For Chloe Freeman, the drive from her home in North Rose, in upstate New York, to Newark-Wayne Community Hospital is a familiar one: 25 minutes southwest, past farmland and apple orchards. When Freeman had her first child there, at age 22, it was May 2020, only a few months into the Covid-19 pandemic. But Freeman and her husband weren’t worried. They knew the route; they had a birthing plan. They checked into Newark-Wayne’s Marshall Birthing Unit on May 13, and in the early hours of the following morning, their daughter was born. Things went smoothly for her second and third births there too.
Freeman, now 28, is expecting her fourth baby—a boy—at the end of December. And this time, she’s worried. She was planning to return to Newark-Wayne, but that’s no longer an option. The hospital closed its birthing unit on September 3, leaving Wayne County without a single hospital that delivers babies. “I was really mad about it,” Freeman said, “not only for myself but for the future of people who are going to be giving birth.”
Since learning of the closure, Freeman and her husband have spent hours together at his desk, using his three computer monitors to map out driving routes across upstate New York. They’ve narrowed it down to two options: When the baby eventually comes, they can drive to Rochester General Hospital, about 51 minutes west along Route 104, or, if Rochester General can’t take them, they’ll go the full hour to Unity Hospital on the other side of the city. Neither option sounds good. Winter in Wayne County is long and hard, snow plows move slowly on country roads, and strong winds blowing in from the south shore of Lake Ontario can be a recipe for snowdrifts or black ice.
“It’s not like I can just book a hotel room for a week or two until the baby comes,” Freeman said. “We can’t pay somebody to watch our kids.” And as Freeman knows well, this being her fourth child in six years, labor tends to go faster with each consecutive birth. “I pushed with my oldest for 20 minutes. I pushed with my second for seven minutes, and then my third one I think was like five minutes. So they kept getting quicker and quicker,” Freeman said. “My husband is very frustrated. ‘This is ridiculous,’ he goes. ‘You’re what, about six months pregnant right now and we’re sitting here trying to figure out the best route to take if you go into labor in the middle of winter?’”
What happened in Wayne County is happening everywhere. More than half of the counties in the United States no longer have a hospital with inpatient labor and delivery services. One in three counties is designated a “maternity care desert,” with no obstetric clinicians or birthing facilities at all. Since 2020, over 146 rural hospitals have stopped delivering babies completely—an average of more than two closures every month. With each new closure, expecting families are forced to travel further for care, and the longer the drive, the greater the danger.
This crisis is spreading at a time when infant and maternal mortality rates in the U.S. are far higher than those of comparable high-income nations like Canada, Australia, France, and Japan, especially for women of color and women in rural areas, who face significantly higher pregnancy risks than those in urban areas. Meanwhile, birth rates are plummeting across the country, thereby reducing the revenue these hospitals depend on to provide maternity care. And the worst is yet to come: The nearly $1 trillion cuts to Medicaid in President Trump’s One Big Beautiful Bill Act are bearing down on hospitals everywhere, pushing rural facilities toward a “fiscal cliff.”
It’s no secret that rural health care in the United States is in serious trouble. The losses in labor and delivery services are symptomatic of a much wider trend; more than 100 rural hospitals across the country have shut their doors entirely in the last decade, leaving over four million Americans without easy access to care. Of those that remain, the Center for Healthcare Quality and Payment Reform, or CHQPR, identifies 700 more at risk of closing in the near future. Physician shortages, aging populations, and low patient volumes all play a role, but the problem essentially comes down to funding. Health insurance payments, including those from private insurers as well as Medicare and Medicaid, are not enough to cover the cost of care. And when a small hospital system is looking to cut costs, labor and delivery is often first on the chopping block.
“A hospital can’t be a hospital unless it has an emergency department. A hospital can’t be a hospital if it doesn’t have inpatient care. But it can be a hospital if it doesn’t have maternity care. So if a hospital needs to eliminate services, then what does it eliminate?” said Harold Miller, president and CEO of CHQPR. American health care largely operates on a fee-for-service model, meaning that providers and health systems are reimbursed by insurers for each individual service they deliver. Every procedure, every office visit, every scan or test has a price tag. Maternity units have high fixed operating costs. They have to be staffed around the clock with nurses and anesthesia coverage, with an operating room ready for emergency C-sections and physicians on call who can perform them, regardless of whether the unit delivers 80 babies a year or 800. But fee-for-service reimbursement rewards the number of births, not how prepared the hospital is to deliver them. As a result, rural maternity units, where volumes are significantly lower and the proportion of patients on Medicaid (which has lower reimbursement rates) is significantly higher, end up operating in the red.
