Sheryl Rich-Kern, Business NH Magazine
The hour-long drive from Colebrook to Berlin winds through a rugged stretch of dense forests, river views and quaint towns scattered across the North Country. It’s pretty, but for Hayley Wallace, a mother of three kids, it’s a long haul.
Wallace, whose three children range in ages from 5 to 12, has been pregnant five times, the last two as a surrogate. The most recent baby was delivered in March for the intended parents. While many view surrogacy as an emotional challenge, Wallace says the real test was logistical.
The drive to prenatal appointments at Androscoggin Valley Hospital (AVH) in Berlin was manageable, but when blood tests revealed anemia at 28 weeks, she faced a two-and-a-half-hour commute each way to Dartmouth Health in Lebanon for regular monitoring.
“It made it really difficult to try and get my kids to school and figure out who was going to pick them up,” she says. “I mean, I made it work because I had to make it work. But it was more difficult than it needed to be.”
Wallace’s struggle is becoming more common. In 2000, there were 26 hospitals with labor and delivery units; today there are 15. The closures, driven by declining birth rates, financial pressures and staff shortages, are turning large swaths of the state into maternity care deserts.
This isn’t solely a NH problem. A study in the Journal of the American Medical Association reported more than 500 hospitals in the U.S. closed their maternity departments since 2010, mostly in rural areas.
Demographic shifts have accelerated the trend. In 2023, NH recorded its lowest birth rate since 1979, according to the Carsey School of Public Policy. Fewer unplanned pregnancies, thanks to publicly supported family planning centers and other educational resources, have also contributed. In 2022, NH had the lowest rate of teen pregnancies in the U.S., according to the Centers for Disease Control and Prevention.
At the same time, rising costs for childcare, education and housing prompt some women to delay having kids or opt out entirely. “We’d be remiss not to include the lack of maternity care into the equation,” says Mackenzie Nicholson, senior director at MomsRising NH, a policy advocacy organization for women and moms. Prospective parents, she notes, want to live where medical care is close to home.
That’s becoming a tougher proposition. Maternity care is one of the costliest services hospitals provide. From 2018 to 2020, pregnancy, childbirth, and postpartum care cost an average of $18,865 per delivery, with nearly $3,000 in out-of-pocket expenses for parents with private insurance, according to the Peterson-KFF Health Tracker. Since then, those figures have continued to climb. Insurers often fail to fully reimburse providers, leaving hospitals to absorb significant losses.
Staffing shortages compound the strain, says Dr. Karen Maynard, an obstetrician at Southern NH Health in Nashua and a member of its board of trustees. Births rarely happen on a set schedule, meaning hospitals must staff highly trained nurses and anesthetists around the clock.
The COVID-19 pandemic only deepened the crisis. “A lot of people in the medical field that were on the edge of thinking, ‘I may want to step out,’ stepped out,” Maynard says.
Grant Expands Access in North CountryIn Coös County, the state’s most rural and largest county, maintaining maternity services remains critical, says Natalie Valliere, clinical coordinator for women’s services at Androscoggin Valley Hospital (AVH). She points out that Upper Connecticut Valley Hospital closed its labor and delivery unit in 2003; Weeks Medical Center followed in 2008. That leaves AVH and Littleton Regional Hospital, both more than an hour away for many northern residents, as the only options.
A federal grant is helping to close that gap. Launched in 2023, the Rural Maternal Obstetric Management Strategies (RMom) program, funded by the Health Resources and Services Administration, supports pregnant and postpartum individuals in northern Grafton and Coös counties. The program brings together three area hospitals and centers like Coös County Family Health. It also collaborates with the North Country Health Consortium, the Family Resource Center in Gorham, and the Women of the Mountains Birth Initiative to provide education, support and home visiting services.
For example, a pregnant patient at 32 weeks experiencing blurred vision and headaches might end up at Androscoggin Valley Hospital with severe preeclampsia. Thanks to RMom funding, first responders are trained to spot and handle hypertensive emergencies, making sure the patient gets to the hospital safely. Nurses who shadowed specialists at Dartmouth Health can quickly assess the situation and arrange a transfer to Dartmouth’s Neonatal Intensive Care Unit.
Telehealth is also improving access. Pregnant women in places like Colebrook can now connect virtually with maternal-fetal medicine specialists at Dartmouth without making five-hour round trips.
A team of community health workers and doulas is also available to help families with transportation, food and other essentials. “These small community hospitals don’t see many high-risk patients, but they need to be ready for whatever walks through the door,” says Daisy Goodman, a nurse-midwife at Dartmouth Health.
Hospital MergersTo stay afloat, many small hospitals have merged—some with Dartmouth Health, the state’s largest nonprofit system, others with for-profit groups. The latest example was the financially strapped Catholic Medical Center (CMC) in Manchester, which was acquired by HCA Healthcare, one of the nation’s largest for-profit hospital chains.
That worries advocates like Nicholson, who points to Frisbie Memorial in Rochester. After merging with HCA in 2020 and pledging to maintain maternity care, the hospital closed its labor and delivery unit just two years later. “It’s concerning,” Nicholson says. “They [HCA] really do put profit over people.”
In a March 2023 press release about HCA reaching a settlement with the state to close labor and delivery services at Frisbie, the then Frisbie CEO stated, “The reduced number of babies delivered at the hospital and across the region, and the departure of OB/GYN caregivers necessitates the shift of labor and delivery services to our sister Portsmouth Regional Hospital facility and other community caregivers.”
