Closing rural labor and delivery units poses problems for women, babies and rural population growth

Addie Comegys travels 45 minutes for her prenatal visits. 
(Photo by Tony Leys, KFF Health News)

As rural women have fewer babies, hospitals that once served more remote locations have closed their labor and delivery units, which leaves rural pregnant women facing maternity care deserts, reports Tony Leys of KFF Health News. In many areas, women leaving or not wanting to relocate to smaller towns with limited obstetric care has contributed to rural population loss.

Rural areas surrounding Oskaloosa, Iowa, population 11,558, illustrate how obstetric care has become long-distance care for some pregnant women. "At least 41 Iowa hospitals have shuttered their labor and delivery units since 2000," Leys writes. "Those facilities, representing about a third of Iowa hospitals, are located mostly in rural areas where birth numbers have plummeted."

Addie Comegys, who lives in southern Iowa and is expecting a baby in August, has spent part of her summer driving "45 minutes each way for prenatal checkups at Oskaloosa's hospital," Leys writes. "Oskaloosa's hospital has kept its labor and delivery unit open, partly by pulling in patients from 14 other counties." Not every smaller hospital has that geographical benefit.

For women who don't have reliable transportation or flexible work schedules, longer travel to see an obstetric provider becomes a barrier to care. Declining births have accelerated the problem. "Katy Kozhimannil, a University of Minnesota health policy professor who studies rural issues, said declining birth numbers and obstetric unit closures can create a vicious cycle," Leys reports. "Fewer babies being born in a region can lead a birthing unit to shutter. Then the loss of such a unit can discourage young people from moving to the area, driving birth numbers even lower."

Despite delivering far fewer babies, some rural hospitals have kept their units open, but that choice has posed care challenges. "A study published in JAMA in 2023 found that women were more likely to suffer serious complications if they gave birth in rural hospitals that handled 110 or fewer births a year," Leys writes. "The authors said they didn't support closing low-volume units because that could lead more women to have complications related to traveling for care. Instead, they recommended improving training and coordination among rural health providers."

New study reviews eight centers that are working to improve rural postpartum care through innovation and collaboration

A new case study highlights eight community-focused postpartum care centers working to address the unique challenges of postpartum health for rural women. The review from the University of Minnesota looked at programs serving rural communities in Colorado, Maine, Minnesota, Montana, Oregon, South Carolina and Washington.

The goal of each center is to reduce maternal mortality rates, which are disproportionally high in rural areas. Each organization reviewed provides support to rural women and their families through access to obstetric care, mental health services, logistical support and social services during pregnancy and after childbirth.

Researchers cite one of their key findings: "Despite challenges related to transportation, stigma, isolation, and affordability, the organizations profiled here innovate, including in their program offerings and finance models, and collaborate with local and national partners to provide a variety of critical resources to postpartum families in their rural communities. . . . Each organization expressed the importance of stable, secure funding for their work."

In the study, each center is reviewed for rural community context. The Postpartum Resource Group in Whitefish, Montana, is an example. The area "is a mountainous community located near Glacier National Park in northwest Montana. The town is one of only three in the [Flathead] county, which occupies 5,098 square miles and is home to about 108,000 people. . . . ."

Each center in the study is reviewed by discussing its services. In Whitefish, researchers spoke with Brooke Jaszczak, the Network Director of Postpartum Resource Group who gave a program overview: "The Postpartum Resource Group is a non-hospital-affiliated, community-based postpartum mental health support group that was founded in 2016 by a midwife who created a support group with her patients. She recognized the need for such support based on both professional and personal experience, as she was also experiencing postpartum mental health challenges at the time."

The researchers write, "Their mission is two-fold: to provide support, education, and resources for mothers and their families who are experiencing postpartum mood disorders, and to educate and inform the community and providers about postpartum mood disorders."

A discussion of each center's challenges is also shared. "In the Flathead Valley, many local residents struggle to afford basics like housing, food, childcare, and health care due to rising costs. Located near Glacier National Park, the region experienced a population increase during the Covid-19 pandemic, as people moved there to work remotely. The service industry workers were priced out of housing and health care, and a rationing of care and preventive services resulted due to their limited resources. Furthermore, the population is very spread out. Between winter weather and poor driving conditions through the mountain passes, it can be difficult to access areas of the community, its resources, and clinicians."

Researchers hope their analysis will inform and encourage other communities looking to bridge the gaps in rural postpartum health. 

With fewer rural hospitals providing obstetric care, freestanding midwife-led birth centers offer one solution

Without rural maternity care, giving birth is more dangerous.
(Photo by Carlo Navarro, Unsplash)

The number of rural hospitals with labor and delivery care has shrunk as financially strapped hospitals shed services, leaving women to find alternative care closer to home. "One solution gaining ground across the U.S. is freestanding midwife-led birth centers, but those also often rely on nearby hospitals when serious complications arise," reports Claire Rush and Laura Ungar of The Associated Press. "The closures have worsened so-called 'maternity care deserts'—counties with no hospitals or birth centers that offer obstetric care and no OB providers. More than two million women of childbearing age live in such areas, the majority of which are rural."

