Over 500 hospitals have closed their labor and delivery departments since 2010, according to a large new study, leaving most rural hospitals and more than a third of urban hospitals without obstetric care.
Those closures, the study found, were slightly offset by the opening of new units in about 130 hospitals. Even so, the share of hospitals without maternity wards increased every year, according to the study, published on Wednesday in JAMA, a prominent medical journal. Maternal deaths remained persistently high over that period, spiking during the pandemic.
Because its data runs only through 2022, the study does not account for the additional challenges that hospitals have faced since the Supreme Court case that overturned Roe v. Wade that year and led many states to restrict abortion. States with abortion bans have experienced a sharp decline in their obstetrician work force.
“We’re more than a decade into a severe maternal mortality crisis in the United States, and access to hospital-based maternity care has continued to decline over that entire time period,” said Katy Kozhimannil, the study’s lead author and a professor of health policy at the University of Minnesota.
Other research from Dr. Kozhimannil and her colleagues has found that the closures of rural maternity wards can lead to an increase in births in emergency rooms or outside of hospitals.
Hospitals are closing their obstetric units in part because those departments tend to lose money, the researchers said. Medicaid, the public insurance program for the poor, covers more than 40 percent of all births in the United States and typically pays doctors and hospitals much less than private insurance does.
“It is rare for an obstetric unit to operate in the black,” Ms. Kozhimannil said. “It is a service line that tends to be subsidized by other more lucrative service lines.”
Hospital administrators often consider the revenue that each bed generates, creating pressure to favor more expensive services. Running a labor and delivery unit can be exceptionally costly because it requires round-the-clock coverage from specialists who can assist in cesarean sections or other medical emergencies.
Hospitals are typically paid a flat rate for each baby delivered, no matter how much a particular delivery may have cost.
“When you’re a small hospital looking at the alternatives of what you could turn a bed into, it might be more advantageous to have a general-ward bed or not even have to staff the bed at all,” said Dr. Scott Lorch, chief of neonatology at the Children’s Hospital of Philadelphia, who has studied obstetric unit closures.
Hospitals have also found themselves hamstrung by nursing shortages. An estimated 100,000 nurses left the work force during the coronavirus pandemic, and hospital administrators say they have struggled to recruit the staff necessary to run maternity wards.
Administrators at Plumas District Hospital, a 16-bed facility in rural California, were willing to cover the losses of a department that usually delivered about 100 babies each year.
“We made the decision that the service was important, and tried to offset it with other service lines,” said Lisette Brown, the hospital’s chief clinical officer.
Even so, the hospital closed its maternity ward in 2022 when it couldn’t recruit enough nursing staff to work in the ward, in a small town surrounded by forests three hours north of Sacramento. Since then, the hospital has had patients in labor turn up anyway and give birth in their emergency room. The nearest hospital that delivers babies is more than an hour away, and Plumas is now trying to open a birth center staffed by midwives to fill the gap.
While a higher share of the country’s rural hospitals do not offer maternity care, the study found that urban hospitals had the highest number of labor and delivery unit closures — 299 — between 2010 and 2022.
Dr. Christ-Ann Magloire, a private-practice obstetrician in Miami, recently lived through one such instance when the maternity ward where she delivered babies abruptly shut down in February.
“It was terrible,” Dr. Magloire said, recalling how she had to quickly find hospitals that could care for her patients scheduled for cesarean sections.
The hospital where she worked, North Shore Medical Center, had typically delivered over 1,500 babies each year. It is the second hospital in Miami to end obstetric services in less than five years. Nearby Hialeah Hospital, which had delivered about 700 babies annually, closed its maternity ward in 2021.
Dr. Magloire sees mostly Medicaid patients, and said they had struggled to relocate their care to other Miami hospitals. She worries that their care could suffer as other hospitals find their own maternity wards more crowded.
“Most can barely get to my office because of transportation issues,” she said. “Now they might be delivering in a different county, where their family can’t visit. It’s traumatizing.”
