Stopping the Loss of Rural Maternity Care

Most Rural Hospitals No Longer Deliver Babies. Less than half (42%) of rural hospitals in the U.S. still offer labor and delivery services. In 10 states, less than one-third do.

Rural Labor and Delivery Units Are Closing at a Rapid Pace. Since the end of 2020, over 100 rural hospitals have stopped delivering babies, an average of two closures every month.

Maternity Care is Far Away for Mothers in Many Rural Communities. In most rural communities, the nearest labor and delivery hospital is more than 30 minutes away, and in many communities, the travel time is more than 50 minutes.

Many More Rural Communities Are at Risk of Losing Maternity Care. More than 130 rural hospitals that are still delivering babies lost money overall in both of the two most recent years, and they could be forced to close labor and delivery services in order to survive.

Higher Payments for Maternity Care Are Needed to Prevent More Closures. A primary reason rural maternity units are closing is that health insurance plans aren’t paying small rural hospitals enough to cover the cost of delivering high-quality maternity care. Medicaid payments are typically far below what it costs a hospital to deliver maternity care, but most private insurance plans also pay less than what it costs to deliver babies in rural communities.

Over 100 Rural Labor & Delivery Units Have Closed Since 2020

Since the end of 2020, more than 100 rural hospitals have stopped delivering babies or announced they will stop during 2025. Over the past 4.5 years, rural labor & delivery units have closed in the majority of states, and in 4 states, 1/4 or more of the rural hospitals stopped delivering babies. The number of closures and announced closures in the first half of 2025 has already nearly reached the number in all of 2024.

Figure 1

Closures of Labor and Delivery Units
at Rural Hospitals, 2021-2025

Sources: “Actual and Announced” are closures that already occurred or will occur by the summer of 2025. “Full-Year Estimate” assumes closures continue to the end of the year at the average monthly rate from the past 4.5 years.

Most Rural Hospitals in the U.S. No Longer Deliver Babies

Less than half (42%) of U.S. rural hospitals still offer labor and delivery services; in 10 states, less than one-third do.

Figure 2

Proportion of Rural Hospitals Still
Offering Labor and Delivery Services

Maternity Care is Far Away for Mothers in Many Rural Communities

If the closest hospital does not offer labor and delivery services, a pregnant woman may have to travel to a different community to deliver her baby. In most urban areas, the travel time to a hospital with labor and delivery services is under 20 minutes, but in rural areas, the travel time is likely to be at least 30 minutes, and it is often 50 minutes or more.

There is a higher risk of complications and death for both mothers and babies in communities that do not have local maternity care services. Women are less likely to obtain adequate prenatal and postpartum care when it is not available locally.

Figure 3

Travel Time from Non-Maternity Care Hospitals
to Closest Hospital with Maternity Services

Many More Rural Communities Are at Risk of Losing Maternity Care

Payments from private insurance plans and Medicaid programs often do not cover the high cost of delivering safe, high-quality maternity care, particularly in rural areas. Many rural hospitals can’t offset financial losses on maternity care because they aren’t making profits on other types of services.

More than 130 rural hospitals that are still delivering babies lost money overall in both of the two most recent years, and they could be forced to close labor and delivery services in order to survive. In 11 states, at least one-fourth of the rural maternity care hospitals are in this situation.

Figure 4

Rural Labor and Delivery Units At Risk of Closing Due to Hospital Financial Losses

A Labor and Delivery unit is counted as “at risk of closing” if the hospital lost money on all patient services (not just labor and delivery services) in both of the two most recent years available and also had a negative total margin in both years.