Less maternity care means having children is more dangerous. "One study showed rural residents have a 9% greater probability of facing life-threatening complications or even death from pregnancy and birth compared to those in urban areas — and having less access to care plays a part," AP reports. "The American Hospital Association says at least 89 obstetric units closed in rural hospitals between 2015 and 2019. More have shuttered since." The main reasons for ending obstetric services include medical labor shortages, lower birth rates, low reimbursements and poor profit margins.

"A lack of money was the major reason why Henry County Medical Center in Paris, Tennessee, closed its OB unit," Rush and Ungar explain. "CEO John Tucker told AP that it was a necessary financial step to save the hospital, which has been struggling for a decade. The percentage of births there covered by Medicaid — 70% — far exceeded the national average of 42%. Tennessee’s Medicaid program paid the hospital about $1,700 per delivery for each mom, a fraction of what the hospital needed, Tucker said. . . . Private insurance pays hospitals more — the median topped $16,000 for cesarean sections in Oregon in 2021. State data shows that’s more than five times what Medicaid doles out."

In Summertown, Tennessee, pop. 900, a new freestanding birthing center is a solution: At The Farm Midwifery Center led by midwife Corina Fitch, where women receive group and individual prenatal care. AP reports, "Some states and communities are taking steps to create more freestanding birth centers. Connecticut Gov. Ned Lamont recently signed legislation that will license such centers and allow them to operate as an alternative for low-risk pregnancies. . . . Alecia McGregor, who studies health policy and politics at the Harvard T.H. Chan School of Public Health, called midwife-led birth centers 'a major sort of contender among the possible solutions' to the maternity care crisis."

The vast gaps between deaths of black and white babies in Southern states look like a crisis with no clear solution

Photo by E+, Getty Images, via KFF Health News

Black babies in Southern states have a much higher risk of dying in their first year than white infants. The South is "where infant mortality is by far the highest in the country, with Mississippi's rate of 8.12 deaths per 1,000 live births ranking worst. . . . Nationally, the average is about 1% for Black infants and less than 0.5% for white infants," reports Lauren Sausser of KFF Health News. Even Southern states making progress still have big gaps: "In Florida and North Carolina, the Black infant mortality rate is more than twice as high."

The figures "reflect politics," Sausser writes. "They're a direct product of generational poverty and racism. . . . Often, babies die under circumstances that state, communities, and parents can help control, like making sure infants don't suffocate in beds or in unsafe cribs or extending health coverage so that young women can afford to see a doctor before they become pregnant. In many of these respects, the South is failing."

Addressing the problem means understanding the causes, and that has been difficult. "Multimillion-dollar programs to improve South Carolina's numbers over the past decade have failed," Sausser reports. "To make things more complicated, separate state agencies have reached different conclusions about the leading cause of infant death." To address prenatal care deficits, "South Carolina and several other states recently extended postpartum Medicaid coverage for women who give birth, which means their coverage remains in place for one year after delivery. Historically, Medicaid coverage was cut off 60 days after having a baby," Sausser writes. "Even when they become pregnant and are newly eligible for Medicaid, it isn't unusual for women in South Carolina to put off seeing a doctor until the third trimester, physicians told KFF Health News. These women can't afford to take time off work, can't find child care, or don't have a car, among other reasons."

When rural hospitals stop delivering babies, fewer expectant mothers receive prenatal care, Iowa study finds

University of Missouri Health Care photo

When rural counties lose their last labor-and-delivery unit, fewer expectant mothers in those counties get adequate prenatal care, even though that care is still available, according to a University of Iowa study.

 “Our study reflects continuing problems in our maternal health system in general, and in rural areas in particular,” Tom Gruca, co-author and professor of marketing, said in a news release. “It suggests a breakdown of maternal health care in rural areas.”

The study, published in the Journal of Rural Health, looked at the impact of the closure of seven labor and delivery units in 2018 and 2019 in rural Iowa, where prenatal care continued after the closure of those units. 

The researchers found that 18 percent of expectant mothers were making an inadequate number of prenatal care visits to a doctor in those hospitals before the closings. Following the closing, that number increased to 22%. “And 18% is not a great number, to begin with,” Gruca said.

Research shows that prenatal care reduces preterm birth and low birth weight babies. 

"All women in rural counties where the only labor-and-delivery unit closed have a 24% higher likelihood of having inadequate prenatal care compared to those in counties that still have a unit. For women enrolled in Medicaid, the difference is even more pronounced, with a 38% higher likelihood of receiving inadequate prenatal care," says the release. 

