Michelle Cubbon had her first child, a boy, at St. Catherine of Siena Hospital in Smithtown, New York, a town of more than 100,000 in the middle of Long Island, where the median household income is $143,789 and many residents commute to white-collar jobs in Manhattan. She and her husband, who was also born at St. Catherine, are planning now for a second child. But when she tried to schedule an appointment with her obstetrician, she discovered that the hospital’s maternity unit — a cornerstone of their town for more than a half a century — was shutting down in February 2024.

“I’m back to square one,” said Cubbon.

The reason? High costs of running the maternity care unit and a nationwide staffing shortage left the hospital unable to hire obstetricians. Such closures have hit hardest in rural parts of the US, and are now menacing in politically conservative red states that are wrestling with abortion restrictions. But Cubbon’s experience shows how maternity ward closures can reach into other communities, even in comparatively wealthy, densely populated towns and suburbs outside major cities.

“If we don’t work to fix this broken system, we’re going to continue to see hospital and OB unit closures, which will have disastrous effects,” said Ndidiamaka Amutah-Onukagha, founder of the Center for Black Maternal Health and Reproductive Justice at Tufts University School of Medicine. “Limiting access to care and pushing people further out of their home communities are direct contributors to maternal morbidity. It’s that simple.”

The danger is well known in far-flung communities: 57% of rural hospitals don’t have maternity wards, and many more are in danger of losing their maternal care units. That translates into longer travel times for expectant mothers, who are likely to be 40 or more minutes away from labor and delivery services. In urban areas, by contrast, patients are typically able to get to reach care within 20 minutes.

But the overall proximity advantage enjoyed by city dwellers isn’t the whole story, as urban hospitals that predominantly serve women of color have been disproportionately affected by maternity ward closures. Amutah-Onukagha’s center found that not only are Black communities more likely to lose obstetric units, the racial makeup of patients at a hospital is an even larger determinant of closures than the number of low-income patients insured by Medicaid. The closures are one contributor to the much higher rates of maternal morbidity and mortality that Black women face.

"My hometown of Trenton, New Jersey, is a maternity care desert. The hospital where I and my siblings were born — there are no OB units there to service the residents,” said Amutah-Onukagha. “How is this possible? You can’t give birth in the capital city of one of the wealthiest states in the US?”

Rushing Delivery

A host of challenges, including staffing, costs and declining births, is putting access increasingly at risk. Obstetric units in suburban Cincinnati, Milwaukee and San Diego have already closed in 2024, according to Becker’s Hospital Review, an industry trade magazine. Many women were redirected to hospitals 30 minutes away. Studies have shown that having a drive of more than 30 minutes reduces prenatal visits, while increasing planned cesarean section rates and births that occur en route to the hospital.

While some laboring women, especially those having their first child, may have enough time to make the journey, extended travel can increase the risk, said Holly Meduri, a nurse who helped deliver babies at St. Catherine’s for 22 years before the unit shuttered in February.

“We all have our idealized version of how our labor and delivery is going to go, and then all of a sudden there are problems,” she said. “If you are bleeding or you’re having a real obstetric emergency like the baby’s cord prolapses, those are things that, within minutes, you need to be delivered.”

Prior to closing the maternity ward, the system that owns St. Catherine of Siena, Catholic Health, assessed the impact on medically underserved groups and worked to ensure care wouldn’t be compromised, a spokesperson said.

No Standards

It’s difficult to pinpoint the size of the problem or determine how quickly it’s growing. States don’t have a standard method to disclose changes, and US government data is often incomplete or inaccurate, said Harold Miller, chief executive officer for the Center for Healthcare Quality and Payment Reform, a nonprofit health policy organization.

“If there were a good source of information about labor and delivery service closures, we would be using it rather than trying to assemble the information ourselves,” Miller said. “It’s not even easy to find accurate information about which hospitals have labor and delivery services.”

Most of the available research, including from Miller’s group, focuses on rural areas. But less formal reporting, and a groundswell of attention on social media, shows a broader lens may be needed.

In the first five months of 2024, 19 US hospitals closed or paused their labor and delivery services, according to a list maintained by Becker’s Hospital Review. That compares with 29 for all of 2023. Nearly half of the 2024 closures were in non-rural areas, and six were in communities with household incomes that surpassed the nationwide median.

Maternity Ward Closures Ripple Beyond Rural Areas

The most recent data available, from the March of Dimes, found the loss of obstetric units led to decreased maternity care access in nearly one in 10 counties across the country between 2018 and 2022. There were 2,826 obstetric units in hospitals in 2020, according to research underway from Peiyin Hung at the University of South Carolina, and even those dated numbers may be inaccurate.