Historically, Miller explained, hospitals losing money on labor and delivery have been able to subsidize their losses with profits made from other, more lucrative services—orthopedics, radiology, or cardiovascular surgery, for example—but as costs rise and birth rates drop, they no longer have the financial wiggle room to sustain maternal care. “Not only can they not subsidize it, they have to eliminate it because otherwise the entire hospital may close,” Miller said.
Three hundred miles away from Wayne County, in Brattleboro, Vermont, Dr. Corina Tennant, chief of obstetrics and gynecology at Brattleboro Memorial Hospital, has been fighting an uphill battle to protect her patients from the uncertainty of a situation like Freeman’s. At the end of June, the Brattleboro Memorial board of directors voted to close the hospital’s birthing center, effective December 31.
“It was obvious that the hospital was hemorrhaging money,” Tennant said. But the decision to shut down maternity care, rather than looking to cut costs elsewhere, caught her off guard. “I literally don’t know how they could possibly justify doing this. People will definitely die. I’ve saved more people’s lives here than I’ve ever saved anywhere else I’ve worked.… We have a really struggling population medically and socially, and people who would not be transferable to another facility.”
Without Brattleboro Memorial, pregnant patients in the surrounding area would likely be directed to hospitals out of state: either 35 minutes to Cheshire Medical Center in Keene, New Hampshire, or 55 minutes to Baystate Franklin Medical Center in Greenfield, Massachusetts, which has already seen an influx of new patients after nearby Mercy Medical Center in Springfield, Massachusetts, suspended its labor and delivery in December 2025. The Brattleboro center is set to deliver approximately 235 newborns by the end of 2026, and “Cheshire has made it very clear that they cannot absorb our volume at all,” Tennant said. “That would be a gigantic increase in their volume, and that’s not absorbable.”
What if there truly is nowhere to go? Laboring mothers end up in the hands of first responders, emergency departments, or strangers on the shoulder of the highway. “What we’re seeing now is an increasing number around the country of women delivering by the side of the road and potentially even having the baby die, or the mother, or both, because they’re not at a hospital that can handle them,” Miller said. In Wayne County, Freeman was told that local emergency medical services would be prepared to step in if anything went wrong. After attending a community input meeting about the impending closure, she did not feel reassured. “Emergency services were like, ‘We’re not in labor and delivery for a reason, we’re not equipped,’” she said. “My husband is obviously very worried because this is my fourth kid; he’s like, ‘I’m not—I don’t—I’m not planning to deliver a baby on the side of the road.… You’re high risk for bleeding,’ he goes, ‘If you start delivering on the side of the road, and you start hemorrhaging, what exactly are the EMTs going to do?’”
“An E.R. could handle a precipitous delivery, but an emergency room absolutely cannot manage a bona fide emergency where a fetus is in harm’s way, or a mother is in harm’s way, because there are no resources for that,” explained Will Hammett, an ob-gyn who worked as medical staff president at OhioHealth Grady Memorial Hospital in Delaware, Ohio, until it discontinued inpatient maternity services on July 31. “The challenge is, if mom’s placenta is separating, if the baby is coming out feet first, if the umbilical cord is coming out in front of the baby, if mom is having a seizure … you absolutely could suffer a neonatal demise or a maternal demise.”
After nearly 30 years at Grady Memorial, Hammett has decided to leave the OhioHealth system entirely following the closure, which he called a “moral and ethical foul.” When the OhioHealth system absorbed Grady Memorial, he said, it agreed to continue supporting basic services, including inpatient maternal care. But if a patient walks into Grady Memorial with an obstetrics emergency today, “the expectation is that the emergency room doctor will call 911,” and emergency services will transfer them to the nearest facility, 30 to 40 minutes away. “We very clearly have had patients with emergencies, walking in the door with a breach presentation, and whether they would have made it to other places or not is, you know, we don’t know,” Hammett said.
“That’s what I think is terrifying about obstetrics: It can all change in unpredictable ways, and it is life-threatening,” Tennant said. “I’m less worried when somebody is ‘high risk’ for delivery because I know what to look out for. My scariest deliveries universally are the people that are healthy and should have normal pregnancies, and something happens that is completely unexpected. The time sensitivity of obstetrics is like nothing else but severe trauma issues.… It is minutes in obstetrics. Gunshot wounds and huge stab wounds are the only other things that are quite that time sensitive.”
