Residents in rural communities across the United States continue to lose access to hospital-based obstetrics services, with the least populated counties in our country losing access at a more rapid rate, according to a recent research report.
The University of Minnesota’s Rural Health Research Center released the report in January, looking at access to hospital-based obstetrics services in each county in all 50 states. Researchers looked at changes in the availability of services between 2010 and 2023, the most recent year for which data was available, with particular attention given to the years 2022 and 2023. What they found was a continued decline in the availability of obstetrics services at hospitals.
Nearly one in 10 (8.6%) of the country’s 3,144 counties lost all hospital-based obstetrics services regardless of rurality, the report found. Of those counties, 26 lost those services between 2022 and 2023, and 21 of those counties were rural.
As a result, 60% of rural counties and 38% of urban counties were without hospital-based obstetric services by 2023.
The less populated a rural county is, the more likely it is to lose obstetrics services, especially “noncore” counties that have no towns with more than 10,000 residents. Among those noncore counties, 148 (or 11%) lost all hospital-based obstetrics services, 15 of those between 2022 and 2023.
“The rural/urban split is not new by any measure,” Julia Interrante, lead researcher of the report, said in an interview with The Daily Yonder. “But those communities that are experiencing loss of services still have women giving birth in them — 5.8 million reproductive-age women live in counties without hospital-based obstetrics, and 2.6 million of those live in rural counties.”
In their conversations with hospital administrators, the researchers found the most common reasons for obstetric closures were workforce shortages, financial losses, clinical safety concerns, and the cost of liability insurance, Interrante explained. The financial and clinical safety factors, she said, are tied to having fewer births in a system where payment for these services is based on volume and doesn’t cover the full costs of keeping those services available, and where policy decisions and too few resources are going toward supports for clinical safety mechanisms in low-birth-volume settings.
Between 2010 and 2023, Iowa, for example, had 20 counties that lost hospital-based obstetrics services. Another nine states had 10 counties that lost all of those services. But in the most recent years (2022-2023), obstetrics service losses were concentrated in five states – California, Idaho, Indiana, Minnesota, and Nebraska — which lost services in two counties each. Illinois and Kansas lost services in three counties, all of which were rural, and Ohio lost those services in four counties, two of them rural.
Only one noncore county, McKenzie County in western North Dakota, gained hospital-based obstetrics in 2023. Yet, between 2010 and 2023, three of that state’s counties lost those services. In 2010, 20% of rural counties in that state had those services, but only 16% had them in 2023, while 50% in urban counties had those services in both 2010 and 2023.
In 2023, more than half of rural counties in 28 states lacked obstetric services. In Florida, North Dakota, Virginia, and West Virginia, more than three-quarters of the rural counties lacked hospital-based obstetrics. In seven states (Florida, Georgia, Illinois, Louisiana, North Dakota, Oklahoma, and Tennessee), 90% or more of rural noncore counties lost those services.
“Loss of these services increases potential risks for maternal and infant health,” the authors of the report wrote. “The findings of this report have both national and local implications and highlight areas for improving access to care and maternal and infant health.”
Harold Miller, with the Center for Healthcare Quality and Payment Reform, said the closures of rural obstetrics units were, in his opinion, a bigger issue than the closing of rural hospitals. One of that organization’s recent reports on rural maternity care found that the issue is continuing to grow.
Fifty-one rural obstetric units have closed in 2024 and 2025, he said.
“That’s an average of more than two closures every month,” he wrote in an email to The Daily Yonder. “The average closure rate was similar in 2022 and 2023 (54 closures in 24 months). That high rate has continued so far in 2026, with four closures in two months.
Another six have closed or are ready to close this year, he said.
“I think it’s a crisis when over 12% of the rural maternity units in the country close in five years and are continuing to close at a rate of two per month,” he said. “It’s certainly a crisis in Indiana, Maine, and West Virginia, which have lost a third or more of their rural OB units in that time period. A half-dozen other states have lost a fifth or more of their rural OB units.”
Those losses, he explained, are also based on under-compensation from Medicare and from private insurance. Almost half of all rural hospitals, and the majority of small rural hospitals, are losing money. Miller noted that his organization’s data show that the biggest problem for small, rural hospitals in most states is low payments from private insurance plans, including Medicare Advantage plans.
The loss of the units not only means that rural women have lost access to labor and delivery services, but they have also lost access to prenatal/postpartum care and gynecological services, research shows. The U.S. already has one of the highest maternal mortality rates among high-income countries globally —according to the Centers for Disease Control and Prevention, in 2022, the U.S. saw 22.3 maternal deaths per every 100,000 live births, nearly three times the rate in South Korea, Canada and France (8.8, 8.4 and 7.6, respectively), and nearly four times the rate of the United Kingdom (5.3).
Beyond the harm to women and newborns, obstetrics unit closures have an economic impact as well, Miller noted.
“It also means that anyone who is considering living/working in a rural community can no longer be certain that the community will have maternity care in the future, even if it has that service today,” he said. “That could make it harder for employers in rural communities (including the hospitals in those communities) to attract and retain younger workers.”
Losses of obstetrics services in rural America is a national issue, he said.
“Reversing this trend will require helping rural communities to recruit and retain a sufficient number of physicians, midwives, and nurses and ensuring that payments from insurance plans are adequate to cover the costs of delivering high-quality maternity care,” he wrote in the report. “Rural maternity care is in a state of crisis, and more women and babies in rural communities will die unnecessarily until the crisis is resolved.”
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