Why This Matters
In most of rural America, the nearest place to give birth is now more than 30 minutes away. In some counties, it is more than an hour. And the distance is growing.
A new report from the Center for Healthcare Quality and Payment Reform — the most comprehensive national accounting of rural maternity care in 2026 — finds that 139 rural hospitals have stopped delivering babies or have announced plans to do so before the end of this year. That represents a 13% reduction in rural labor and delivery units since the end of 2020, and it continues a trend that has been accelerating every year.
For women in affected communities, the math is direct. Without a local labor and delivery unit, they face longer drives to deliver, less access to prenatal care, and, in an emergency, the possibility that they will be far from the help they need when complications arise.
What We Know So Far
According to the CHQPR's June 2026 report, only 41% of rural hospitals in the United States now offer labor and delivery services. In 12 states, fewer than one-third of rural hospitals provide any maternity care at all.
The closures have been sustained and consistent. Since the end of 2020, rural America has lost labor and delivery capacity at an average rate of more than two units per month. The pace in 2025 was among the fastest in the five years, with 27 hospitals closing their units or announcing planned closures, second only to the 34 recorded in 2023, according to Healthcare Dive.
More than 200 rural hospitals have stopped delivering babies over the past decade in total, according to CHQPR data. The current wave since 2020 represents the steepest consecutive five-year decline on record.
Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, described the situation in plain terms. "The number of births are going down, everything is more expensive in rural areas, health insurance plans don't cover the cost of births, and hospitals don't have the resources to offset those losses because they're losing money on other services, too," Miller told Stateline.
Where the Risk Is Highest
The closure rate is not uniform across states. Arkansas has seen 27% of its rural labor and delivery units close since 2020, according to CHQPR's state-level analysis. Among Arkansas rural hospitals that still have labor and delivery units in 2026, 44% are now considered at risk of closing.
Missouri, Nebraska, and other Great Plains states face similar pressure. A January 2026 CHQPR report on Missouri found that 50% of the state's remaining 58 rural hospitals are at risk of closure overall, with 21% projected to close within the next two to three years.
The geographic consequence is measurable. In most urban areas, the travel time to a hospital with labor and delivery services is under 20 minutes. In rural areas, CHQPR data show that travel time is likely to be at least 30 minutes, and often 50 minutes or more. For a pregnant woman experiencing a postpartum hemorrhage, pre-eclamptic seizure, or fetal distress, every minute of that distance carries clinical consequences.
Rural states with the highest proportion of hospitals that no longer offer labor and delivery include states across the South, Plains, and Mountain West, where the combination of low birth volume, provider shortages, and thin hospital operating margins creates the sharpest risk.
What Doctors and Experts Say
Miller has outlined the structural problem in repeated public statements: a labor and delivery unit must always maintain a minimum level of staffing, regardless of how many births actually occur. That includes a physician capable of performing cesarean sections, obstetric nurses, and an anesthetist available for C-sections and labor pain management.
"There's a minimum fixed cost you incur as a hospital to have all of that, regardless of how many births there are," Miller told Stateline. "You can't subsidize a losing service when you don't have profit coming in from other services."
The result is a structural trap. Insurers pay per birth, not for the standby capacity that makes safe birth possible. When birth volume falls, as it has in many rural counties due to population decline and demographic shifts, the fixed costs of maintaining a labor and delivery unit outpace the revenue it generates. Hospitals facing losses across multiple departments cannot use profits from other services to offset those losses when those other services are also losing money.
What the Evidence Shows and What It Does Not
Rural women already face dramatically higher pregnancy-related mortality than their urban counterparts. Research published in the American Journal of Public Health found that from 2016 to 2019, maternal mortality in rural areas was nearly twice as high as in urban areas, with rural rates continuing to rise even as urban rates stabilized.
A separate analysis in ScienceDirect found that during the pandemic years, rural pregnancy-associated death rates for obstetric causes were significantly higher than both suburban and urban rates, and rose further during the pandemic period.
What the evidence does not prove is that closing a specific labor and delivery unit directly causes any individual maternal death. The causal chain is indirect but consistent: longer travel time to obstetric care correlates with higher rates of emergency births, lower prenatal care utilization, and worse neonatal outcomes. When communities lose local maternity services, their emergency rooms see more unplanned deliveries, and their mothers begin prenatal care later, according to CHQPR research.
