When Maternity Wards Disappear: The Crisis of Rural Birth Care
More than 100 rural maternity units have shut down since 2020, leaving many women hours from safe delivery. The answer isn’t home birth—it’s rebuilding trust, structure, and responsibility.
Why closing rural maternity units increases deaths and what rebuilding safe access must look like
A quiet emergency is unfolding in rural America. In 2025 alone, 27 maternity units have closed or announced plans to close, bringing the total to 116 closures since 2020 according to the Center for Healthcare Quality and Payment Reform. For many communities, this means the nearest delivery room is now more than an hour away. For pregnant women, it can mean life or death.
Labor and delivery is one of the most labor-intensive services in medicine. It requires 24 hour readiness, highly trained nurses, anesthesia support, rapid surgical capability, and the ability to respond instantly to emergencies that cannot wait for transfer. Yet rural hospitals operate on razor-thin margins. When reimbursement systems reward volume rather than vigilance, obstetrics is often the first service to go. A maternity unit without enough births to break even becomes a liability rather than a lifeline.
The CHQPR report warned that rural maternity care is in crisis and that more women and babies will die unnecessarily until the system is rebuilt. They are correct. The solution is not to shift births into living rooms under the banner of choice. It is to make rural birth care sustainable, accountable, and safe.
What Happens When Access Disappears
New evidence confirms what clinicians in rural communities have observed for years. A large national study in JAMA Network Open found that infant mortality rises markedly as maternity care access declines. Counties with full access to obstetric services had an infant mortality rate of 5.2 deaths per 1000 live births, while counties with no access reached 6.5 deaths per 1000. After adjusting for demographics and clinical factors, infants in no-access counties had a fourteen percent higher risk of dying in the first year of life. Infants in low-access counties had a twelve percent increase in risk. Both neonatal and postneonatal deaths followed the same pattern. The researchers concluded that as many as one in eight infant deaths in no-access regions may be attributable to loss of maternity care access.
This study reinforces a simple truth. When maternity units disappear, survival outcomes worsen. Birth is time sensitive. Delay kills.
How Much Is Not Enough and How Far Is Too Far
Multiple studies show that maternity units performing below a certain annual delivery volume experience higher rates of complications. Obstetrics is a team sport that depends on collective experience, rapid coordination, and constant practice. When units handle only a few dozen births each year, the staff cannot maintain readiness. Hospitals conducting fewer than 500 deliveries annually have significantly higher rates of cesarean complications, postpartum hemorrhage, and neonatal morbidity compared with higher-volume centers.
Distance compounds the danger. When travel time to a delivery hospital exceeds 30 minutes, the risk of adverse outcomes rises sharply. For many rural families, a 45 to 90 minute trip is now routine. That delay can convert treatable emergencies such as cord prolapse or placental abruption into fatal events before arrival.
European health systems confronting similar geography have responded by creating maternity hotel units near regional hospitals where women in late pregnancy can stay temporarily under midwifery supervision, yet remain within immediate reach of full obstetric services. These models protect access while preserving safety. They demonstrate that safe childbirth requires human presence and institutional preparedness, not ideology or improvisation.
The Mirage of Home Birth as a Substitute
When rural maternity units close, home birth can appear to be the only remaining option. Yet most maternal deaths and near misses occur suddenly and unpredictably. Postpartum hemorrhage, eclampsia, and shoulder dystocia do not respect distance or good intentions. No midwife, however skilled, can replace hospital infrastructure when seconds matter.
Home birth advocates often say that with careful selection, some women can safely deliver at home. That is true only when strict criteria, licensure, and liability coverage are enforced. Birth attendants must be professionally certified, insured, and obligated to transfer the instant a deviation from normal appears. Anything less turns necessity into danger.
The United States has a unique challenge. The largest group promoting home birth, Certified Professional Midwives, do not meet uniform national safety standards. Unlike Certified Nurse-Midwives, they do not require a nursing degree, often train outside regulated systems, and are licensed in only about half the states. They are not integrated into hospitals, have no standardized oversight, and often practice without liability insurance.
Over the last decade, every major obstetric and midwifery organization has urged CPMs to align education and credentialing with international standards. These calls have been ignored. As a result, two separate systems exist. One is fully accountable and integrated. The other is self-regulated and structurally disconnected from emergency resources.
Data reflect this divide. Planned home births managed by CPMs have higher rates of perinatal death, neonatal seizures, and low Apgar scores compared with CNM-attended or physician-attended births. In states with permissive regulation, delayed transfers have increased maternal and neonatal morbidity. The issue is not inherent to home birth itself. The danger comes from inadequate training, lack of oversight, and absence of integration with hospital systems.
Without professional accountability, informed consent collapses. Women cannot meaningfully weigh risk if the attendant is not qualified to assess it. Until all midwives are required to meet equivalent educational and legal standards, the term home birth cannot reliably signal safety.
Why L&D Units Are So Hard to Keep Open
Running a labor unit in a rural setting means maintaining round-the-clock staffing for events that may occur only a few times per week. Obstetric nurses, anesthesiologists, and physicians must be ready twenty-four hours a day. Beds must remain prepared even when empty. Without that readiness, there is nowhere safe for a woman in labor to go.
CHQPR proposes that payers cover the standby capacity required for obstetric safety, not just the births themselves. This mirrors how fire departments are funded. We do not pay only when a fire occurs. We pay to maintain readiness.
Ethical Duty and Systemic Failure
Closing a maternity unit without an alternative facility violates the principle of nonmaleficence. It increases preventable harm. Hospitals, insurers, and governments share responsibility for this risk. Financial survival cannot be separated from patient survival.
Workforce shortages compound the problem. Few new obstetricians want the unrelenting on-call demands of rural practice. Solutions include shared regional call pools, tele-perinatal consultation, loan forgiveness, and AI-supported monitoring to extend specialist reach. Technology can help but cannot replace physical proximity when delivery becomes dangerous.
Rebuilding the System
A safer system must follow principles:
Safety before volume. Fund readiness, staffing, and rapid response capability.
Professional accountability. Require licensure, ongoing training, clear low-risk criteria, and liability insurance for any practitioner attending births outside hospitals.
Regional integration. Build transport and referral systems that ensure rapid escalation when needed.
If home births are permitted, they must be restricted to well-selected, clearly defined low-risk pregnancies. Anything outside those boundaries belongs in a hospital.
A National Reckoning
The United States already faces the highest maternal mortality among high-income nations. Shrinking maternity access will widen this gap. It is not enough to valorize natural birth or rely on non-integrated midwifery systems. We need policy environments that protect both autonomy and safety. Women in rural America deserve not only choice but survival.
Reflection
If the nearest hospital is an hour away, is a community truly choosing how it gives birth, or simply adapting to abandonment? Until maternity care is treated as essential infrastructure, closure will continue to masquerade as empowerment rather than neglect.