Getting to the hospital in time for delivery, of course, is only part of the problem. In the third trimester, the standard prenatal schedule for a low-risk pregnancy calls for appointments every two weeks; and after 36 weeks, women should see their providers weekly. That’s easier said than done when the appointment is over an hour away. “I didn’t go to my two-week postpartum appointment because it was an hour and 45 minutes,” said Kathleen Cook-Polson in Maher, Colorado. Delta County Memorial Hospital, home to Cook-Polson’s closest labor and delivery unit, suspended obstetric care in September 2025. “Would I have been back in time to pick up my daughter from preschool?” asked JillAnn Knonenborg in Giles County, Virginia, who learned she was pregnant with her second daughter weeks before the LewisGale Hospital Montgomery labor and delivery unit in Blacksburg, Virginia, announced its closure in 2024. “It’s a lot of gas money, and gas is almost five bucks a gallon here,” said Chelsea Buckell, a mother of five in Warren, Pennsylvania. Warren General Hospital discontinued inpatient labor and delivery on January 13; Buckell’s youngest son was born a few months later in Jamestown, New York, 40 minutes away. “There’s definitely other women here, especially younger mothers, that don’t have the stability or the finances to make those types of trips,” she added. “You have to figure out, OK, I have to go to the doctor this week. How am I going to save the gas money out of groceries? How am I going to save the gas money not paying this bill? And rather than having to deal with that stress and worry, women are like, ‘We just won’t have kids.’”
As if rural hospitals aren’t facing enough of a budget crunch, they now have to contend with cuts from the federal government. Medicaid alone pays for roughly 40 percent of all births in the U.S., and nearly half of births in rural areas—but it pays substantially lower reimbursement rates to hospitals and physicians than private health insurance. According to a study by the nonprofit Health Care Cost Institute, employer-sponsored health insurance plans pay an average $8,732 more per delivery than Medicaid, putting facilities that serve a high proportion of Medicaid patients (rural hospitals chief among them) at a dramatic disadvantage. The One Big Beautiful Bill Act, which the Republican-controlled Congress passed and Trump signed into law last year, pays for its $4.5 trillion tax cuts—largely benefiting corporations and the wealthy—in part by cutting $911 billion from Medicaid over 10 years. The cuts begin to take effect after November’s midterm elections, and hospitals are bracing for what is certain to be another devastating blow to rural maternity care.
“Medicaid cuts—they’re the nail in the coffin for countless rural and urban labor and delivery units,” said Vaishu Jawahar, director of policy programs for the health care advocacy group Protect Our Care. “I don’t think it makes sense, if you claim to be wanting to take care of mothers and kids, to then cut a trillion dollars from the program that pays for 40 percent of maternity care.”
Faced with these Medicaid cuts, struggling hospitals see no choice: They’re preemptively cutting labor and delivery because “they may not be able to afford the chance that they’re going to lose even more money and put the entire hospital at risk,” Miller said. And some hospitals are making their reasoning clear: The statement announcing the end of labor and delivery at St. Mary’s Sacred Heart Hospital in Lavonia, Georgia, reads, “Recent Congressional cuts to Medicaid solidified this decision”; in Franklin, Indiana, Johnson Memorial Health directly cited “provisions of the One Beautiful Bill Act, passed in 2025,” which will “cut Medicaid reimbursement to Indiana hospitals by a projected $12.7 billion,” as a reason for closing obstetric services.
“This is how you lose a community over generations—over a generation, really,” Tennant said. She’s seen patients in Brattleboro decide not to have children based on their limited access to care, and “the number one thing that Vermont needs is young people,” she added. It’s true: Between April 2020 and July 2023, 81 percent of rural counties reported more deaths than births. The pandemic played a role, but rural communities in the U.S. have been hollowing out for years as populations age and younger residents relocate to urban centers in search of better jobs, social and civic engagement, and, in many cases, stronger health care infrastructure. For those that remain, the loss of maternity services can make an already difficult decision to start a family feel even harder. When Newark-Wayne announced the closure of its labor and delivery unit, it pointed to a decline in births at the hospital as a key factor in the decision. “But the thing is,” Freeman said, “they’re pushing people not to want to have kids. Women aren’t feeling wanted in that role because they don’t feel like they’re getting the care they need.”
Brattleboro Memorial recently announced that, after receiving new funding from Vermont’s Rural Health Transformation Program, its birthing center will remain open for the time being. In the small town of Damariscotta, Maine, a robust community effort to save the labor and delivery unit at MaineHealth’s Lincoln Hospital is making headway. The fight to keep these units open is, ultimately, a fight for rural America: Fewer maternity wards mean fewer births, fewer births mean fewer young people, fewer young people mean weaker economies, and weaker economies mean fewer maternity wards. “I would call it a vicious negative cycle,” Miller said.
Freeman has heard it all: the low birth volumes, the financial strain, the staffing shortages. Her concern is not simply about where she will give birth in December but what kind of community her children and their friends will grow up in—and whether, by the time they are old enough to start families of their own, there will be a future for them in the place they call home. “What about the community now that are having kids?” she asked. “What about in 20 years when my kids are having kids?”