MedicalDaily Evidence Check
- Source: Center for Healthcare Quality and Payment Reform, June 2026
- What it shows: 139 rural hospital labor and delivery closures or planned closures since end of 2020; 13% reduction; 41% of rural hospitals still offer these services
- What it does not prove: Direct causation between any specific closure and an individual maternal death; the relationship is correlational but well-documented across multiple studies
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What readers should know: Rural communities losing maternity care face higher rates of emergency room deliveries, reduced prenatal care access, and documented increases in maternal and infant risk
Who Faces the Greatest Risk?
The women most directly affected include:
- Those living in rural counties where the nearest hospital with labor and delivery is more than 30 minutes away
- Women with high-risk pregnancies who need access to obstetric specialists, neonatal intensive care units, or emergency surgical capability
- Low-income women in rural areas who rely on Medicaid, which typically reimburses hospitals at rates well below the cost of delivering care
- Women without reliable transportation, particularly in counties without public transit options
- Women in the third trimester who may not have time for extended travel if complications arise suddenly
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Indigenous and Black women in rural areas, who face compounding disparities in both access and outcomes
Symptoms and Warning Signs to Watch For
Pregnant women in rural communities should be aware of warning signs that require immediate emergency care, regardless of distance to a delivery hospital:
- Severe or sudden headache, especially with vision changes or swelling
- Sudden upper abdominal pain, particularly under the ribs
- Heavy vaginal bleeding at any stage of pregnancy
- Signs of preterm labor before 37 weeks, including regular contractions, low back pain, or pelvic pressure
- Decreased fetal movement after 28 weeks
- Fever above 100.4°F during pregnancy or within the first six weeks after delivery
Women in communities without nearby labor and delivery services should establish a detailed birth plan with their provider well in advance of their due date, including the route to the nearest hospital and an emergency contact plan.
What You Can Do Now
- Identify the nearest hospital with a full labor and delivery unit before you reach the third trimester. Travel times in rural areas can be longer than expected due to weather, road conditions, or seasonal closures.
- Ask your prenatal provider which hospital they are affiliated with and whether that hospital has cesarean section capability and a neonatal intensive care unit.
- If you or someone you know is in a rural area with limited maternity access, speak with a clinician about whether a birth plan that includes leaving for the hospital earlier than typical is appropriate.
- Contact your state's Medicaid office to verify whether prenatal and maternity services are covered at your nearest facility.
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Reach out to your county or state health department for information on local prenatal care resources, telehealth prenatal services, and community health workers who may be available in your area.
Cost and Access: What Patients Should Know
Inadequate insurance reimbursement is the central structural driver of rural labor and delivery closures, according to CHQPR. Medicaid payments are typically far below what it costs a hospital to deliver maternity care, and most private insurance plans also pay less than the actual cost of care at small rural facilities with high fixed costs.
For women without insurance, federally qualified health centers can provide prenatal care at reduced or no cost on a sliding-fee scale. Community health workers and doulas may be available through state and county health departments. Telehealth prenatal consultations are increasingly available and can supplement in-person care when distance is a barrier.
Women navigating maternity care in rural areas can also contact March of Dimes for state-specific resources, including information on maternity care deserts and local support programs.
What Happens Next
CHQPR has called for specific payment reforms to prevent further closures, including requiring health insurance plans to cover the fixed costs of maintaining rural maternity units at smaller facilities with lower birth volumes. Without changes to reimbursement policy, the organization projects that additional closures will continue at approximately the current pace.
Federal Medicaid policy changes in 2025 and 2026, including proposed reductions in Medicaid funding, add further pressure to the rural hospitals most dependent on Medicaid revenue. The CHQPR rural hospital monitoring program updates its state-by-state analysis periodically and remains the most reliable ongoing source for tracking which facilities remain at risk.
MedicalDaily will continue covering this story as additional state-level data become available.
The Bottom Line
Rural America is losing maternity care at a rate that has not slowed in five years, and the hospitals still providing it are doing so under mounting financial strain. With 139 rural labor and delivery units now gone or scheduled to close since 2020, rural women in the South, Great Plains, and Mountain West face longer distances, fewer resources, and documented higher rates of pregnancy-related risk than their urban counterparts. Payment reform is the central solution identified by researchers and policy experts. Until it arrives, the closures are likely to continue.