The researchers said the drop in prenatal-care rates might be attributed to expectant mothers' thinking that the hospital did away with all maternity services when the labor-and-delivery unit closed. They said poor mothers' access to prenatal care is complicated because not all health care providers accept Medicaid. 

Gruca said one solution could be creation of a central source of information that expectant mothers can use to find health-care professionals who provide the care they need and accept the insurance they have.

Rural hospitals keep closing their maternity units, leaving many women far from care and their babies at more risk

Hills outside of Toppenish, Washington. Ambulances are often slow to arrive on the Yakama Indian Reservation, which spreads over a million acres. (Photo by Ruth Fremson, The New York Times)

Suspensions of obstetric services in rural hospitals "appear to have accelerated" in the last year, "as hospitals from Maine to California have jettisoned maternity units, mostly in rural areas where the population has dwindled and the number of births has declined," reports Roni Caryn Rabin of The New York Times. "A study of hospital administrators carried out before the pandemic found that 20 percent of them said they did not expect to be providing labor and delivery services in five years’ time."

The closings are predicted to continue. "From 2015 to 2019, there were at least 89 obstetric-unit closures in rural hospitals across the country. By 2020, about half of rural community hospitals did not provide obstetrics care, according to the American Hospital Association," Rabin writes. "In the past year, the closures appear to have accelerated, as hospitals from Maine to California have jettisoned maternity units, mostly in rural areas where the population has dwindled and the number of births has declined."

Hospital closures leave pregnant women feeling vulnerable and betrayed. Rabin reports from Toppenish, Washington, where "frustration and fear erupted at a recent City Council meeting, which drew such a large crowd that it spilled into the hallway outside the chambers." Astria Toppenish Hospital "had committed to keeping certain services, including labor and delivery, available for at least a decade after acquiring the hospital," Rabin writes. "Now the hospital said it could not afford to do so, and the state has taken no action." Leslie Swan, a Native American doula, told Rabin, “There will be lives lost — people need to know that."

Toppenish is on the Yakama Indian Reservation, but is "the canary in the coal mine" for other rural hospitals' obsttric units, Cassie Sauer, president and chief executive of the Washington State Hospital Association, told Rabin, who writes, "The closure in Toppenish mirrors national trends as financially strained hospitals come to a harsh conclusion: Childbirth doesn’t pay, at least not in low-income communities."

Obstetric units are expensive. They "must be staffed 24 hours a day, seven days a week, with a team of specialized nurses and backup services, including pediatrics and anesthesia," Rabin reports. "In Washington State, Medicaid would pay $6,344 for a childbirth, about one-third of the $18,193 paid by private plans, according to an analysis by the Health Care Cost Institute. . . In wealthier communities, private insurance helps offset low Medicaid payments to hospitals. But in rural areas where poverty is more entrenched, there are too few privately insured patients."

Rabin recounts the downward spiral of U.S. maternal care: "The United States is already the most dangerous developed country in the world for women to give birth, with more than one death for every 5,000 live deliveries. . . . Recent figures show that the problems are particularly acute in minority communities and especially among Native American women, whose risk of dying of pregnancy-related complications is three times as high as that of white women. . . . According to the March of Dimes, the maternal health nonprofit, seven million women of childbearing age reside in counties where there is no hospital-based obstetric care, no birthing center, no obstetrician-gynecologist and no certified nurse midwife, or where those services are at least a 30-minute drive away."

That has effects on mothers and babies, the Centers for Disease Control says: "Severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health. Using the most recent list of indicators, SMM has been steadily increasing in recent years and affected more than 50,000 women in the United States in 2014."

Pregnancy riskier for rural women without health insurance

Illustration by Alexis Jang, The New York Times

The physical demands of pregnancy are risky, and "Women and birthing people in rural America are at higher risk of adverse maternal-health outcomes, including maternal morbidity and mortality . . . One possible factor: lower enrollment in health insurance," the University Michigan reports on a study by researchers there. "Residents of rural communities had lower rates of continuous health insurance before, during and after pregnancy compared to those in urban cities."

Lead author Dr. Lindsay Admon said in the news release, "Being uninsured during the time of pregnancy has been associated with less adequate prenatal and postpartum care, which decreases opportunities to address risk factors affecting health outcomes for both the birthing person and baby. . . . Our study suggests that uninsurance disproportionately affects rural residents during pivotal stages of pregnancy."

To flesh out disparities, "Researchers analyzed survey data from 154,992 post-partum individuals in 43 states in 2016-19, including roughly 16 %, or 32,178, rural residents," the release says. "They compared rates of those without any insurance or had gaps in coverage between rural and urban residents during preconception, at the time of birth, and postpartum."

Admon noted, “Rural inequities persisted regardless of age, marital status or insurance type. But these differences were even more significant among specific racial and ethnic groups." The release says: "In each of the three periods, rural residents who were non-Hispanic white, married, and with intended pregnancies experienced greater odds of less adequate or consistent insurance compared to their urban counterparts. They were also less likely to have commercial health insurance during any of those times."

