Over the past 20 years, New Hampshire has lost 10 labor and delivery units — most recently the unit at Derry’s Parkland Medical Center closed in 2020 — leaving swaths of the state without a hospital unit that specializes in delivering babies.

Once delivery units close, they do not open again. Concord Hospital announced last month it would not reopen the labor and delivery unit at Lakes Region General Hospital if the sale of that hospital’s assets to Concord Hospital is approved by the state.

The labor and delivery unit at Lakes Region closed in 2018 after years of losing money and declining birthrates, and Concord Hospital executives do not see those trends changing.

“What happened in Laconia is unfortunately no different than what’s happening all over rural America,” said Kevin Donovan, CEO of the company that owns Lakes Region and Franklin Hospital.

What happened in Laconia was the number of births at the hospital fell from more than 500 in 2005 to 262 in 2017, Donovan said. It became impossible to attract doctors and nurses. More of the women delivering babies did not have private health insurance and relied instead on Medicaid.

By 2018, the numbers didn’t work anymore. The unit closed that spring.

New Hampshire’s remaining rural labor and delivery units face similar headwinds.

“We stay open by the skin of our teeth,” said Kimberly Force, Littleton Hospital’s clinical director of inpatient services.

Littleton delivers an average of 325 babies a year, Force said, and loses money in the process. Most patients have Medicaid for insurance, with reimbursement rates below the cost of care.

“It’s almost a community service,” Force said.

At Speare Memorial Hospital in Plymouth, Beth Simpson, nurse director of the obstetrics unit, said they have been seeing more patients from the Lakes Region since 2018, which means a little more revenue. But she said Speare still struggles to attract nurses and sees more patients without private insurance.

The hospitals left standing after another labor and delivery unit closes benefit from delivering more babies. Littleton picked up more patients after units closed at Upper Connecticut Valley Hospital, Weeks Hospital and Cottage Hospital, which has helped, Force said.

But families have had to adjust. They have a plan, they leave for the hospital earlier.

“Nobody wants to be in rip-roaring labor driving from Pittsburg down to here,” Force said.

With 10 units around the state now closed, women have to travel farther to deliver babies, especially in central New Hampshire, where a stripe of closures from Claremont to Wolfeboro left a “maternity desert,” said Timothy Fisher, a Dartmouth-Hitchcock Medical Center obstetrician and Dartmouth Medical School professor.

Fisher and a team of researchers at Dartmouth-Hitchcock are studying the impact of these closures, using information from 250,000 birth certificates of babies born between 2000 and 2018.

In places where a labor and delivery unit has closed, Fisher said, more babies were born in emergency rooms. More women ended up delivering at home, when they had planned to give birth in a hospital. More babies were born on the road, on the way to a hospital.

Cutting labor, delivery costs

In almost every hospital, Fisher said, labor and delivery units lose money. Hospitals are often willing to accept the losses, until financial strain pushes executives to make cuts.

“Unfortunately, maternity services are often first on that chopping block,” Fisher said

New Hampshire’s declining birth rate has made it even harder to sustain a birthing center. Hospitals’ costs don’t decrease with fewer births. Labor and delivery units have to be fully staffed 24 hours a day, 365 days a year, even if they only deliver one baby every day or two.

The financial strain is more acute in hospitals where more patients use Medicaid, the health insurance program for poor and disabled people run jointly by the state and federal government. Hospitals where more women have Medicaid insurance have been more likely to close their labor and delivery units, because Medicaid does not reimburse hospitals the full cost of delivering a baby.

Medicaid reimbursement rates in New Hampshire are the fifth-lowest in the country for obstetric care, according to the Kaiser Family Foundation.

In Vermont, a state where birthrates are about as low as New Hampshire, only one labor and delivery unit has closed since 2000, Fisher said. Vermont’s somewhat higher Medicaid reimbursement rate might be one factor keeping more labor and delivery units open, Fisher said.

Where labor and delivery units are still open, Fisher said, an average 23% of new mothers have Medicaid insurance. Where units have closed, the average was 39%. At Lakes Region General, more than 60% of women giving birth had Medicaid insurance, said the parent company’s Donovan.

Closures where most patients have Medicaid means poor women in small towns are the ones losing out on close-to-home medical care.

Finding transportation to a hospital an hour away might be a challenge during labor — never mind about finding a ride, childcare and arranging time off work for several visits during pregnancy, and regular care after the baby is born.

“From a human impact standpoint, this is a really big deal,” Fisher said.

Struggling to find doctors, nurses

Maybe the labor and delivery unit at Lakes Region General would have held on for a few more years if New Hampshire had a higher Medicaid reimbursement rate, Donovan said.

But he thinks it still would have become too difficult to hire people willing to work in a small, rural birthing center.

“No matter how much Medicaid paid us for an inpatient stay for a laboring mom,” Donovan said, “I was still going to have the problem of, ‘Can I still get an obstetrician that’s going to want to come to a high-call, low-volume community?’”

Clinical professionals have to perform a certain number of deliveries each year to stay certified with their professional organizations, Donovan said. At a hospital like Lakes, with 250 or so births a year, a doctor would have to be on call every other night or more to hit that target.

Problems of delivering few babies have pushed smaller birthing centers to close for years. Volume and staffing were a big part of the 2009 decision to close the unit at Huggins Hospital in Wolfeboro, said Monika O’Clair, vice president of strategy and community relations for Huggins.

Filling the void after closures

Although the Lakes Region labor and delivery unit closed in 2018, Donovan is proud the hospital found a way to keep offering prenatal and postpartum care in Laconia.

Concord Hospital is running Laconia-area clinics for regular visits during pregnancy. After the baby is born, Donovan said, women can get care in Laconia and find local doctors to care for their children.

As smaller hospitals around the country close their labor and delivery units, Erin Collins, vice president of nursing and administrator for women’s and children’s services, said she sees more partnerships like this, with women delivering at a larger, central hospital, and getting care before and after the baby is born closer to home.

Collins said Concord doctors are trying to help Lakes Region patients recognize when they are in labor earlier in the process, so they will have time to get to the hospital, and is helping train emergency responders in case women end up giving birth outside a hospital.

During the pandemic, most hospitals have started using phone or video visits for some prenatal care, said Dartmouth-Hitchcock’s Fisher. But there’s still a need for in-person visits, particularly for high-risk pregnancies. Fisher said some Dartmouth doctors are collaborating with local providers, calling in while an in-person health care provider performs an ultrasound at a local doctor’s office.

The state’s remaining small birthing centers, like Littleton, are doing their best to hold on. More patients with private insurance would help stabilize the unit financially, as would a higher Medicaid reimbursement rate.

But things are looking up in other ways, Littleton Hospital’s Force said.

Littleton is expecting what she called a “COVID baby boom,” with a slightly-higher-than-average number of births expected this spring (though Brookings Institute researchers have projected a national “baby bust” of about 300,000 fewer births than usual). With young people moving to Littleton, Force said it has been getting easier to hire nurses. Maybe higher birth rates aren’t far off.

“I think there’s potential,” Force said.