Maternity units are closing across America, forcing expectant mothers to hit the road
By Amanda Musa and John Bonifield, CNN
In picturesque Bonner County, Idaho, Leandra Wright, 40, is pregnant with her seventh child.
Wright is due in August, but three weeks ago, the hospital where she had planned to deliver, Bonner General Health, announced that it would be suspending its labor and delivery services in May.
Now, she’s facing a potentially precarious drive to another hospital 45 minutes from her home.
“It’s frustrating and worrisome,” Wright said.
Wright has a history of fast labors. Her 15-year-old son, Noah, was born on the way to the hospital.
“My fifth child was born on the side of the highway,” Wright said. “It was wintertime, and my hospital at the time in California was about 40 minutes away, and the roads were icy, so we didn’t make it in time.”
By the time she and Noah got to the hospital, about 15 minutes after he was born, his body temperature was lower than normal.
“It worries me not to have a doctor there and worries me to have to go through that,” Wright said.
Residents of Bonner County aren’t the only ones dealing with unexpected maternity unit closures.
Since 2011, 217 hospitals in the United States have closed their labor and delivery departments, according to a report by the health care consulting firm Chartis.
A CNN tally shows that at least 13 such closures have been announced in the past year alone.
Closures nationwide
Services provided at maternity units vary from hospital to hospital. Most offer obstetrics care in which an obstetrician will deliver a baby, either vaginally or via cesarean section. These units also provide perinatal care, which is medical and supportive care before and after delivery.
Other services provided may include lactation specialists and private delivery rooms.
After May 19, Bonner General Health will no longer offer obstetrical services, meaning there will be zero obstetricians practicing there. Consequently, the hospital will no longer deliver babies. Additionally, the unit will no longer provide 24-hour anesthesia support or post-resuscitation or pre-transportation stabilization care for critically ill newborns.
Some hospitals that have recently closed their maternity units still offer perinatal care, along with routine gynecological care.
Bonner General is planning to establish a clinic where perinatal care will be offered. Gynecological services — such as surgical services, preventative care, wellness exams and family planning — will still be provided at a nearby women’s health clinic.
The Chartis report says that the states with the highest loss of access to obstetrical care are Minnesota, Texas, Iowa, Kansas and Wisconsin, with each losing more than 10 facilities.
Data released last fall by the infant and maternal health nonprofit March of Dimes also shows that more than 2.2 million women of childbearing age across 1,119 US counties are living in “maternity care deserts,” meaning their counties have no hospitals offering obstetric care, no birth centers and no obstetric providers.
Maternity care deserts have been linked to a lack of adequate prenatal care or treatment for pregnancy complications and even an increased risk of maternal death for a year after giving birth.
Money is one reason why maternity units are being shuttered.
According to the American Hospital Association, 42% of births in the US are paid for by Medicaid, which has low reimbursement rates. Employer-sponsored insurance pays about $15,000 for a delivery, and Medicaid pays about $6,500, according to the Health Care Cost Institute, a nonprofit that analyzes health care cost and utilization data.
“Medicaid funds about half of all births nationally and more than half of births in rural areas,” said Dr. Katy Kozhimannil, a public health researcher at the University of Minnesota who has conducted research on the growing number of maternity care deserts.
Kozhimannil says communities that are most likely to be affected by maternity unit closures tend to be remote towns in rural counties in states with “less generous Medicaid programs.”
Hospitals in larger cities are often able to offset low reimbursement rates from Medicaid births with births covered by employer-sponsored insurance, according to Dr. Sina Haeri, a maternal-fetal medicine specialist and CEO of Ouma Health, a company that provides virtual prenatal and perinatal care to mothers living in maternity care deserts.
Many large hospitals also have neonatal intensive care units.
“If you have a NICU, that’s a substantial revenue generator for a hospital,” Haeri said.
Most rural hospitals do not have a NICU, only a nursery where they care for full-term, healthy babies, he said. Due to that financial burden, it does not make financial sense for many rural hospitals to keep labor and delivery units open.
A low volume of births is another reason for the closures.
In announcing the closure, Bonner General noted that in 2022, it delivered just 265 babies, which the hospital characterized as a significant decrease.
Rural hospital administrators providing obstetric care say it takes at least 200 births annually for a unit to remain safe and financially viable, according to a study led by Kozhimannil for the University of Minnesota’s Rural Health Research Center.
Many administrators surveyed said they are working to keep units open despite low birth rates.
“Of all the folks that we surveyed, about a third of them were still operating, even though they had fewer than 200 births a year,” Kozhimannil said. “We asked why, and they said, ‘because our community needs it.’ “
Another issue for hospital administrators is staffing and recruitment.