Insurance that extends past 60 days after birth also needs review, the release says: "This lack of coverage the year after pregnancy is especially worrisome, Admon says, since rural residents without postpartum insurance in the study were more likely to be older than 35 and have obesity or chronic hypertension compared with uninsured urban residents." Admon added, "We need to explore policies that help increase insurance enrollment during all phases of pregnancy and that account for rural differences . . . Health insurance is critical to accessing quality healthcare and improving maternal health in the U.S. We hope these findings help inform policies that address rural–urban inequities in maternity care access and maternal health across the country."

Congress's auditing arm says states could keep more rural delivery rooms open by raising Medicaid reimbursements

Increasing state Medicaid reimbursement rates for rural hospitals could help them keep their obstetric units open, the Government Accountability Office said in a report Wednesday.

More than half of rural counties "did not have such services in 2018, according to the most recent data available," the report notes. "Studies showed that closures were focused in rural counties that were sparsely populated, had a majority of Black or African American residents, and were considered low income."

The GAO, the auditing arm of Congress, interviewed stakeholders, who said Medicaid reimbursement and physician recruitment and retention are the most important factors in keeping delivery rooms open. "Stakeholders said Medicaid reimbursement rates set by states do not cover the full cost of providing obstetric services. This may mean particular financial losses for hospitals providing these services in rural areas, where a higher proportion of births are covered by Medicaid. Medicaid covered 50 percent of rural births in 2018, compared to 43 percent of births for the United States as a whole."

"Recruiting and retaining providers is particularly challenging for rural areas, as they must compete with urban areas for a limited pool of providers to staff obstetric units that require a full range of maternal health providers, such as physicians and nurses, as well as anesthesiologists." The report said obstetric services would also benefit from more remote consultations, such as videoconferencing, to {ensure that rural patients who live longer distances from higher levels of obstetric care have access to such care through their own clinicians in their communities."

The report also suggests "establishing regional partnerships—such as a hub-and-spoke model where a larger hospital partners with smaller rural hospitals for care coordination and to provide training and other resources. . . . For example, a specialist from the hub hospital could help manage a rural patient's high-risk condition as needed and support the rural clinician for planning delivery at the local hospital."

USA Today series shows gaps in health care for rural moms

USA Today's Nada Hassanein has just published a four-part series on disparities in health care among rural mothers. Part one has an overview of the issue; part two focuses on inequalities among rural indigenous people; part three has data on maternal mortality among rural women of color, and part four explores the historical roots of the phenomenon.

"About 2 million rural women of childbearing age live in maternity care deserts at least 25 miles away from a labor and delivery unit," Hassanein reports. "Rural hospitals and obstetric wards, already scarce, have continued to shut down in record numbers. Women of color are even more vulnerable . . . and the federal government has only recently started to identify the problem. The maternal death rate for rural Black women is three times higher than for rural white women, a 2021 Government Accountability Office report found, and the rate of severe maternal illness for those Black mothers was twice that of white women.

"The Covid-19 pandemic made matters worse. The nation’s overall maternal death rate increased, and disparities widened. While the death rate for white mothers rose in 2020 from about 18 to 19 deaths per 100,000, Black mothers' death rates remained three times as high, soaring from 44 to 55 deaths. Hispanic mothers' death rates also surged, from 12 to 18 per 100,000, according to the CDC. At the same time, half of rural hospitals already had no obstetric care, and two dozen hospitals shut down entirely."

Stories from three states show higher risk of pregnancy and childbirth in rural areas, as abortion laws pose complications

Pregnancy-related mortality per 100,000 live births
(Daily Yonder graph, adapted by The Rural Blog)

"Rural women are twice as likely to die from pregnancy complications than women in large metropolitan areas, federal data shows," Sarah Melotte reports for The Daily Yonder. The lack of pregnancy and childbirth care in rural hospitals, especially for high-risk cases, contributes to the problem. And rural women of color and their babies face even worse odds. Stories out of Montana, Nebraska and Texas illustrate the overall trend, made more worrisome fears that that eroding abortion rights will increase the number of high-risk pregnancies. Montana State University sociologist Maggie Thorsen told Melotte that the U.S. is already "the only industrialized country in the world that has a growing maternal mortality rate."

Fewer than half of the nation's rural counties had obstetric services in 2019, a Commonwealth Fund study found. Many hospitals have shuttered them (a trend the pandemic has accelerated), citing expense, lack of personnel, and declining rural birthrates. "Women unable to reach obstetrics units in time to give birth can end up delivering in an emergency room en route to the desired hospital. This can have deadly consequences for individuals with high-risk pregnancies," Melotte reports. "Common complications associated with these births include hemorrhaging, preterm birth, and preeclampsia."

