Rural regions, such as the area surrounding this southern Iowa town, once had many more births and facilities to support them.
At least 41 Iowa hospitals have closed their labor and delivery units since 2000, representing about one-third of all Iowa hospitals. These closures primarily affect rural areas where birth rates have plummeted. In some Iowa counties, annual birth rates have dropped by three-quarters since the peak of the baby boom in the 1950s and ’60s, when many rural hospitals were built or expanded, according to state and federal records.
This trend is occurring nationwide, as hospitals struggle to maintain staff and facilities to safely handle the declining number of births. More than half of rural U.S. hospitals now lack obstetric services.
“People just aren’t having as many kids,” said Addie Comegys, a resident of southern Iowa who has traveled 45 minutes each way for prenatal checkups at Oskaloosa’s hospital this summer. Her mother had six children, starting in the 1980s, when large families were more common.
“Now, if you have three kids, people are like, ‘Oh my gosh, are you ever going to stop?’” said Comegys, 29, who is expecting her second child in late August.
Many Americans today choose to have smaller families or no children at all, aided by modern birth control methods. This trend is amplified in small towns when young adults move away, taking their childbearing potential with them.
Hospital leaders who close obstetrics units often cite declining birth rates, staffing challenges, and financial losses. These closures can particularly challenge pregnant women who lack reliable transportation and flexible schedules needed to travel long distances for prenatal care and birthing services.
The baby boom peaked in 1957, with about 4.3 million children born in the United States. By 2022, the annual number of births had dropped below 3.7 million, even as the overall U.S. population nearly doubled during the same period.
West Virginia has seen the steepest decline in births, a 62% drop over the past 65 years, according to federal data. Iowa’s births dropped 43% during this period. Of Iowa’s 99 counties, only four—all urban or suburban—recorded more births.
Births have increased in only 13 states since 1957, mostly in states like Arizona, California, Florida, and Nevada, which have attracted waves of newcomers from other states and countries. However, even these states have seen obstetrics units close in rural areas.
In Iowa, Oskaloosa’s hospital has bucked the trend and kept its labor and delivery unit open, partly by drawing patients from 14 other counties. Last year, the hospital successfully recruited two obstetrician-gynecologists to expand its services.
Mahaska Health, the publicly owned hospital in Oskaloosa, expects to deliver 250 babies this year, up from about 160 in previous years, according to CEO Kevin DeRonde.
“It’s an essential service, and we needed to keep it going and grow it,” DeRonde said.
Many U.S. hospitals now dropping obstetrics units were built or expanded in the mid-1900s during a rural-hospital building boom fueled by federal incentives, such as the Hill-Burton Act.
“It was an amazing program,” said Brock Slabach, COO of the National Rural Health Association. “Basically, if you were a county that wanted a hospital, they gave you the money.”
In addition to declining birth rates, obstetrics units face reduced occupancy because most patients now go home after a night or two, whereas patients used to stay for several days after giving birth.
Dwindling caseloads can raise safety concerns for obstetrics units. A 2023 study published in JAMA found that women were more likely to suffer serious complications if they gave birth in rural hospitals handling 110 or fewer births annually. The authors did not support closing low-volume units, as this could lead to more complications related to traveling for care. Instead, they recommended improving training and coordination among rural health providers.
Stephanie Radke, an obstetrics and gynecology professor at the University of Iowa, said it is almost inevitable that when rural birth rates plunge, some obstetrics units will close. “We talk about that as a bad event, but we don’t really talk about why it happens,” she said.
Radke emphasized that maintaining a set number of obstetrics units is less important than ensuring good care for pregnant women and their babies. It is difficult to maintain quality care when the staff doesn’t consistently practice deliveries, but it is hard to define that line. “What is realistic?” she said. “I don’t think a unit should be open that only delivers 50 babies a year.”
In some cases, hospitals near each other have consolidated obstetrics units, pooling resources into one program that has enough staff and handles sufficient cases. “You’re not always really creating a care desert when that happens,” she said.
The decline in births has accelerated in many areas in recent years. Kenneth Johnson, a sociology professor and demographer at the University of New Hampshire, said it is understandable that many rural hospitals have closed obstetrics units. “I’m actually surprised some of them have lasted as long as they have,” he said.
Johnson noted that rural areas experiencing the steepest population declines tend to be far from cities and lack recreational attractions, such as mountains or large bodies of water. Some rural areas have avoided population losses by attracting immigrant workers, who tend to have larger families in the first generation or two after moving to the U.S.
Katy Kozhimannil, a health policy professor at the University of Minnesota, said declining birth rates and obstetric unit closures can create a vicious cycle. Fewer babies being born in a region can lead a birthing unit to close. Then, the loss of such a unit can discourage young people from moving to the area, driving birth rates even lower.
In many regions, people with private insurance, flexible schedules, and reliable transportation choose to travel to larger hospitals for their prenatal care and delivery. This leaves rural hospitals with a larger proportion of patients on Medicaid, a public program that pays about half what private insurance pays for the same services.
Iowa ranks near the bottom of all states for obstetrician-gynecologists per capita. However, Oskaloosa’s hospital successfully recruited Taylar Swartz and Garth Summers, a married couple who recently completed their obstetrics training. Swartz grew up in the area and wanted to return to serve women there.
Swartz hopes the number of obstetrics units will stabilize after the wave of closures. “It’s not even just for delivery, but we need access just to women’s health care in general,” she said. “I would love to see women’s health care be at the forefront of our government’s mind.”
Swartz noted that Iowa has only one obstetrics training program, at the University of Iowa. She and her husband plan to help spark interest in rural obstetrics by hosting University of Iowa residency rotations at the Oskaloosa hospital.
Comegys, a patient of Swartz’s, could have chosen a hospital birthing center closer to her home but wasn’t confident in its quality. Other hospitals in her region had closed their obstetrics units. She is grateful to have a flexible job, a reliable car, and a supportive family, so she can travel to Oskaloosa for checkups and delivery. She knows many other women are not as fortunate and worries that more obstetrics units are at risk.
“It’s sad, but I could see more closing,” she said.
