By Tony Leys for KFF Health News.
Broadcast version by Mark Moran for Iowa News Service reporting for the KFF Health News-Public News Service Collaboration

Rural regions like the one surrounding this southern Iowa town used to have a lot more babies, and many more places to give birth to them.

At least 41 Iowa hospitals have shuttered their labor and delivery units since 2000. Those facilities, representing about a third of all Iowa hospitals, are located mostly in rural areas where birth numbers have plummeted. In some Iowa counties, annual numbers of births have fallen by three-quarters since the height of the baby boom in the 1950s and ’60s, when many rural hospitals were built or expanded, state and federal records show.

Similar trends are playing out nationwide, as hospitals struggle to maintain staff and facilities to safely handle dwindling numbers of births. More than half of rural U.S. hospitals now lack the service.

“People just aren’t having as many kids,” said Addie Comegys, who lives in southern Iowa and has regularly traveled 45 minutes each way for prenatal checkups at Oskaloosa’s hospital this summer. Her mother had six children, starting in the 1980s, when big families didn’t seem so rare.

“Now, if you have three kids, people are like, ‘Oh my gosh, are you ever going to stop?’” said Comegys, 29, who is expecting her second child in late August.

These days, many Americans choose to have small families or no children at all. Modern birth control methods help make such decisions stick. The trend is amplified in small towns when young adults move away, taking any childbearing potential with them.

Hospital leaders who close obstetrics units often cite declining birth numbers, along with staffing challenges and financial losses. The closures can be a particular challenge for pregnant women who lack the reliable transportation and flexible schedules needed to travel long distances for prenatal care and birthing services.

The baby boom peaked in 1957, when about 4.3 million children were born in the United States. The annual number of births dropped below 3.7 million by 2022, even though the overall U.S. population nearly doubled over that same period.

West Virginia has seen the steepest decline in births, a 62% drop in those 65 years, according to federal data. Iowa’s births dropped 43% over that period. Of the state’s 99 counties, just four — all urban or suburban — recorded more births.

Births have increased in only 13 states since 1957. Most of them, such as Arizona, California, Florida, and Nevada, are places that have attracted waves of newcomers from other states and countries. But even those states have had obstetrics units close in rural areas.

In Iowa, Oskaloosa’s hospital has bucked the trend and kept its labor and delivery unit open, partly by pulling in patients from 14 other counties. Last year, the hospital even managed the rare feat of recruiting two obstetrician-gynecologists to expand its services.

The publicly owned hospital, called Mahaska Health, expects to deliver 250 babies this year, up from about 160 in previous years, CEO Kevin DeRonde said.

“It’s an essential service, and we needed to keep it going and grow it,” DeRonde said.

Many of the U.S. hospitals that are now dropping obstetrics units were built or expanded in the mid-1900s, when America went on a rural-hospital building spree, thanks to federal funding from the Hill-Burton Act.

“It was an amazing program,” said Brock Slabach, chief operations officer for the National Rural Health Association. “Basically, if you were a county that wanted a hospital, they gave you the money.”

Slabach said that in addition to declining birth numbers, obstetrics units are experiencing a drop in occupancy because most patients go home after a night or two. In the past, patients typically spent several days in the hospital after giving birth.

Dwindling caseloads can raise safety concerns for obstetrics units.

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. 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.

Stephanie Radke, a University of Iowa obstetrics and gynecology professor who studies access to birthing services, said it is almost inevitable that when rural birth numbers plunge, some obstetrics units will close. “We talk about that as a bad event, but we don’t really talk about why it happens,” she said.

Radke said maintaining a set number of obstetrics units is less important than ensuring good care for pregnant women and their babies. It’s difficult to maintain quality of care when the staff doesn’t consistently practice deliveries, she said, but it is hard to define that line. “What is realistic?” she said. “I don’t think a unit should be open that only delivers 50 babies a year.”

In some cases, she said, hospitals near each other have consolidated obstetrics units, pooling their resources into one program that has enough staffers and handles sufficient cases. “You’re not always really creating a care desert when that happens,” she said.

The decline in births has accelerated in many areas in recent years. Kenneth Johnson, a sociology professor and demographer at the University of New Hampshire, said it is understandable that many rural hospitals have closed obstetrics units. “I’m actually surprised some of them have lasted as long as they have,” he said.

Johnson said rural areas that have seen the steepest population declines tend to be far from cities and lack recreational attractions, such as mountains or large bodies of water. Some have avoided population losses by attracting immigrant workers, who tend to have larger families in the first generation or two after they move to the U.S., he said.

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. 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.

In many regions, people with private insurance, flexible schedules, and reliable transportation choose to travel to larger hospitals for their prenatal care and to give birth, Kozhimannil said. That leaves rural hospitals with a larger proportion of patients on Medicaid, a public program that pays about half what private insurance pays for the same services, she said.

