The closure of labor and delivery (L&D) units is a rapidly accelerating trend across the United States. This issue is especially pronounced in rural areas, where over 100 rural hospitals have stopped offering birthing services since the end of 2020. The decline in local hospital-based obstetrics affects expectant mothers and the broader healthcare system. The loss of these units creates “maternity deserts,” areas where access to local birthing facilities is severely limited or nonexistent.
Financial and Economic Pressures
The provision of labor and delivery services requires a hospital to maintain substantial fixed costs regardless of the number of babies born. A fully operational L&D unit must be ready 24 hours a day, seven days a week, demanding constant staffing by specialized personnel and the availability of operating rooms for emergency procedures like Cesarean sections. Hospitals must also have specialized equipment for both maternal and neonatal care, a significant financial outlay that smaller facilities with low birth volumes struggle to absorb.
These high fixed costs are often compounded by an unfavorable payer mix, particularly in rural hospitals. Medicaid, which has lower reimbursement rates than commercial insurance, covers approximately 47% of births in rural areas. This reliance on low-reimbursing government payers means the revenue often fails to cover the actual cost of providing specialized care. Closing a low-volume L&D unit, while detrimental to the community, is often the most effective step a small hospital can take to improve its overall financial stability, as many units already operate at a loss.
Workforce Crisis and Staffing Shortages
The lack of specialized personnel is a major factor forcing L&D closures, even in some financially solvent facilities. Labor and delivery requires a highly specific team, including obstetricians, specialized L&D nurses, and anesthesiologists, who must be available instantly. The demand for these providers far outpaces the supply; the U.S. is projected to meet only 82% of the anticipated demand for OB/GYNs by 2037.
This shortage is exacerbated by high rates of burnout among existing staff. Nearly 30% of OB/GYNs report burnout, driving experienced physicians to leave the profession earlier. Geographic disparities make staffing difficult for rural hospitals, which cannot compete with the salaries or call schedules offered by larger medical centers. Specialized staff are often unwilling to live in isolated areas or shoulder the immense on-call burden of a low-volume unit, forcing units to cease operations.
The Role of Malpractice and Liability Costs
Obstetrics is statistically one of the highest-risk medical specialties for litigation, translating directly into extremely high insurance premiums. Birth-related injury claims often involve large payouts because they can result in lifelong care needs for the infant. The expectation of a perfect outcome in every delivery makes any adverse event a potential cause for a lawsuit.
OB/GYNs face some of the highest malpractice insurance premiums of any medical specialty, sometimes exceeding $200,000 annually. This enormous cost acts as a barrier for hospitals operating on thin margins and for independent practitioners. High liability costs lead approximately 30% of OB/GYNs to stop delivering babies within 12 years of practice, shifting to gynecological care only. For small, rural hospitals, covering insurance for a specialized team can render the L&D unit financially unsustainable, forcing closure to mitigate risk.
Impact on Patient Access and Health Outcomes
The closure of local L&D units has severe consequences for patient access, creating vast areas known as “maternity deserts.” These are counties that lack any hospital, birth center, or obstetric provider. Over 35% of all U.S. counties currently qualify as maternity deserts, affecting millions of women of childbearing age.
In rural communities, the loss of an L&D unit means pregnant women face significantly longer travel times to the nearest birthing facility. For 70% of rural hospitals that have closed units, the nearest alternative is now more than 30 minutes away. This increased travel time during labor is associated with a higher risk of complications, including emergency roadside deliveries and delays in receiving time-sensitive interventions.
Pregnant individuals living in these deserts have poorer health outcomes, including higher rates of preterm birth and increased maternal and neonatal morbidity. These negative effects are disproportionately felt by vulnerable populations, such as women of color and those with lower incomes. The lack of local care compromises the continuous prenatal and postpartum monitoring vital for safe pregnancies.