Leandra Wright (40) is expecting her seventh child in Bonner County, Idaho.
Wright's due date is August. However, three weeks ago the hospital where she planned to give birth, Bonner General Health announced that they would suspend their labor and delivery service in May.
She now faces a potentially dangerous drive to a hospital located 45 minutes away from her house.
Wright stated that the situation was "frustrating and worrying."
Wright is no stranger to fast labors. Her 15-year old son, Noah was born as she drove to the hospital.
Wright stated that her fifth child was delivered on the side of a highway. It was wintertime and the hospital was 40 minutes away in California. The roads were icy and we couldn't get there in time.
When she and Noah arrived at the hospital about 15 minutes after his birth, Noah's body temperature was below normal.
Wright said, "It makes me nervous not having a doctor on site and to have to deal with that."
The closure of maternity units is not a problem that only affects residents in Bonner County.
According to a chartis report, 217 hospitals have closed their labor-and-delivery departments in the United States since 2011.
CNN has tallied at least 13 closures in the last year.
The services provided by maternity units can vary from one hospital to another. The majority of maternity units offer obstetrics, which is a form of care where an obstetrician delivers a baby either vaginally (via cesarean) or by c-section. These units provide perinatal, or medical and supportive care both before and after birth.
Additional services may include lactation consultants and private delivery rooms.
Bonner General Health is no longer offering obstetrical care after May 19. This means that there are no obstetricians working there. The hospital will not deliver babies. The unit will also no longer provide 24 hour anesthesia support, post-resuscitation care or pre-transport stabilization for critically ill infants.
Some hospitals have closed their maternity units, but still provide perinatal care along with routine gynecological treatment.
Bonner General plans to open a clinic that will provide perinatal care. The nearby women's clinic will continue to provide gynecological care such as preventative health, wellness exams, and family planning.
Chartis' report states that Minnesota, Texas Iowa, Kansas, and Wisconsin have lost more than 10 obstetrical facilities each.
March of Dimes, a nonprofit organization dedicated to maternal and infant health, released data last fall that showed more than 2.2 millions women of childbearing years living in 1,119 US counties were "maternity deserts." This means their counties had no obstetric hospitals or birth centers.
Maternity deserts are associated with a lack in prenatal care and treatment of pregnancy complications, as well as an increased risk of death of mothers for the first year following childbirth.
The closure of maternity units is partly due to financial reasons.
According to the American Hospital Association (AHA), Medicaid reimburses only a small percentage of the cost of births. According to the Health Care Cost Institute (a nonprofit organization that analyses health care costs and utilization data), employer-sponsored insurance covers about $15,000 of a birth, while Medicaid covers about $6,500.
"Medicaid funds approximately half of all births nationwide and more than 50% of births in the rural areas," Dr. Katy Kozhimannil said, a researcher on public health at the University of Minnesota. She has done research on the increasing number of maternity deserts.
Kozhimannil states that communities most likely to suffer from maternity unit closings are remote towns and rural counties, in states with "less liberal Medicaid programs."
According to Dr. Sina Haeri of Ouma Health a company which provides virtual prenatal and postnatal care for mothers in areas with limited maternity care, hospitals in large cities can often offset the low reimbursement rates associated with Medicaid births by allowing births to be covered by an employer's insurance.
There are neonatal intensive-care units in many large hospitals.
Haeri stated that a NICU is a significant revenue generator for a facility.
He said that most rural hospitals don't have a NICU. They only have a nursery, where they take care of healthy, full-term babies. Many rural hospitals cannot afford to keep their labor and delivery departments open due to the financial burden.
Closures are also due to a low number of births.
The hospital noted in its announcement of the closure that it had delivered only 265 babies in 2022. This was deemed by the hospital to be a significant decline.
According to Kozhimannil, a researcher at the University of Minnesota Rural Health Research Center, rural hospital administrators who provide obstetrical care claim that it takes 200 births per year for an obstetric unit to be safe and financially viable.
Many administrators who responded to the survey said that they were working hard to keep their units open, despite low birthrates.
Kozhimannil stated that "of all the people we surveyed, a third were still in operation, despite having fewer than 200 babies born a year." "We asked them why and they replied, 'because the community needs it. "
Staffing and recruitment is another issue facing hospital administrators.
Erin Binnall is a spokesperson for Bonner General Health. She said that the decision to close Bonner General’s labor and birth unit was directly impacted by the lack of qualified and experienced doctors and nurses within the state.