Staffing Shortages

Chief among the causes is the shortage of obstetricians and gynecologists, the doctors who focus on the reproductive health of women.

There were about 50,000 OB-GYNs in the US in 2018, about 1,000 fewer than needed, and the total has declined since then, according to the US Department of Health and Human Services. The agency projects the deficit will increase to 5,000 by 2030 as retirements pick up among the nation’s aging physician workforce.

New doctors are unlikely to fill the gap since the number of residency spots funded by the federal government has been largely frozen since 1997. That’s creating a bottleneck in addressing the shortage, said Atul Grover, executive director of the American Association of Medical Colleges Research and Action Institute.

The number of residency applications dipped temporarily after the Supreme Court’s Dobbs v. Jackson decision in June 2022, which rolled back federal abortion protections, Grover said. The ruling creates potential legal ramifications for doctors who perform the procedure on women in medical distress, which can require delicate decisions about when lives are on the line.

And yet the demand for these accredited specialists are among the highest for all physicians, according to AMN Healthcare, one of the nation’s largest health staffing agencies. More pregnancies are occurring in high-risk women, including those who are over age 35, obese or have hypertension, requiring greater expertise.

“Recruitment and retention of this highly trained, skilled workforce is further complicated as many rural and underserved areas do not present as an attractive option,” Amutah-Onukagha said in an email. “Conversely, major cities push talent away with exorbitant cost of living and astronomical insurance rates.”

High Costs

Just keeping the doctors can be difficult — and expensive. At St. Catherine’s, negotiations broke down between the hospital and the obstetricians who used to practice there, and the hospital wasn’t able to hire replacements.

“Despite our best efforts to find alternative options for coverage, as of February 1, there will be no OB-GYN physicians at St. Catherine of Siena to provide maternity services,” a spokesperson said.

Delivering babies is often a money loser, putting them at the top of the list for cuts when hospitals are struggling financially, said Erik Swanson, senior vice president of data and analytics at Kaufman Hall, a health care consulting firm that tracks hospital profit margins. Malpractice insurance rates alone can top $150,000 a year for a single OB-GYN, higher than most surgical specialties.

Maternity wards require specialists, including anesthesiologists and labor-and-delivery nurses, and must be staffed around the clock. Ideally, there should be a one-to-one nursing ratio, said Anne Banfield, a fellow at the American College of Obstetricians and Gynecologists.

The Supreme Court Dobbs decision on abortion can also give hospitals a different cost to weigh, raising legal, moral and ethical questions for doctors who have taken the Hippocratic Oath pledging to do no harm.

There are tight restrictions on the procedure in 14 states currently, and the question of whether it can be performed to protect the health of the woman has been hotly contested. The nation’s top court allowed Idaho to enforce its near-total ban even for women in medical distress for five months in early 2024, until issuing an about-face in June.

Declining Births

Spreading out those fixed costs is getting more difficult. There were 72,000 fewer births in 2023 than a year earlier, according to the Centers for Disease Control and Prevention, even as the number of women aged 15 to 44 grows.

The situation is exacerbated in areas where many patients have Medicaid, the US insurance program for the poor that covers about 40% of births nationwide. It typically only pays a fraction of the cost of care, Grover said.

“When hospitals look at the bottom line, if they’re talking about replacing joints versus delivering babies, they’re going to choose replacing joints all day long,” Banfield said.

Still, some communities have managed to rescue their imperiled obstetric units. In Troy, New York, for example, staffers and community members banded together to save the only maternity ward in Rensselaer County, just east of the capital Albany. Participants in the “Save Burdett Birth Center” campaign organized rallies, issued a community impact survey, and testified at a hearing with the New York Attorney General. As front yards in the region filled with pink lawn signs in support of the facility, the campaign gained the attention of the New York State Assembly, which allocated $5 million to keep the birth center open for another five years.

Nationwide, state and federal officials are taking proactive steps to help make labor and delivery wards viable. In the US Senate, a group of Democratic lawmakers introduced legislation to increase Medicaid reimbursement rates for births in rural hospitals, while California and Virginia have allocated state funds to create new OB-GYN residency spots.

When maternity wards close down, the effects aren’t limited to the communities nearby. Health care workers are forced to adjust, too. Meduri, the St. Catherine’s nurse, retrained to work in the operating room, but it’s not the same.

“I’ve gone from being an expert to the novice,” she said. “It’s a grieving process.”