If CMC were to close its maternity unit, it would increase pressure on Manchester’s only other hospital, Elliot Hospital, which delivered 2,248 babies in FY2024 and houses southern NH’s only Level III NICU, receiving transfers from hospitals like Portsmouth Regional.
In an April 15 press release, CMC said it “remains committed to providing compassionate, patient-centered maternity care,” averaging about 1,000 births annually. The hospital also plans to add five or six certified nurse midwives.
Any conversation about access must include equity, Nicholson says. More than 11% of NH’s population is non-white and continues to grow. Black and Latino women remain three to four times more likely to die during childbirth than white women. “That statistic should scare everyone,” Nicholson says.
Many experts predict that health care mergers will continue. Nationally, there were 72 hospital mergers and acquisitions in 2024, the most since the 79 deals in 2020, according to a Healthcare Financial Management Association report. Lucy Hodder, professor and director of health law programs at UNH Franklin Pierce School of Law, says these acquisitions can reduce access to essential care, as for-profit hospitals are quick to shutter unprofitable services like obstetrics in favor of high-margin procedures.
Some hospitals are investing in their labor and delivery programs. In April, Concord Hospital unveiled one of the 10 newly-renovated maternity suites at The Family Place, its labor and delivery practice. Mothers can deliver their babies in the suites where they stay and the rooms include upgraded amenities, including a jacuzzi tub for pain management.
Maternal health, Hodder says, extends beyond the delivery room. It includes prenatal and postpartum care, family planning and behavioral health—services that don’t make money but save lives.
When the opioid crisis surged, explains Hodder, health leaders moved to better support pregnant women struggling with addiction. A NH Moms in Recovery program catering to pregnant and postpartum women started in 2013.
More recently, state lawmakers extended postpartum Medicaid coverage from 60 days to a full year. This was a critical move, as overdose risk among pregnant and postpartum women is highest seven to 12 months after delivery.
A new bipartisan bill, SB 246, which was set aside in committee, would have required Medicaid to cover maternal depression screenings from pregnancy through well-child visits for up to six months. It would also fund rural EMS training for labor emergencies and support independent birth centers.
Medicaid expansion played a key role in widening access to care for parents, even if they didn’t fall into the traditional low-income categories. By raising income eligibility to 138% of the federal poverty level, the expansion opened the door to insurance for nearly 60,000 people who previously fell through the cracks, according to the NH Fiscal Policy Institute.
That access now hangs in the balance. New Hampshire is one of eight states with a “trigger law” that will automatically repeal the expansion if the federal government reduces its share of funding.
These potential cuts are “keeping administrators up at night,” says Dr. Joseph Ebner, chief medical officer and obstetrician with Speare Memorial Hospital in Plymouth. About 60% of the hospital’s obstetric patients are on Medicaid, a figure that is even higher for pediatrics.
Labor and delivery units at small hospitals are “loss leaders,” Ebner says, but are essential to community trust.
Goodman of Dartmouth Health worries these Medicaid cuts could undermine maternal mental health services. “What about perinatal depression? Someone who’s been successfully treated during pregnancy—are we really going to take their medication away postpartum, when they need it the most?”
Family Planning Budget CutsAnother looming threat to women is cuts to family planning programs. The NH House is proposing to slash $840,000 from four family planning program centers serving Manchester, Nashua, Coos County, and the Lakes Region. The centers provide low to no-cost sexual and reproductive health care services, including regular checkups, lab work and emotional support.
At Amoskeag Health in Manchester, one of the affected clinics, nearly 300 babies are delivered each year. Most of its 16,000 patients are low-income, on Medicaid or uninsured. If the program is cut, more than 400 women would lose access to prenatal care, contraception and postpartum support.
“Eliminating the Family Planning Program will likely lead to an increase in teen pregnancies and unwanted pregnancies, particularly in families already struggling financially,” says President and CEO Kris McCracken. “Such a change would place an even greater strain on these families and could force many into difficult choices, including the decision to terminate pregnancies due to a lack of resources and support.”
Independent Birthing CentersExpectant parents seeking a more intimate birth experience once had five independent birthing centers to choose from across NH. Today, only three remain. The Concord Birth Center closed in 2023. The Monadnock Birth Center in Swanzey shuttered a year later, ending a 16-year run. About a third of Monadnock’s patients were on Medicaid, founder Mary Lawlor says.
“We were paying to do Medicaid births, not being paid to do them,” she says. “There wasn’t a single year that I didn’t lose money. I had to borrow money pretty much every year I was open.”
Katherine Bramhall, co-owner of Gentle Landing Birth Center in Hanover, acknowledges the financial pressures. She opened her practice in 2021 in response to the 2018 federal Strong Start study, which found that free-standing, midwife-led birth centers significantly improve maternal health outcomes. Nonetheless, running an independent birth center remains an uphill battle. Bramhall describes a system where commercial insurance companies routinely deny claims without review, forcing providers to fight for reimbursement.
Despite this, Gentle Landing is thriving, with Bramhall expecting to deliver 65 babies this year, up from 40 in previous years. She attributes this growth to increasing demand for personalized, low-intervention birthing options. “There’s got to be hope for families,” she says.
This story is part of Critical Condition: What hospital consolidation means for care, access, and your community, a special series co-produced by partners in the Granite State News Collaborative. These stories are being shared by media outlets across New Hampshire. We want to hear from you! Take our short survey at https://tinyurl.com/3au39uct about your healthcare experiences. For more information, visit collaborativenh.org.