After May 19, Bonner General Health won't have consistent, reliable pediatric coverage for neonatal resuscitations or perinatal care. Bonner General Health's top priority is the safety of its patients. Binnall, in an email to CNN, said that BGH cannot provide neonatal resuscitation services if it does not have board-certified neonatal resuscitation providers who are willing to be on call and present during delivery.
The American Hospital Association recognizes that some hospitals are facing staffing issues.
In a press release, the association stated that a hospital would not be able to provide care if it could not recruit and retain nurses, doctors, and other caregivers who are appropriately trained. Such challenges are magnified in rural America where the workforce is stretched by an aging population that has led to a dramatic decrease in demand for certain services, such as Labor and Delivery.
Wright is thinking about moving due to the lack of maternity care and pediatric services in Bonner County.
The closures may also be due to more stringent abortion laws.
In a press release issued last month, Bonner General stated that Idaho's "legal climate and political climate" is causing highly-respected, talented physicians to leave. The Idaho Legislature also continues to pass and introduce bills criminalizing physicians who provide medical care that is nationally recognized as standard care.
Guttmacher Institute reports that Idaho has the most restrictive anti-abortion law in the nation: a total ban with only a few exceptions.
Guttmacher says Idaho requires a "positive defense," meaning that a provider must "prove in court that the abortion met the legal exception criteria."
Kozhimannil believes that closures of rural communities, no matter what the cause, are more than just an inconvenience. These closures also put the safety of families at risk.
The long drive isn’t just an inconvenience. She said that it was actually associated with health hazards. "The result that we have seen is an increase in premature births." Preterm births are the biggest risk factor in infant mortality. It is a major risk factor for cognitive and developmental delays in children.
Haeri claims that the decrease in maternal care has also a direct effect on maternal mortality.
According to a National Center for Health Statistics report, the maternal mortality rate in 2021, the latest year for which data are available, was 32.9 deaths for every 100,000 live births. This compares with rates of 20,1 in 2019 and 23,8 in 2020. The US maternal death rate in 2021 was 1,205.
According to the National Institutes of Health, complications can be caused by conditions such as obesity, diabetes, high blood pressure and multiple pregnancy. Pre-eclampsia is more common in pregnant women older than 35.
Haeri says that the solutions to this growing problem will be complex as labor and delivery units continue closing their doors.
He said: "I believe anyone who comes to you to say that the current system works is lying," he said. "We know the current system of maternity care is not working."
Kozhimannil’s research found that many of the women living in deserts for maternity care are from minority communities.
She said: "When we did that research, the communities who were raising alarms about this... tended to primarily be Black, indigenous, or tribal groups in rural areas." "Black communities and tribal communities across the country but particularly in the West, Mountain West, and Midwest.
Haeri believes that a woman can find a solution at her fingertips.
He said: "I always tell women that if they have a mobile phone, then she should be able to use it."
In a study from 2021, women living in remote parts of the US would benefit from telehealth services. This would reduce the number of "in person prenatal care visits" and increase the access to care.
The American College of Obstetricians and Gynecologists (ACOG) recommends that women with low-risk pregnancy attend 12-14 prenatal appointments. A study found that women in remote areas could benefit from the expansion of prenatal appointments via telehealth.
Haeri says that Ouma is a mother who works with women who are often remote and at high risk.
He believes that the promotion of midwifery services and doulas would also help to boost maternity care in America.
He says that certified nurse midwives are often available to help remote mothers, especially those who have high risks or decide to deliver at home.
According to the American College of Nurse Midwives, midwives are not just able to deliver babies. They can also use medical equipment, perform at-home physical examinations, prescribe medication, order diagnostic and lab tests, and assess risks. Doulas, who help mothers during the birthing process, are often present in home births as well as hospital births.
The midwifery model is a winner when it comes down to maternal care. Doula involvement in advocacy leads to better outcomes for maternity care and better outcomes. I don't think we have made it easy to integrate these two components into our maternity services here in the US.
Everyone has babies
Wright and her fiancé have both considered leaving Idaho after living there for ten years. It's mainly because of the lack of maternity care and pediatric services at Bonner General Health.
"I feel secure with [my] doctor. Wright explained that she must now get to know her doctor in the next few months, before having her second child.
She is uncertain that there are solutions for mothers who feel the same way as her.
She said that everyone has babies, no matter where they live. It's a problem for women who are pregnant and don't drive, or who have high-risk pregnancies, or who are first time mothers.
This report was contributed by CNN's Jacqueline Howard, Katherine Dillinger, and Elizabeth Cohen.