MARSHALLTOWN, Iowa — Last month’s closing of the obstetrics unit at the Marshalltown hospital was only the most recent in Iowa’s rural communities, which has forced some expectant mothers to skimp on prenatal care and undergo frantic trips when labor commences.

Since 2000, 34 of Iowa’s 118 community hospitals have closed their birthing units, according to the Iowa Department of Public Health. There have been two so far this year, down from eight closures last year — the most in a single year.

Most of those closures have happened at smaller facilities than the 49-bed Marshalltown hospital.

Iowa’s aging population is a key reason for these closures, Dr. Stephen Hunter, vice chairman of obstetrics at the University of Iowa Hospitals & Clinics in Iowa City, told Iowa Public Radio .

“Some rural counties have lost as many as 40% of their population in the last three decades,” Hunter said. “That’s a lot of people gone, unfortunately. That leaves a system that’s not adequate for those that remain in those counties.”

Hunter said the state is also facing a severe shortage of OB/GYNs and family practice doctors who practice obstetrics. And, he said, Medicaid reimbursements are so low for obstetrics that hospitals can’t support the service.

According to figures from the University of Iowa Hospitals & Clinics, Medicaid reimbursed it about one-third of what commercial insurance plans did for services such as ultrasounds and deliveries last year.

Competition from bigger hospitals in bigger cities presents a business challenge, too.

“There simply aren’t enough women choosing to deliver locally,” UnityPoint Health President Jenni Friedly said. “This is a problem that has been going on for a long time. There are enough women becoming pregnant, but they are going elsewhere to deliver. It’s clear OB/GYN patients are already selecting Ames and Des Moines for their care.”

Stephanie Trusty, a nurse who tracks birthing trends for the state, told the Marshalltown Times-Republican that “some of these birthing units are beautiful. They’re like a four-star hotel.”

But does the loss of birthing units at the smaller hospitals and consolidation of birthing services affect health outcomes? A 2017 University of Minnesota study said the loss of labor and delivery units in smaller, more remote counties is linked with a decrease in prenatal care and increase in out-of-hospital and preterm births.

The Iowa Public Health Department and the University of Iowa are keeping watch for any such problems, but so far have not seen any sizable incidence, Trusty said.

Hansen Family Hospital CEO Doug Morse in Iowa Falls told Iowa Public Radio that hospital officials decided labor and delivery care were too expensive to continue in the aging, rural community with a declining birth rate.

After three months of public meetings, Morse said, hospital officials opted to use half the money they would save to turn the unit into a mental health program for seniors.

“It really did become fairly clear that people recognize that this wasn’t necessarily ... delivering babies isn’t necessarily a service that matches an elderly population,” he said.

The closing of the birth unit at the Iowa Falls hospital forced Jessica Sheridan to change her plans to have her baby born there, just five minutes from her home. She established relationships with doctors in Ames, an hour away, where her daughter was delivered in mid-December.

“We were lucky. It was nice weather,” Sheridan said.

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