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From the Cradle to the Grave

The shutdown of rural maternity units is the direct result of a culture that devalues birth.

Babies in Baskets
(Photo by © Minnesota Historical Society/CORBIS/Corbis via Getty Images)

Rural hospitals are shutting down their maternity units, the New York Times reported Sunday. Nearly 100 hospitals, mostly in poorer areas of the country, stopped offering maternal care between 2015 and 2019, with at least one third of all rural hospitals reporting in 2020 that they did not provide obstetrics services. Apparently, these hospitals just can’t afford to keep the 24-hour units staffed—certainly not with the price of labor these days. 

But budgets never tell the whole story. In this case, they are barely the first chapter in a long book, one which tells of the multitude of ways in which birth has been devalued over the last several decades.


Maternity units in rural regions are too expensive in part because Medicaid pays hospitals significantly less per birth than does private insurance—a fresh tally mark for all those who said federalizing healthcare would lead to worse care. The Times reporter names the average price hospitals are paid for a birth by Medicaid in Washington State: a pitiful $6,344 per birth, while private insurance pays an average of $18,193, a threefold increase. The spread is similarly dismal across the country, with an average price disparity of nearly $9,000 between private insurance and Medicaid reimbursements. At least 42 percent of all pregnant women in the United States in 2020 were covered by Medicaid at the time of their birth.

In wealthier areas, the private insurance payouts often balance the books. Not so much in rural areas, where, coincidentally, a growing plurality of pregnant women are to be found. In 2021, the largest demographic of pregnant women were those below the poverty line, accounting for 40 percent of all U.S. births. Those who are getting pregnant these days are often poor and without private insurance, meaning even an increase in birth rates may not necessarily mean the return of rural maternity units, assuming no significant change in Medicaid prices.

But even taking Medicaid out of the picture entirely wouldn’t necessarily solve the problem. Private insurance outpays Medicaid by the thousands across the board, whether you’re getting a hip replacement or are on a ventilator for Covid-19, and rural hospitals aren’t shuttering general surgery. There is another cause, then, that harms maternity care specifically: namely, a decline in demand for maternal services overall, especially by those who can pay.

With the rate of U.S. child births hitting a record low in 2018, and improvements since then negligible, is it any wonder the business of being born is not half so profitable as it once was? This is not a new data point, of course. We have seen headlines about declining birth rates for probably a decade now, and the causes are as well known as they are unlikely to change. Abortion on demand (the overturn of Roe last summer doesn’t seem to have made a dent in this yet, but more time will tell), declining intimacy rates, and rising infertility are just my generation’s addition to the litany of social and biological barriers between young couples and a quiverfull of children that began to be erected during the sexual revolution. Without a significant increase in birth rates, we can expect it won’t just be the maternity wings at the hospitals closing; other maternity-adjacent services will disappear, too, for lack of demand. 

If the end of the maternity wing meant the return of women to healthier, less invasive childbirth practices, this would be a good thing. Unfortunately, midwives and birth centers remain in the very small minority of available healthcare, and are often only partly covered by insurance. As bad as Medicaid payments are to hospitals, they are even worse to birthing centers. Instead, history suggests these impoverished and constrained mothers will take recourse another way, one that is easier on paper, but bears eternal consequences.

Women below the poverty line account for a full half of all abortions nationally. That number rises to 75 percent when the criteria is broadened to all low-income women. It is a relevant piece in the puzzle when we consider the reasons women get abortions—the cost of having a child is no small consideration. The loss of maternal care at the local hospital introduces a whole host of financial complications, from the loss of time at work to drive out of town to the next nearest hospital, or the risk of avoidable complications, which bring with them further medical bills and more time off work. It might be just the thing to tip a struggling mother’s decision in the direction of death.

For the hospital managers balancing the bank books, the decision to close a maternity unit might be nothing more than a sad but necessary concession to stay afloat. But for the women and their unborn children, and for our nation’s future, the consequences will be much greater.