A recent study of Montana maternity deserts illustrates the trend. Thorsen and others found that pregnant Montanans drove an average of 42 minutes from home to give birth, but that trips of several hours were not unusual. About 44% of the state's population lives in rural areas, more than twice the national average, Melotte reports. About half of its counties are maternity-care deserts, and 10% of the state's population—some 93,000 people—live in those deserts.

Native American women in Montana have even higher rates of complications or death in childbirth. Indigenous women (who tend to live in rural areas) are less likely to live within an hour's drive of high-level obstetric services than white women; not many Indian Health Services hospitals in the state provide such services, Thorsen told Melotte.

A story from Nebraska highlights other facets of the issue. Emergency help can be hard to access in rural areas. One rural woman who had preeclampsia called an ambulance, but it took so long to get there that she ended up giving birth in the ambulance, assisted by an EMT who had never delivered a baby, Addie Costello reports for the Flatwater Free Press. Local primary-care physicians can provide some obstetric services, but many are retiring and not enough doctors are replacing them.

Many rural hospitals can't afford to maintain obstetric units since rural births are more likely to be covered by Medicaid than by private insurance. Nebraska Medicaid reimburses at half the private rate, Costello reports. The story also emphasizes health disparities for women of color and their babies.

In Texas, which leads the nation in maternity-ward closures, a recent story presents one of the more extreme examples of a maternity desert: Big Bend Regional Medical Center is the only hospital in 12,000 square miles. It has an obstetric unit, but for more than a year that unit "has closed routinely, sometimes with little notice. Some months it’s been open only three days a week," Claire Suddath reports for Bloomberg. "Big Bend doesn’t really have a choice. In the past two years, almost all its labor and delivery nurses quit. The hospital has tried to replace them, but the national nursing shortage caused by the pandemic has made that impossible. When Big Bend is too short-staffed to deliver a baby safely, its labor and delivery unit has to close."

The staffing shortages also extend to Big Bend's ambulances; the county has two, but only enough EMTs to run one. And when the hospital can't deliver babies, the ambulance must drive a patient to the nearest hospital that can. That means the area's only ambulance is out of pocket for at least five hours.

Canadian study links living near hydraulic-fracturing wells before and during pregnancy to poor birth outcomes

Hydraulic-fracturing wells in relation to
communities in Alberta, 2013-2018
(University of Calgary map)

A newly published study adds to growing evidence that living near hydraulic fracturing wells can harm infants and children. University of Calgary researchers studied nearly 35,000 pregnancies in rural Alberta from 2013 to 2018, and found that people who lived within 10 kilometers of 100 or more fracking sites in the year before getting pregnant were significantly more likely to give birth to infants who were premature and/or small for their gestational age.

"Past studies conducted in California and Pennsylvania have linked exposure to fracking sites and risk of spontaneous preterm birth," Lei Lei Wu reports for MedPage Today. "In addition, previous U.S. studies have suggested that living near fracking sites is associated with greater risk of mortality among the elderly, as well as heightened risk of heart failure.

Several factors could explain the link between fracking wells and adverse birth outcomes, the researchers said. "The quality of water and air may be lower near fracking sites due to contamination and the constant activity of heavy trucks, they noted, adding that around 90% of rural Albertans rely on groundwater for drinking," Wu reports. "They also noted that of the 240 chemicals in fracking fluids with toxicity information available, 103 are linked to reproductive toxicity."

Rural hospitals have accelerated maternity ward closures during pandemic, citing lack of personnel and money

Hospitals have been shuttering maternity wards for years, but the trend seems to have accelerated during the pandemic, especially in rural and Black or Hispanic communities. That will likely hurt health outcomes for rural pregnant women and their babies.

The U.S. "already sees far more deaths per capita among infants and pregnant women than comparably wealthy countries. And during the first year of the pandemic, the number of maternal deaths in the United States rose sharply," Dylan Scott reports for Vox. "Researchers from the University of Minnesota have found when a labor and delivery department closes, there tend to be more emergency deliveries and more preterm births, which are the leading cause of infant mortality."

Rural and minority communities are less likely to have access to all types of health care as it is, including obstetrics. "Before the recent closures, more than half of the rural counties in the United States already didn’t have a nearby hospital where babies could be delivered," Scott reports.

Hospitals cite various factors for closing maternity wards, including declining birthrates and staff shortages. And with fewer births, hospitals worry that staffers' obstetrics skills might get rusty, leading to worse health outcomes for patients, Scott reports.

Finances are also an issue. "Pandemic relief funding that has helped stabilize hospitals’ finances is also starting to run out," Scott reports. "Some hospitals argue that these closures are not financially motivated, but labor and delivery services are not a moneymaker for them. More than 40 percent of births in the United States are covered by Medicaid, and the program’s low reimbursement rates have been cited in the past to explain a hospital’s decision to close its OB department."

