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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California could be in for some big cuts to health care for low-income families under a second Trump administration, according to health experts.

Policy specialists at the nonprofit KFF said they are bracing for Trump allies in Congress to make major reductions to Medicaid expansion under the Affordable Care Act, in order to pay for big tax cuts promised by the president-elect.

Larry Levitt, executive vice president of health policy at KFF, said it would force states to backfill or raise costs.

"For the ACA, simply letting enhanced financial aid expire after next year would result in big out-of-pocket premium increases, reduced enrollment and more people uninsured," Levitt projected.

Robert F. Kennedy Jr., President-elect Trump's choice for Health and Human Services Secretary, did not say much on the campaign trail about funding for Medicaid or the Affordable Care Act, so his positions are unclear. Kennedy has expressed skepticism about vaccines and has said the U.S. should stop putting fluoride in drinking water.

Jennifer Kates, senior vice president and director of the Global Health and HIV Policy Program for KFF, said the Centers for Disease Control and Prevention cannot require states to follow its recommendations on vaccines and fluoridation.

"That's up to states and local governments," Kates explained. "But CDC can recommend, and if those recommendations are not being made or being watered down or changed, that sends a message to states, to schools, to parents."

Health advocates are also raising concerns DACA recipients could lose access to health plans sold on the state marketplaces created under the Affordable Care Act. Changes to so-called "public charge" rules could make families with mixed immigration status hesitant to use Medicaid benefits.


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Some Kentuckians are more likely to be diagnosed with cancer and more likely to die from the disease than others.

Dr. Nathan Vanderford, associate professor of toxicology and cancer biology at the University of Kentucky College of Medicine, said Kentucky has a massive cancer problem. The Commonwealth ranks first in the nation for overall cancer incidence rates and second for overall cancer mortality rates, around 30,000 cases each year and 10,000 deaths. He added Appalachia is ground zero for cancer.

"What's worse is that the cancer problem is significantly greater in eastern Kentucky," Vanderford pointed out. "There are 54 counties in Eastern Kentucky that are in the Appalachian region and cancer rates there are significantly higher."

Lung cancer incidence rates are more than 100% higher in Eastern Kentucky versus the national average. Appalachian Kentucky residents are 8% more likely to die from a preventable or screenable cancer than their non-Appalachian counterparts.

Vanderford pointed out more than 150 Appalachian students have participated in the Appalachian Career Training in Oncology program, an education and intervention program aiming to address cancer disparities. Dozens of participants have gone on to medical school.

"We engage high school students and undergraduate students from any of the 54 Appalachian counties in cancer research, cancer education, clinical shadowing, all around the goal of motivating and preparing them to pursue cancer-related careers," Vanderford outlined.

Holly Burke, coordinator of the program, said participating students explore how cancer has affected their families and communities, particularly lung cancer.

"They talked about experiences with cancer and why they think the rates are so high," Burke observed. "And then they also gave solutions on what they think can be done to lower those rates."

The American Cancer Society recommends yearly screening for lung cancer for people aged 50-80 years old who smoke, or formerly smoked and have a 20-pack a year or greater history of smoking.

By Marlowe Starling and Andrew Wasley for Sentient.
Broadcast version by Mike Moen for Minnesota News Connection reporting for the Sentient-Public News Service Collaboration

As global leaders at the UN in New York pledged to tackle human suffering caused by antimicrobial resistance, the U.S. food giant Cargill was found to be slaughtering cattle containing residues of powerful antibiotics.

Data obtained by the Bureau of Investigative Journalism (TBIJ) covering the past two years showed that farms supplying Cargill are still using antibiotics that the World Health Organization (WHO) deems vital for human health.

Two years ago, TBIJ revealed that Cargill, which sold beef to McDonalds, sourced meat from farms that used at least five critically important antibiotics. At the time, Cargill said it was "committed not to use antibiotics that are critically important for human medicines," although it defended using other human antibiotics in farming.

This time, there were 12 different antibiotics found to be in use, including two of the most important types.

