nursing homes or rehab facilities. One estimate shows that nearly 800 more rural hospitals are currently at risk of closure due to financial challenges.
For hospitals looking to balance a tight budget, closing the obstetric unit is a common solution. Over 500 hospitals closed their labor and delivery departments in the last decade, with more than half of them rural.
“There are really high fixed costs to providing obstetric services,” Interrante said, adding that hospitals need to cover expensive labor and delivery malpractice insurance, operating room fees, and a 24/7 staff. “If you are a smaller rural hospital that has fewer births, the revenue coming in doesn’t cover those fixed costs.”
It leaves thousands of pregnant people far away from gestational ultrasounds, check-ups, and trained doctors. Infant mortality rates are notably higher in rural areas, and pregnant residents are more likely to be admitted to the intensive care unit or face fatal birth complications.
Emergency rooms aren’t a strong substitute. ERs are facing similar closure trends, and Interrante said most emergency providers aren’t equipped with the training and resources needed to treat complex obstetric cases, even when they are nearby.
Urban healthcare faces similar hurdles: More urban hospitals closed than opened between 2019 to 2023. A handful of rural counties have increased their obstetric care levels in recent years, though this pales in comparison to the number of closures.
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