Closing a maternity ward can also hurt a community's relationship with the hospital. "There is a fundamental shift in a rural community when a hospital closes its OB unit," University of Minnesota professor and maternal mortality expert Katy Backes Kozhimannil told Scott. "It’s like a place where you can’t even be born. You can only die. The sense of that is really palpable."

Pandemic roundup: why Covid can cause stillbirths; peer-to-peer mental health services for farmers; nearly 1 in 5 health-care workers have quit since the beginning of the pandemic

Here's a roundup of recent news stories about the pandemic and vaccination efforts:

It's already well established that stillbirths have increased in many areas with high Covid-19 rates. Now a new study suggests why: A coronavirus infection can invade and destroy the placenta, likely leading to stillbirths, the study says. Read more here.

Nearly a fifth of American health-care workers have quit since the beginning of the pandemic as they get increasingly burned out by the demands of overcrowded hospitals. A portrait of a Minnesota hospital shows what that stress looks like. Read more here.

Worker burnout is only one reason hospitals can't handle the new normal, says one analysis. Rural hospitals especially will continue to lose out: Urban hospitals with deeper pockets will keep poaching rural staff (example: traveling nurses), enabling lucrative elective surgeries. Smaller hospitals will continue to shoulder a disproportionate share of mild-to-moderate Covid-19 patients and will be more likely to have to pause elective surgeries and other non-Covid care. Read more here.

During the Delta variant surge last summer, rural counties with low vaccinations rates were hit the hardest, researchers found. Counties where the coronavirus vaccination rate was below 30% saw nearly double the case rate of counties where vaccination rates were over 50%. Read more here.

The pandemic has increased farmers' need for mental-health services, but many are reluctant to admit they need help. Programs that teach peer-to-peer counseling can be especially effective, but those and other programs may need more funding to remain sustainable. Read more here.

In January, more than 3,000 hospitalized patients became infected with the coronavirus during their stay, more than in any other month of the pandemic, new data show. Read more here.

The Food and Drug Administration delayed its review of Pfizer's coronavirus vaccine for children under 5 years old earlier this month. Sources familiar with the decision now say it's because a few children in the study got breakthrough infections of the Omicron variant after two doses of the vaccine. Since so few people get breakthrough infections, even a handful could be statistically significant. FDA officials and Pfizer agreed it would be better to wait for a larger sample size to assess the vaccine's effectiveness for that age group with both two doses and three doses. Results are expected in early April. Read more here.

Midwives can help fill the rural childbirth services gap, but say they're burned out and need better reimbursement

Rural women have less access to maternity and childbirth services, a trend only made worse by the coronavirus pandemic and one that contributes to higher mother and child mortality rates in rural areas, especially among people of color. Midwives are stepping in to help fill the gap, often with government support, but many are facing the same kind of stress and burnout other health-care professionals have reported, and say they aren't being reimbursed enough, reports Aallyah Wright of Stateline.

"In interviews with Stateline, midwives from rural areas say they’re overwhelmed and facing burnout because of an uptick in patients—even as they’re eager to help," Wright reports. "Doulas, who assist parents during childbirth but don’t provide medical care, also are seeing an increase in demand."

The need is great. More than half of rural counties don't have a hospital that delivers babies. That endangers the lives of mothers and infants; rural American women and infants face significantly higher mortality rates than in other wealthy countries. Many pregnant women who don't live near a hospital with obstetrical services have transportation problems that make it difficult to get to one further away that does. And even women who can make the trip are often pressured to give birth by scheduled Caesarian section, which carries health risks, rather than chance going into labor and not being able to make it to the hospital on time.

Other barriers to access have emerged during the pandemic: many pregnant women haven't felt safe going to a hospital or haven't been able to contact their care providers, Wright reports. Those issues, along with pandemic hospital staffing shortages, have prompted many pregnant women to turn to midwives.

"Some states, recognizing a dire need for midwifery and doula support services, have passed laws to expand care, while members of Congress are considering federal investment. Rural health experts and leaders stress that policies should focus on the challenges of affordability, insurance coverage and lack of providers in rural areas," Wright reports. "This year, at least eight states—Arizona, Arkansas, California, Colorado, Connecticut, Louisiana, Nevada and Rhode Island—have passed laws that aim to improve birthing outcomes. Many of the laws have expanded Medicaid and other health insurance coverage for midwifery and doula services, required health facilities to allow doulas to attend births or increased pathways for students to become licensed midwives."

But some states don't recognize midwives as qualified medical providers or limit what services they can provide. And even in the states that do, many midwives say the government isn't reimbursing them enough for Medicaid patients. "The Biden administration’s proposed Build Back Better Act would provide additional funding for postpartum Medicaid coverage as well as financial and programmatic support for doulas and nursing students, "Wright reports.

