Fewer than half of rural hospitals in the U.S. have maternity units, a situation that forces pregnant women to travel longer distances for care or face giving birth in an emergency room. It has also prompted government officials and families to scramble for answers.
Closures have worsened so-called maternity care deserts -- counties, mostly rural, with no hospitals or birth centers and no obstetrics providers. More than two million women of childbearing age live in these areas. And having fewer hospital maternity units makes having babies less safe, doctors and researchers say.
"Moms have complications everywhere. Babies have complications everywhere," said Dr. Eric Scott Palmer, a neonatologist who practiced at Henry County Medical Center in rural Tennessee before it ended obstetric services this month. "There will be people hurt. It's not a question of if -- simply when."
The American Hospital Association says at least 89 obstetric units closed in rural hospitals between 2015 and 2019, and more have shuttered since. The main reasons are decreasing numbers of births; staffing issues; low reimbursement from Medicaid; and financial distress, according to Peiyin Hung, deputy director of the University of South Carolina's Rural and Minority Health Research Center.
Alisha Alderson felt the effects of a nearby "desert" widening as she was forced to move in with her brother in Idaho after the nearest hospital within 40 miles of her eastern Oregon home closed.
"I was sitting in a hair salon a few days ago and some people started joking about me giving birth on the side of the road," the 45-year-old said. "And in that moment, I just pictured all the things that could go wrong with my baby and broke down in tears in front of strangers."
Officials at Saint Alphonsus, the hospital in Baker City where Alderson wanted to give birth, cited a shortage of obstetrics nurses and declining deliveries. While they said financial concerns didn't factor into the decision, they also underlined the unit had operated in the red over the last 10 years.
A lack of money was the major reason why Henry County Medical Center in Paris, Tenn., closed its obstetrics unit. CEO John Tucker told The Associated Press that it was a necessary step to save the hospital overall. He also said the number of deliveries had dropped in recent years.
Six days before the unit closed, just one woman was there to deliver. All of the other rooms contained empty beds and bassinets. Art had been removed from the walls.
Dr. Pamela Evans, who helped with deliveries for years and will stay on as a gynecologist, said she fears pre-term deliveries, infant mortality and low-birthweight babies are bound to get worse. Prenatal care suffers when people must travel long distances or take lots of time off work for appointments, she said. Not all insurance covers out-of-state deliveries, and it's an hour or more to some alternative in-state hospitals that families are looking at.
A solution to the rural care crisis might be about two hours away, where a handful of women sat in a circle for a prenatal group meeting at The Farm Midwifery Center, a storied place in Summertown, Tenn., that's more than a half-century old. Midwife Corina Fitch led discussions and gave them individual checkups.
"This is the perfect place for me," said pregnant mom Betsy Baarspul of Nashville, whose first child was born in an emergency C-section in a hospital.
Some states and communities are taking steps to create more free-standing birth centers. Connecticut Gov. Ned Lamont recently signed legislation that will license such centers to operate as an alternative for women with low-risk pregnancies.
Alecia McGregor, who studies health policy and politics at the Harvard T.H. Chan School of Public Health, said midwife-led birth centers "can be a very important solution to lowering costs within the U.S. health care system and improving outcomes."
A report on deliveries at The Farm in its first 40 years showed 5% of clients were transported to the hospital.
Doctors told The Associated Press that rural hospitals will need to be part of the equation, and they believe governments must do more.
Oregon politicians mobilized this summer and considered requesting the help of obstetrics nurses from the U.S. Public Health Service Commissioned Corps, which largely responds to natural disasters and disease outbreaks. While the idea didn't pan out, the federal service sent experts to Baker City who recommended several things, including looking into establishing a free-standing birth center.
County commissioner Shane Alderson -- the husband of Alisha -- said rural communities shouldn't be stripped of health care options because of their size or the number of low-income people with public insurance.
"That's not equitable," he said. "People can't survive like that."
Alisha Alderson, her husband, Shane, and their daughter, Adeline, 5, say goodbye to Alisha's mother, Patricia Conway, at an assisted living facility in Baker City, Ore., on Friday, Sept. 1, 2023. The Alderson's are headed to Idaho where Alisha is to give birth later in September, because of the closing of Baker City's only obstetrical unit. (AP Photo/Kyle Green)
John Tucker, CEO of the Henry County Medical Center in Paris, Tenn., talks on Tuesday, Aug. 29, 2023, about the closing of the facility's maternity ward. Tucker said lack of money was the main reason for closing its obstetric unit, and it was a necessary step toward saving the hospital, which has been struggling financially for a decade. (AP Photo/Mark Humphrey)
Katie O'Brien, left, hugs Dr. Pam Evans, an obstetrician, after O'Brien gave pictures of O'Brien's son whom Evans delivered as O'Brien visits the maternity ward at the Henry County Medical Center in Paris, Tenn., on Tuesday, Aug. 29, 2023. With the closing of the maternity ward at the facility in early September, Evans fears that things like preterm deliveries, infant mortality and low-birthweight babies — a measure in which the county already ranks poorly — are bound to get worse. (AP Photo/Mark Humphrey)
The Henry County Medical Center in Paris, Tenn., is seen on Tuesday, Aug. 29, 2023. Hospital CEO John Tucker said lack of money was the main reason for closing the hospital's obstetric unit, and it was a necessary step toward saving the entire facility, which has been struggling financially for a decade. (AP Photo/Mark Humphrey)
Dr. Pam Evans, an obstetrician, poses in one of her exam rooms that is decorated with photographs of children she has delivered at the Henry County Medical Center in Paris, Tenn., on Tuesday, Aug. 29, 2023. With the closing of the maternity ward at the facility in early September, Evans fears that things like preterm deliveries, infant mortality and low-birthweight babies — a measure in which the county already ranks poorly — are bound to get worse. (AP Photo/Mark Humphrey)
Dr. Eric Scott Palmer, a neonatologist, poses for a portrait in the special care nursery at the Henry County Medical Center in Paris, Tenn., on Tuesday, Aug. 29, 2023. Palmer said that when the facility closes its maternity and special care facility, "There will be people hurt. It's not a question of if — simply when." (AP Photo/Mark Humphrey)
Katie O'Brien holds her son, Bennett, on Tuesday, Aug. 29, 2023, in the birthing room where she delivered him in July at the Henry County Medical Center in Paris, Tenn. The maternity ward at the hospital closed in early September. "It's a horrible thing for our community," says O'Brien. "Any young person looking to move here won't want to come. Why would you want to come somewhere where you can't have a baby safely?" (AP Photo/Mark Humphrey)
Lacy Kee holds her son, Walt, 2, in a birthing room at the Henry County Medical Center in Paris, Tenn., on Tuesday, Aug. 29, 2023. With the closing of the obstetrics unit, Kee, who gave birth to Walt at the facility, said shell have to drive 45 minutes and cross the state line into Kentucky to give birth to her third child in early October. Shes especially concerned because she has gestational diabetes and recently had a scare with her fetus heart rate. (AP Photo/Mark Humphrey)
A sign calling for the saving of the Henry County Medical Center obstetric unit is displayed in a yard in Paris, Tenn., on Tuesday, Aug. 29, 2023. Hospital CEO John Tucker said lack of money was the main reason for closing the hospital's obstetric unit, and it was a necessary step toward saving the entire facility, which has been struggling financially for a decade. (AP Photo/Mark Humphrey)