State-by-State Data on Closures, Risk of Closure, and Travel Times

RURAL MATERNITY CARE AT RISK
State
 Closures of Rural
Labor & Delivery 
 Rural Hospitals
Without L&D Services 
Rural Hospitals Still Providing
Labor and Delivery (L&D) Services in 2025
# of
L&D
Units
Closed
Since
20201		 % of
Rural
Hospital
L&D
Units
Closed		 # of
Rural
Hospitals
With No
L&D
in 2025		 Median
Driving Time
(in Minutes)
to Hospital
With
L&D Services		 % of
Rural
Hospitals
With L&D
in 2025		 # of
Rural
Hospitals
With L&D
Services		 # of
L&D Units
at Risk
of
Closing2		 % of
L&D Units
at Risk
of
Closing2		 Median
Minutes
to Alternative
L&D Hospital
Florida 2 50% 20 50 9% 2 0 0% >90
Indiana 12 33% 30 30 45% 25 2 8% 33
Maine 6 33% 12 45 50% 12 2 17% 42
Connecticut 1 25% 1 31 75% 3 2 67% 38
Ohio 8 20% 38 30 46% 33 3 9% 30
Pennsylvania 4 18% 31 39 38% 19 1 5% 38
Alabama 3 17% 36 45 29% 15 3 20% 39
Wyoming 3 17% 11 60 58% 15 3 20% 51
Illinois 4 16% 58 32 27% 21 1 5% 39
Idaho 3 16% 14 39 53% 16 4 25% 38
Colorado 3 15% 25 44 42% 18 1 6% 48
California 4 14% 34 49 41% 24 2 8% 46
Arkansas 3 14% 34 39 35% 18 5 28% 46
South Carolina 2 14% 12 39 50% 12 0 0% 39
Wisconsin 6 13% 39 32 51% 40 4 10% 29
Minnesota 7 12% 49 31 50% 49 5 10% 29
West Virginia 1 11% 25 44 24% 8 2 25% 47
South Dakota 2 11% 32 48 35% 17 1 6% 47
Virginia 1 9% 21 42 32% 10 0 0% 45
Iowa 3 8% 58 31 38% 35 2 6% 32
Nebraska 3 8% 36 31 50% 36 4 11% 31
Missouri 2 7% 33 35 44% 26 7 27% 43
Georgia 2 7% 47 35 36% 27 3 11% 40
Arizona 1 7% 14 48 50% 14 0 0% 70
Michigan 2 6% 35 35 46% 30 2 7% 45
New Mexico 1 5% 9 63 68% 19 3 16% 56
Montana 1 5% 35 60 36% 20 1 5% 54
Washington 1 5% 25 39 44% 20 6 30% 39
Texas 3 4% 93 37 42% 67 14 21% 41
Mississippi 1 4% 50 35 32% 23 3 13% 35
New York 1 4% 28 38 46% 24 8 33% 44
Oregon 1 4% 9 38 73% 24 4 17% 43
Tennessee 1 4% 30 36 44% 24 5 21% 37
Kentucky 1 3% 42 32 42% 31 0 0% 34
North Carolina 1 3% 20 33 64% 36 2 6% 38
Kansas 1 3% 65 32 36% 37 15 41% 39
Alaska 0 0% 5 >90 71% 12 1 8% >90
Delaware 0 0% 0
100% 3 0 0% 27
Hawaii 0 0% 7 38 46% 6 1 17% 68
Louisiana 0 0% 42 36 26% 15 2 13% 32
Maryland 0 0% 2 48 60% 3 0 0% 64
Massachusetts 0 0% 2 28 67% 4 2 50% 76
Nevada 0 0% 10 56 29% 4 1 25% >90
New Hampshire 0 0% 9 34 47% 8 1 12% 47
North Dakota 0 0% 31 63 21% 8 3 38% 83
Oklahoma 0 0% 57 39 30% 25 5 20% 46
Utah 0 0% 1 35 95% 21 1 5% 36
Vermont 0 0% 3 34 77% 10 1 10% 43
New Jersey3








Rhode Island3








U.S. Total 101 9% 1,320 36 42% 969 138 14% 39
Data are current as of April 2025
1 Includes closures that have already occurred and announced closures that will occur later in 2025.
2 A Labor and Delivery unit is counted as being "at risk of closing" if the hospital lost money on all patient services (not just L&D services) in both of the two most recent years available and
also had a negative total margin in both years.
3 New Jersey and Rhode Island have no rural hospitals.

Actions Needed to Preserve and Strengthen Rural Maternity Care

Rural hospitals can’t provide labor and delivery services if they are unable to recruit an adequate number of qualified clinicians and staff, but they can’t afford to employ those staff unless health insurance plans pay the hospital adequately for their services. Maintaining access to high-quality maternity care in rural areas requires addressing both the workforce recruitment and payment challenges facing rural hospitals.

Help Rural Communities Attract and Retain a Maternity Care Workforce

Safe, high-quality maternity care requires having physicians who can perform cesarean sections, physicians and/or midwives who can assist women with vaginal deliveries, nurses who are trained in obstetric care, and anesthesiologists and/or nurse anesthetists, all of whom are available on a 24/7 basis to manage deliveries and perform cesarean sections when necessary. Obstetricians and family physicians who can perform C-sections are increasingly unable or unwilling to be on call for a large number of nights and weekends every month. As a result, hospitals have to either employ more physicians, contract with additional physicians to cover on-call shifts, or change to entirely different models of staffing, such as hiring or contracting for ob-gyn hospitalists or laborists. In addition, all hospitals have been experiencing challenges recruiting and retaining registered nurses, but the challenges are greater for maternity care hospitals because they need nurses who have training and experience in obstetrics.

A national workforce shortage requires a national solution. Otherwise, filling a position at one small rural hospital may simply create or extend a vacancy at another hospital, and hospitals with greater financial resources may be filling their positions at the expense of hospitals in lower-income communities. A rural maternity workforce strategy must include:

Pay Adequately for Maternity Care Services

Higher costs for maternity care staffing mean that higher payments are needed from insurance plans to cover those costs. Moreover, payments per birth that are adequate at a large hospital will be too low to support maternity care at a small rural hospital. The reason is that the total cost of having physicians, nurses, midwives, and anesthetists available 24/7 can be the same at a small hospital as a larger hospital, but since there are fewer births at the small hospital, the same payment per birth generates insufficient revenue to cover that cost.

It is often assumed that low Medicaid payments and uninsured patients are the reasons hospitals lose money on maternity services, but over 40% of births in rural communities are paid for by private health plans, so inadequate payments from private payers also threaten the viability of rural maternity care.