Such legislation can help, "but it’s going to take more rural-centric, comprehensive policies to fix health infrastructure needs in rural America that have been exacerbated by the pandemic, said Katy Kozhimannil, health researcher and director of the Rural Health Research Center at the University of Minnesota," Wright reports. "Those needs include recruiting and retaining a skilled workforce and finding ways to keep labor and delivery units open despite relatively few births. Many rural hospitals have taken a financial hit, Kozhimannil said, and the pandemic has caused them to reduce services."

Rural women face dwindling access to hospital childbirth services; Connecticut woman's ordeal is an example

A rural Connecticut woman's recent ordeal highlights a recent study noting that rural women, especially in communities of color, often have more difficulty accessing hospital childbirth services.

Shantell Jones lives in Windham, a town of 25,000, 41 percent Latino. She lives six blocks from a hospital, but when she went into early labor the ambulance had to drive to another one 30 minutes away because Windham Hospital shuttered its labor and delivery services last year, Jean Lee reports for NBC News. Ten minutes into the drive, Jones gave birth in the ambulance as it parked by the side of the highway, and though she and her son are healthy, others are not so lucky sometimes. 

Pregnant women without easy access to a hospital with obstetric services could be at an increased risk of giving birth prematurely, giving birth in an emergency room, or outside of a hospital entirely, public-health experts say. Thousands of other pregnant rural women are facing that risk as hospitals reduce or close obstetric services to cut costs. "Nationwide, 53 rural counties lost obstetrics care from 2014 through 2018, according to a 2020 study in the Journal of the American Medical Association." It also found that 1.045 of the out of 1,976 rural counties "never had hospitals with obstetrics services to begin with."

Communities of color and those with high poverty rates are especially at risk. Not only are they more likely to lose or never have local obstetric services, but they're more likely to have transportation issues or lack insurance that would cover a pricey ambulance ride to a hospital further away, Lee reports. Local ambulance services might not be able to respond as readily because they're stretched thin too.

Quick hits: Future of farm shows; ghost towns sold; defining rurality; doulas increasingly popular in rural pregnancies

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email heather.chapman@uky.edu.

Farming experts have a web discussion on YouTube about the future of farm shows, what needs to change, and what needs to be preserved. Read more here.

What happens when a town is abandoned? Sometimes real-estate agents sell the whole thing as a ghost-town package. Read more here.

A Daily Yonder piece discusses why it's so difficult to define rurality, and lays out the most common definitions of "rural," who uses them, and why. Read more here.

Rural residents often have less access to childbirth services, but a specialized health-care worker called a doula is becoming increasingly popular in rural communities to help provide support to mother and child during pregnancy and after birth. Read more here.

Rural hospitals that joined chains were more likely to stop maternal and neonatal services, limit mental-health access

Average number of hospital stays for maternal/neonatal care, surgical services and mental health/substance-use disorder, for merged and independent hospitals (Health Affairs graph; click on the image to enlarge it)

Rural hospitals that were acquired in mergers from 2009 to 2016 were more likely than their independent peers to shutter their maternal, neonatal and surgical services, and more likely to limit access to mental-health care, on-site diagnostic technologies, and non-emergency outpatient services, according to a newly published study in the journal Health Affairs.

In essence, the researchers found, a merger might save a hospital from closing, but make it less responsive to community needs. Merged hospitals were also less likely to be critical-access hospitals, and more likely to be privately owned, have more beds than average, and be located in the South.

The study compared 172 rural hospitals that merged with larger systems between 2009 and 2016 and compared them with 549 hospitals that remained independent, using data from annual American Hospital Association surveys. In the year after hospitals were acquired, the average number that provided any maternal or neonatal services fell 6.7 percentage points more than independent hospitals. Two years afterward, that gap increased to 7.2 percentage points, but at three years post-merger and beyond, the gap virtually vanished.

One year after being acquired, merged hospitals were 5 percent less likely like to offer surgical services than independent hospitals. The statistical gap became insignificant two and three years after merger. Analysis showed that locals weren't accessing those services elsewhere nearby, so the data suggests that the merger didn't generally hurt patient access to inpatient care.

Admissions for patients with mental-health issues or substance-use disorders stayed about the same for the first two years after hospitals were acquired, but increased during the same time period for independent hospitals. That and other data suggests that communities with merged hospitals may have reduced access to behavioral health care.

The study is the second from the federal Agency for Healthcare Research and Quality and IBM Watson Health to examine the benefits and consequences to health-care access for people whose local hospital was acquired. The first one found that merged rural hospitals had lower overall lower death rates, especially from heart attacks.

Religious exemptions for vaccinations were on the rise even before Biden mandate, which will take months to implement

"Religious exemptions are becoming another major flashpoint in the Covid-19 vaccination debate. Even though the world's major religions generally support the use of vaccines to control infectious disease, some religious-liberty advocates maintain that vaccine mandates must accommodate people who refuse because of deeply held religious beliefs," Jay Tokasz reports for The Buffalo News. "Others say the religious exemption threatens public-health efforts by giving people who disagree with vaccine mandates for political reasons an easy loophole."