Iowa ranks near the bottom of all states for obstetrician-gynecologists per capita. But Oskaloosa’s hospital hit the jackpot last year, when it recruited Taylar Swartz and Garth Summers, a married couple who both recently finished their obstetrics training. Swartz grew up in the area, and she wanted to return to serve women there.

She hopes the number of obstetrics units will level off after the wave of closures. “It's not even just for delivery, but we need access just to women's health care in general,” she said. “I would love to see women's health care be at the forefront of our government's mind.”

Swartz noted that the state has only one obstetrics training program, which is at the University of Iowa. She said she and her husband plan to help spark interest in rural obstetrics by hosting University of Iowa residency rotations at the Oskaloosa hospital.

Comegys, a patient of Swartz’s, could have chosen a hospital birthing center closer to her home, but she wasn’t confident in its quality. Other hospitals in her region had shuttered their obstetrics units. She is grateful to have a flexible job, a reliable car, and a supportive family, so she can travel to Oskaloosa for checkups and to give birth there. She knows many other women are not so lucky, and she worries other obstetrics units are at risk.

“It’s sad, but I could see more closing,” she said.


Tony Leys wrote this story for KFF Health News.


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By Ramona Schindelheim for WorkingNation.
Broadcast version by Isobel Charle for Oregon News Service reporting for the WorkingNation-Public News Service Collaboration

From a translator helping a neighbor navigate health services or locate a food bank, a doula assisting a mother during childbirth, or a former inmate working with people exiting prison to reach healthier outcomes, community health workers have a wide range of roles.

They are frontline public health workers who usually live in the communities they serve and include volunteers. Research shows they have positive impacts by helping people access preventive care resulting in things like an increase in cancer screenings and reducing the risk of cardiovascular disease.

Community health workers (CHWs), also called promotores in Spanish-speaking communities, have existed for generations and have largely been under the radar. But their importance was thrust into the spotlight when COVID hit, sparking growing efforts to bring more structure to their workforce and ensure their jobs are sustainable.

Community Health Workers: Trusted Voices

"Because of the pandemic, there was the awareness that a lot of people didn't have trusted information. There are a lot of barriers for communities and accessing health care resources and getting trusted information, specifically looking at Black, Brown, Indigenous communities, immigrant, refugee communities," explains Jennine Smart, executive director, Oregon Community Health Workers Association.

"Being able to have a workforce that's already connected in community-based space to provide reliable, trusted, and honest information has been pivotal.

"It really amplified the recognition of this workforce and the value that CHWs bring more broadly to communities and really serving as a liaison and a bridge between health settings, health systems, and communities," adds Smart.

Those settings can include hospitals, clinics and community organizations. And CHWs are in demand.

The Bureau of Labor Statistics counts 63,400 CHWs in the United States, although that may be an undercount since there are different job titles for CHWs, especially in community health organizations.

It's estimated that jobs for CHWs will grow 13% between 2023 and 2033.

The median salary is $48,200, according to the BLS , with a high school diploma or equivalent required.

Empowering Through Technology

Among the latest efforts to create sustainable jobs for CHWs is the work of Pear Suite, a digital health company launched in 2021.

I spoke with the co-founder and CEO Colby Takeda at CES 2025 in January.

"Our company is all about empowering them, supporting them with technology, with software system that allows them to document all their activities, track the needs of individuals, track how they're getting support, whether it's through organizations or health care system or social services," says Takeda, who has personal experience with caregiver support as well as the nonprofit sector.

The company counts more than 175 partners in community-based organizations and health care companies and says it's had an impact on more than 100,000 lives.

Takeda explains the Pear Suite is providing accessible training in different languages to convert a community health worker's lived experience and help them with credentials and certifications since there is no standardization process across the country.

States have their own certification process and reimbursement process. Grants had funded much of this work, but 29 states now allow services by CHW to be reimbursed by Medicaid, according to a 2022 KFF survey.

Pear Suite, says Takeda, is helping CHWs utilize their technology to track their work. "It's really infrastructure for them to get more revenue, whether it's through reimbursement, through the new Medicaid or Medicare policies that allow for community health workers to now get paid or for them to secure more funding through grants with better data," stresses Takeda.

And it comes with hurdles.

"These organizations and these workers have been on paper and spreadsheets for many years. For them to transition to now a system for them to document and do claims and maintain compliance with health plans has been really challenging," he adds.

Takeda explains that the company provides wraparound support teams to better understand contracts with health plans and things like compliance and how to do claims.

The result, he says, is that community based organizations that can range from a small community center to a barbershop now have a formal structure.

"These are people that are providing screenings or resources to early young mothers to individuals who are facing homelessness or health sickness. These are organizations that have been doing this work for decades but never got paid by the health care system. We're now helping them get paid sometimes the average of $15,000 a month additional, which is huge for them," says Takeda.