Employers should require their health insurance plans to demonstrate that their payments are adequate to cover the cost of rural maternity care services. Similarly, states should require Medicaid plans to pay adequate amounts for rural maternity care services. This includes payments for: (1) perinatal care services from physicians and midwives; (2) assistance during labor and delivery from appropriately-trained nurses; (3) anesthesia services (for pain relief and C-sections); and (4) telemedicine assistance from specialists for complex cases. Payment amounts must be higher in communities that have difficulty attracting staff, and payments must also be higher in communities with smaller numbers of births to ensure the hospital can afford the cost of on-call coverage.

Require Adequate Payments from Private and Public Payers for Other Rural Healthcare Services

It does little good to pay adequately for maternity care if losses on other services force a hospital to close completely. The majority of small rural maternity care hospitals are losing money on other services such as emergency care and primary care. Many small rural hospitals are at risk of shutting down because of the overall financial losses they have been experiencing. Rural Hospitals at Risk of Closing provides more information on the extent of this problem and how to address it.

The primary cause of these overall losses is not low Medicaid or Medicare payments or losses on uninsured patients. As shown in the chart below, the biggest problem is private insurance companies (including Medicare Advantage plans as well as commercial health insurance) paying rural hospitals less than what it costs to deliver services to patients. Conversely, the small rural maternity hospitals that avoid overall losses do so by receiving payments from private health plans that not only cover the costs of services (of all types) to the patients with private insurance but also offset the hospitals’ losses on services to uninsured and Medicaid patients.

Figure 5

Payer-Specific Profits/Losses on Patient Services at Rural Maternity Care Hospitals

The bars show the median profit or loss on all services (both maternity and non-maternity) delivered to patients with each type of insurance.

Source: Hospital cost reports for 2023-24 at rural hospitals with labor and delivery services.

Employers and residents of rural communities should only choose health plans that pay adequately for services delivered at the rural hospital. It is particularly important to ensure that payments from insurance plans support the costs of primary care and gynecologic care as well as obstetric care:

Create Standby Capacity Payments to Support the Fixed Costs of Maternity Care

Financial losses in maternity care are caused not only by the inadequate amounts paid by insurance plans, but by the problematic method currently used to pay for services. The physicians and staff at a maternity care hospital must be standing by, 24 hours a day, ready to deliver a baby at all times. Currently, however, they are only paid when they actually deliver a baby, even though there may be no deliveries at all on many days. As a result, when there are fewer pregnancies than expected, the hospital and clinicians will lose money, even if payments would have been adequate for a larger number of births. Moreover, since payments are typically higher for C-sections, hospitals and clinicians that support natural childbirth and reduce their C-section rate could lose money as a result.

A better approach is for private insurers and Medicaid programs to pay for maternity care using a combination of two different types of payments instead of just fees for services:

  1. Standby Capacity Payments. If a rural hospital and its physicians and midwives maintain the round-the-clock staffing needed to deliver babies and perform C-sections at any time, a health insurance plan should pay them a monthly or quarterly Standby Capacity Payment for each woman of childbearing age who is insured by that health plan and lives in the hospital’s service area. The amount of the Standby Capacity Payment should be equal to the amount needed to maintain adequate on-call staffing for labor and delivery services, divided by the total number of insured women ages 15-44 in the community. In aggregate, the Standby Capacity Payments from all private and public health plans would provide the hospital, physicians, and midwives with sufficient revenue to cover the fixed costs of labor and delivery services.

  2. Delivery Fees. In addition to the Standby Capacity Payments, the hospital and clinicians should receive a Delivery Fee when labor and delivery services are provided to an individual mother. If the hospital’s fixed costs for labor & delivery and the on-call costs for physicians and midwives are paid for through the Standby Capacity Payments, the Delivery Fee would only need to cover the extra (i.e., variable) time and costs associated with individual births. As a result, the Delivery Fee could be much smaller than current payments for labor and delivery. In addition, the Delivery Fee should be the same amount for a vaginal delivery and a C-section, so there is no financial penalty if the hospital, physicians, and midwives are able to safely increase the proportion of vaginal deliveries and reduce the number of C-sections.

Under this two-part payment system, both spending for the health plans and revenue for the hospital and clinicians would be far more predictable than under the current system of paying per birth.

More details on this approach to payment are described in A Better Way to Pay Rural Hospitals.

Immediate Action is Needed to Address the Crisis in Rural Maternity Care

The U.S. has one of the highest rates of mortality for both infants and mothers among the world’s advanced economies. Pregnant women are more likely to die in the U.S. than in Australia, Britain, Canada, France, Germany, and most other developed countries. Moreover, Black women in the U.S. are 2-3 times as likely to die for pregnancy-related causes as other racial and ethnic subgroups.

Over 80% of pregnancy-related deaths are preventable with appropriate prenatal, labor & delivery, and post-partum care. Although improvements in maternity care are needed in all parts of the country to reduce mortality rates, one of the greatest challenges is in rural areas, because most rural hospitals are no longer providing maternity care at all. The problem will get even worse if more rural communities lose maternity care services. 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.

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. Federal and state government officials and private employers must take immediate action to ensure that all health insurance plans are paying adequately to support high-quality maternity care in every community.