The notion is becoming particularly popular among conservatives and evangelical Christians, two frequently overlapping demographics that are among the most resistant to the coronavirus vaccine. "Mat Staver, the founder and chair of Liberty Counsel, a conservative Christian legal organization, said his group had received more than 20,000 queries on religious exemptions in recent weeks," Ruth Graham reports for The New York Times. "In rural Hudson, Iowa, Sam Jones has informed his small congregation at Faith Baptist Church that he is willing to provide them with a four-paragraph letter stating that 'a Christian has no responsibility to obey any government outside of the scope that has been designated by God.'"

Major religions almost unanimously support coronavirus vaccination. Albert Mohler, president of the Southern Baptist Theological Seminary in Louisville, gave Christians the green light to get vaccinated when vaccines were released in December, and offered seven points to consider as they decide whether to get the shots, generally encouraging vaccination.

Anecdotally, the resistance seems to come largely from resentment toward a Democrat-issued mandate like the one President Biden issued Friday, one that will take months to implement. The same groups resisting the vaccine in Mississippi have made little fuss in recent years over state vaccination mandates for routine childhood maladies such as measles, polio and chicken pox, Sheryl Gay Stolberg reports for the Times. The Republican-led state has some of the strictest vaccine mandates, with no exceptions for religious or philosophical objections.

The widespread resistance to the coronavirus vaccine mandate is already causing trouble, Timothy Bella reports for The Washington Post. Lewis County General Hospital in rural New York will no longer deliver babies because it's too short-staffed; at least six maternity ward employees quit over the mandate.

FOLLOW-UP: A Tulsa pastor is offering to write religious exemptions in exchange for cash. In just a couple days, more than 30,000 people have downloaded the form from the church's website.

U.S. birth rate falls as young women delay childbearing to focus on school and work; decline seems less in rural areas

Change in birth rate by county. In 1996-2007, rates grew fastest in small cities and rural areas; in 2007-2019, they fell nearly everywhere. New York Times maps, adapted by The Rural Blog. Click map to enlarge; here for interactive version.

Younger women across the U.S., including in rural areas, are increasingly delaying childbearing to focus on education and careers. "The result has been the slowest growth of the American population since the 1930s, and a profound change in American motherhood," Sabrina Tavernise, Claire Cain Miller, Quoctrung Bui and Robert Gebeloff report for The New York Times. "Women under 30 have become much less likely to have children. Since 2007, the birth rate for women in their 20s has fallen by 28 percent, and the biggest recent declines have been among unmarried women. The only age groups in which birthrates rose over that period were women in their 30s and 40s — but even those began to decline over the past three years."

The trend became evident in the past decade, with the birth rate falling fastest in places with the highest job growth (which are more often metro counties). No cause has been established, but women in such areas may therefore have more of an incentive to delay motherhood, said Caitlin Myers, a Middlebury College economics professor who analyzed county-level birth records for the Times. As women become more educated, they become more convinced that motherhood has a price, she said.

It's happening in rural counties, too, though not as much as in metro counties. "The large urban counties that have gained the most jobs and population since the recession have seen birthrates fall twice as fast as smaller, rural counties that have not recovered as strongly," the Times reports. Fertility tends to be higher in economically stagnant areas, and childbearing often has more cultural importance for women.

Also, anecdotal evidence suggests that rural women seeking higher education may have skewed the numbers toward metro counties by moving to cities to pursue a degree and a career afterward. Several women interviewed in the Times story had done just that. 

Percentage of people 25 and up with at least a bachelor's degree, from 2005-09 on the left, and 2015-19 on the right. U.S. Census Bureau maps, adapted by The Rural Blog. Click the image to enlarge it or click here for the original report.

Rural women at higher risk of birth complications, death; toolkit can help rural areas plan maternal-health programs

Rural residents are at a higher risk of death during pregnancy or within a year after birth from pregnancy-related causes, according to newly released data from the Centers for Disease Control and Prevention. reviewed by the Government Accountability Office. The data covers 2011 to 2016, the most recent data available at the time of the review.

 Overall, pregnancy-related deaths in the U.S. increased about 3% from 2000 to 2015, the GAO reports, and rural women face increased risks.

The pregnancy-related mortality rate in the largest metropolitan counties during that time was 14.6 per 100,00 live births. That's compared to 16.2 in medium and small metro counties, 19.8 in micropolitan counties, and 23.8 in noncore counties, the most rural. Black women were more likely to die or suffer health complications than women of other ethnicities, across population size. Much of this is due to lack of obstetric and prenatal services.

In related news, the Rural Health Information Hub has launched a Rural Maternal Health Toolkit meant to help rural communities learn how to plan, create and fund maternal-health programs. Read more here.