As Home Births Rise, Obstetric Care Disappears

Home births have increased steadily across the United States over the past decade. Many pregnant individuals choose home birth because they prefer a more personalized birthing experience, wish to avoid medical interventions, or feel more comfortable delivering in a familiar environment. While many home births occur without complication, childbirth does not always go according to plan. Research suggests that 10-15% of home births ultimately require transfer to a hospital for emergency obstetric care, demonstrating the continued importance of access to hospital-based services even among those who choose to deliver outside of them.

Yet at the same time that more families are relying on hospitals as a critical safety net during obstetric emergencies, labor and delivery units are disappearing from communities across the country. More than 2 million women of reproductive age now live in counties without hospital-based obstetric services. For pregnant individuals experiencing complications during labor, every mile and every minute can make a difference. As labor and delivery units close across the country, particularly in rural communities, growing numbers of pregnant individuals are being forced to travel farther distances for prenatal care and childbirth.

To investigate how obstetric unit closures affect geographic access to care, Lindsay Admon and colleagues analyzed national hospital and census tract data from 2010 to 2021 to measure changes in travel time to the nearest hospital offering obstetric services. Counties were categorized into three groups: counties that maintained obstetric services throughout the study period, counties that never had obstetric services, and counties that lost all obstetric services between 2010 and 2021. Researchers then measured the proportion of reproductive-aged women living within a 30-minute drive of obstetric care.

The implications of these findings extend beyond the inconvenience of a longer drive to the hospital.

The findings demonstrated substantial declines in access among communities experiencing obstetric unit closures. In counties that lost all obstetric services, 93.3% of reproductive-aged women lived within 30 minutes of obstetric care in 2010. By 2021, that amount had declined dramatically to only 59.7%.

The disparities were even more striking in rural communities. In nonmetropolitan counties adjacent to metropolitan areas, access within 30 minutes declined by more than 53%. As obstetric units closed, a growing proportion of women were forced to travel 30 to 60 minutes or more to reach care.

The implications of these findings extend beyond the inconvenience of a longer drive to the hospital. For many pregnant individuals, increased travel times can create substantial logistical and financial challenges throughout pregnancy. Prenatal appointments may require taking additional time off work, arranging childcare, and traveling long distances multiple times during a pregnancy. For individuals without reliable transportation, these barriers can make it more difficult to receive consistent prenatal care and monitor potential complications before they become emergencies.

The consequences of obstetric unit closures may be particularly severe in rural communities, where pregnant individuals already face higher rates of severe maternal morbidity and nearly double the risk of pregnancy-related death compared to their urban counterparts. Research has found that rural maternity ward closures are associated with increases in both out-of-hospital births and preterm births, suggesting that reduced access to care may have consequences that extend beyond longer travel times. While some individuals choose home birth as a preferred birthing option, others may find themselves with limited alternatives as nearby labor and delivery units disappear. For those experiencing complications during labor, increasing distances to emergency obstetric care may further exacerbate existing maternal health disparities in rural America.

Improving maternal health outcomes will require policy solutions to prevent further obstetric unit closures and to strengthen access to maternity care in underserved communities. Potential strategies include increasing financial support for rural hospitals, expanding Medicaid reimbursement for obstetric services, strengthening emergency transport systems, investing in maternal health care workforce development, and expanding access to prenatal care through telehealth and community-based programs. Without meaningful intervention, continued declines in hospital-based obstetric care may further increase reliance on higher-risk home births and contribute to preventable maternal and infant deaths across the United States.