These drugs, known as "highest priority critically important" antibiotics or HP-CIAs, are so important for human health that the WHO warned livestock farmers to stop using them entirely. Use on farms can make the drugs - which are often the last treatments available for treating serious bacterial infections - less effective.

Leaders attending the high-level meeting at UN headquarters yesterday made an international declaration to cut the number of deaths caused by antibiotic resistance. The draft specifically mentions cuts in drug use on livestock farms.

Megan Brown, a sixth-generation hog and cattle farmer based in California, said that enforcement of existing rules on antibiotic use in farming in the U.S.: "Historically, we've shown we really can't be trusted unless we're made to."

Cargill said there was no evidence that beef with excessive antibiotic residues had entered the food chain as any cattle testing at these levels would be segregated, and that the company complied with relevant food safety standards.

New Rules in Farmers' Hands

In 2023, the US Department of Agriculture introduced a rule requiring a vet's prescription before farmers could get antibiotics for their animals. However, the new rule still leaves farmers in control of how to give antibiotics and relies on them to make sure there's enough time between treatment and slaughter, according to Crystal Heath, a vet.

Heath is also the founder and executive director of Our Honor, a nonprofit that advocates for animal welfare. She says that intensive livestock farming has created a vicious cycle that relies on confining animals in smaller and smaller spaces. This in turn increases the risk of sickness, leading to more antibiotics being used. "This is going to be a problem for as long as we raise animals this way," she told Sentient and TBIJ.

Daniel Czyz, a microbiologist at the University of Florida who studies antimicrobial resistance, said: "It all boils down to lowering the price of the production and increasing the profits for producers that are already struggling."

The FDA rule was meant to minimize people's exposure to antibiotic-resistant bacteria, which can increase the risk of superbugs spreading to people.

Antibiotic residues can linger in meat products if an animal is slaughtered too soon after being treated, before the drug has cleared its system. The U.S. government routinely investigates livestock farms that send animals for slaughter that contain drug residues, including antibiotics.

Brown, the cattle farmer, said that while some farmers still felt under pressure to send their animals on for slaughter soon after treatment, the FDA rule had changed how she used antibiotics. "I'm not going to send it to the yard until I know the withdrawal is gone," she said.

These days Brown uses vaccinations more often than antibiotics, which she says boosts the value of her cattle while reducing the risk of disease. The drugs, she added, are expensive.

Antibiotic Wild West

While Brown has taken steps to reduce antibiotic residues, the US Department of Agriculture's food safety agency recently questioned certain meat industry claims that some beef products have been raised without antibiotics.

The agency collected samples from nearly 200 cattle slaughtered at U.S. meat-packing plants and analyzed them for 180 veterinary drugs. One in five of the samples from the "raised without antibiotic" market contained antibiotic residues.

A prominent industry association continues to defend some controversial uses of antibiotics. Social media posts by the Animal Agriculture Alliance (AAA), a lobby group with links to Cargill through one of its board members, appear to endorse "preventative" antibiotics for farm animals - using the drugs on animals who are not unwell - despite concerns that this increases the risk of drug resistance. Preventative antibiotic treatment was recently restricted in the EU in 2022.

Another AAA post claims that there is "little overlap between antibiotics used in animal agriculture and antibiotics used in human medicine." This is at odds with the views of many public health experts, including the WHO, who agree that farms' use of antibiotics is directly contributing to drug-resistant disease in humans.

The AAA did not respond to requests for comment.

Cargill said: "Our position has been and continues to be a commitment to finding ways to reduce the use of human antibiotics across our operations and supply chains, while protecting the health and well-being of animals in our supply chains."

"We don't want to use antibiotics in agriculture that are clinically used for humans," said Czyz. He warned that once a disease develops resistance to a drug, it's difficult or impossible to reverse.

For real progress to happen, according to Czyz, there needs to be a coordinated global approach to the problem of antimicrobial resistance, as shown at the UN this week. "We cannot target [antimicrobial resistance] at one place if another place neglects the issue," he said.


Marlowe Starling and Andrew Wasley wrote this article for Sentient.


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