Using Skills From Lived Experiences for a Living

One community health worker who credits Takeda's technology with helping his work become more sustainable is Joe Calderon, a former inmate who served 17 years in prison who has made it his mission to build better outcomes for people in his California community while supporting his family.

"Now I can change my life, my family's life, and my community's life, by slowly making a little bit more money by creating my own organization" says Calderon, a manager of recruiting and training for Urban Alchemy, based in San Francisco with a mission to "heal neighborhoods by employing the unique talents of returning citizens to transform communities and spaces."

Calderon has a Community Health Worker certificate from San Francisco City College and started out as a community health worker after exiting prison.

"I found my voice for advocacy as I watched so many men die in prison of treatable diseases," he explains. And he says it made him think more about health care when he had to take medicine for high blood pressure at the age of 29years old while behind bars. It's his lived experience that has spurred him to change outcomes of the communities he knows.

"No one ever taught me to go to the doctor. I already knew, when I started to see about health care, that the communities that I came from, in my perspective, took better care of our cars. Our cars had tinted windows, rims and beat. But nobody was talking about going to the dentist. Nobody was talking about going to the doctor regularly," adds Calderon.

Building a Sustainable Workforce

On a wider scale, Oregon, where a statewide professional workforce association for community health workers was established in 2011 and has an 80 training requirement for CHWs is aiming to take its new partnership with Pear Suite to a new level.

"We really want to support the sustainability of the workforce, right, and that we don't want to just get everybody trained as a CHW. We want to make sure that folks are able to be employed, and that we have a sustainable workforce," explains the Oregon Community Health Workers Association's Jennine Smart.

To do that, Smart explains, the organization is looking to use the platform to build a network that will take over the administrative burden of billing management while at the same time creating a system to get a more comprehensive view of the work done by community health workers.

"So we're looking at building a community based organization network. And so it'd be community based organizations that are employing community health workers and providing community health worker services. And then we'd hold a contract with Medicaid" explains Smart.

In short, it would provide structure not just for billing but case management. She describes the goal as building a more comprehensive payment system that hasn't always included all the work they do in an effort to recognize the key roles CHWs play.

She adds, "Those are the folks who are out there. They're getting their feet wet. They're in the dirt, they're really doing that connected hard work that is so meaningful."


Ramona Schindelheim wrote this article for WorkingNation.

Support for this reporting was provided by Lumina Foundation.


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The Missouri Foundation for Health is partnering with The Marshall Project on the launch of a St. Louis nonprofit newsroom highlighting the legal system's effect on health, especially in marginalized communities.

The Marshall Project focuses on investigative, data-driven journalism to explain the justice system, especially to those affected by it. With the foundation's support, its St. Louis newsroom will cover topics like the death penalty, juvenile justice, health care in prison conditions and reentry challenges.

Molly Crisp, senior communications strategist at the foundation, shared the goals of the new partnership.

"We recognize that the criminal justice system disproportionately harms certain populations and that exacerbates health inequities," Crisp explained. "We're hoping through this partnership that we're bringing to light some of the issues that are rampant in the legal system and that we can address those issues."

Statistics show low-income marginalized communities face higher pollution, increasing asthma risk, along with other health problems, and incarcerated individuals often endure long waits for medical care and face barriers to mental health treatment due to staff shortages and limited resources.

Katie Moore, a reporter for the Marshall Project, said its goal is to investigate such issues both locally and statewide.

"We have been talking with different groups, individuals who are connected to the criminal justice system in some way," Moore noted. "To see what their concerns are, what they see as being missing in the media landscape in St. Louis in terms of coverage of some of these more in-depth investigative issues."

With an increasing number of older people who are incarcerated, Missouri prisons face growing health care demands, including the need for geriatric care and hospice services.

Ohioans are seeing changes in their water infrastructure as cities work to replace lead service lines, a requirement under federal regulations.

But concerns have risen over the materials being used for replacements.

Teresa McGrath, chief research officer with the group Habitable, said while lead exposure poses significant health risks, she cautions against replacing these pipes with polyvinyl chloride due to its environmental and health implications.

"It's important to get those lead pipes out. Let's prioritize that," said McGrath. "But let's not make a regrettable substitution while we do that."

PVC production involves hazardous chemicals, including vinyl chloride, a known human carcinogen. However, PVC remains a popular choice because of its lower cost and ease of installation.

Environmental health advocate Yvette Jordan - the chair emeritus of the Newark Education Workers Caucus, and a steering committee member at Lead Free NJ - underscores the importance for Ohioans to be well informed about their environments.

"What is in their home?" said Jordan. "If they have a service line, is it plastic? Copper? What exactly is it and how does that affect their health, their community, and most importantly their families and children who are most affected by this?"

McGrath highlighted specific concerns about PVC and alternative materials that could be safer.

"The best available water pipe that we have evaluated for use inside a home is copper pipes," said McGrath, "and we will be the first ones to tell you that copper pipes are not perfect, but it is the best available."




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