The decision to close Bonner General’s labor and delivery unit was also directly affected by a lack of experienced, qualified doctors and nurses in the state, said Erin Binnall, a Bonner General Health spokesperson.
“After May 19th, Bonner General Health will no longer have reliable, consistent pediatric coverage to manage neonatal resuscitations and perinatal care. Bonner General’s number one priority is patient safety. Not having board-certified providers certified in neonatal resuscitation willing to provide call and be present during deliveries makes it unsafe and unethical for BGH to provide these services,” Binnall told CNN by email.
The American Hospital Association acknowledges the staffing challenges some hospitals face.
“Simply put, if a hospital cannot recruit and retain the providers, nurses, and other appropriately trained caregivers to sustainably support a service then it cannot provide that care,” the association said in a statement. “Such challenges are only magnified in rural America, where workforce strain is compounded by aging demographics that in some communities has dramatically decreased demand for services like Labor and Delivery.”
More stringent abortion laws may be playing a role in the closures, too.
Bonner General said in a news release last month that due to Idaho’s “legal and political climate, highly respected, talented physicians are leaving. In addition, the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.”
According to the Guttmacher Institute, Idaho has one of the strictest anti-abortion laws in the country: a complete ban that has only a few exceptions.
Idaho requires an “affirmative defense,” Guttmacher says, meaning a provider “has to prove in court that an abortion met the criteria for a legal exception.”
No matter the reason, Kozhimannil said, closures in rural communities aren’t just a nuisance. They also put families at risk.
“That long drive isn’t just an inconvenience. It actually is associated with health risks,” she said. “The consequence that we saw is an increase in preterm births. Preterm birth is the largest risk factor for infant mortality. It is a huge risk factor for developmental and cognitive delays for kids.”
Haeri says the decline in maternal care also has a clear effect on maternal mortality rates.
The maternal death rate for 2021 — the year for which the most recent data is available — was 32.9 deaths per 100,000 live births in the US, compared with rates of 20.1 in 2019 and 23.8 in 2020, according to a report from the National Center for Health Statistics. In raw numbers, 1,205 women died of maternal causes in the US in 2021.
Conditions such as high blood pressure, obesity, and diabetes may raise a person’s risk of complications, as can being pregnant with multiples, according to the National Institutes of Health. Pregnant women over the age of 35 are at a higher risk of pre-eclampsia.
Searching for solutions
As labor and delivery units continue to shut their doors, possible solutions to the growing problem are complex, Haeri says.
“I think anyone that comes to you and says the current system is working is lying to you,” he said. “We all know that the current maternity system is not good.”
Kozhimannil’s research has found that many women who live in maternity care deserts are members of minority communities.
“When we conducted that research, we found the communities that were raising the alarm about this … tended to be Black and indigenous, or tribal communities in rural places,” she said. “Black communities in the South and East and tribal communities throughout the country, but especially in the West, Mountain West and Midwest.”
Haeri says one possible solution is at a woman’s fingertips.
“I always say if a woman’s got a cell phone, she should have access,” he said.
A 2021 study found that women who live in remote areas of the US could benefit from telehealth visits, which would decrease the number of “in-person prenatal care visits and increase access to care.”
The American College of Obstetricians and Gynecologists recommends 12 to 14 prenatal care appointments for women with low-risk pregnancies, and the study suggests that expansion of prenatal telehealth appointments could help women living in remote areas better adhere to those guidelines.
Ouma works with mothers who are typically remote and high-risk, Haeri says.
He also believes that promoting midwifery and doula services would help bolster maternity care in the US.
Certified nurse midwives often assist remote mothers who are high-risk or who decide to give birth at home, he says.
Midwives not only deliver babies, they often work with medical equipment and can administer at-home physical exams, prescribe medications, order lab and diagnostic tests, and assess risk management, according to the American College of Nurse Midwives. Doulas — who guide mothers through the birthing process — are often present at home births and even hospital births.
“That midwifery model shines when it comes to maternal care. [And] doula advocacy involvement leads to better outcomes and maternity care, and I think as a system, we haven’t made it easier for those two components to be really an integral part of our maternity care in the US,” Haeri said.
‘Everybody has babies’
After living in Idaho for 10 years, Wright says, she and her fiancé have considered leaving the state. The lack of maternity and pediatric care at Bonner General Health is a big reason why.
“I feel safe being with [my] doctors. Now, I have to get to know a doctor within a couple of months before my next baby is born,” Wright said.
As she awaits the arrival of her new son, she feels doubtful that there is a solution for mothers like her.
“Everywhere — no matter what — everybody has babies,” she said. “It’s posing a problem for people who have babies who don’t have the income to drive or have high risk pregnancies or first-time mothers who don’t even know what to expect.”
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CNN’s Elizabeth Cohen, Katherine Dillinger and Jacqueline Howard contributed to this report.
