At Shenandoah Medical Center in southwest Iowa, Dr. Martee MacLeod-Kozal is the only full-time OB-GYN on staff, with other providers helping cover on-call shifts and clinic hours to keep the labor and delivery unit running. The nearest other hospital offering labor and delivery is in Creston, about an hour and 20 minutes away, leaving expectant mothers across the region with few nearby options if something goes wrong.
The situation in Shenandoah reflects a statewide pattern of gaps in labor and delivery services, as reported by 3 News Now. Expectant mothers in rural Iowa often travel more than an hour to deliver, and the station's reporting found that long patient travel times increase the risk that emergencies cannot be addressed quickly. According to the American Medical Association, 57% of Iowa counties lack an obstetric facility entirely, and the state has just 3.3 OB-GYNs per 10,000 women of reproductive age, compared to a national average of 4.5.
Those numbers track with a broader statistical picture: a March of Dimes analysis from August found that 39.4% of Iowa counties qualify as maternity care deserts, meaning they have neither a hospital birthing center nor a practicing obstetric clinician, according to March of Dimes. Data examined by the Center for Healthcare Quality and Payment Reform in February 2024 showed that 61% of Iowa's rural hospitals no longer provide labor and delivery services at all, and 58% of those still offering the service operate at a financial loss on overall patient care.
A Shrinking Statewide Map of Birthing Units
The decline did not happen overnight. Academic research published in the International Journal of Population Data Science found that 41 hospital birthing units in Iowa have closed since 2000, a loss of nearly half of the state's previously available birthing units over two decades, per the International Journal of Population Data Science. MacLeod-Kozal told 3 News Now that being an OB is difficult, and that maintaining a labor and delivery unit requires both OB-GYNs willing to provide the care and hospitals willing to support it.
Shenandoah Medical Center has tried to adapt to the pressures squeezing rural obstetric care by starting its own ambulance service and bringing on an overnight nurse-midwife to help ease staffing strain, per the station's report. Those local fixes come as Iowa lawmakers have also taken steps aimed at the underlying problem: Governor Kim Reynolds signed House File 161 in February 2023, capping non-economic damages in medical malpractice lawsuits at $2 million against hospitals and $1 million against independent clinics, with the goal of easing liability concerns that discourage physician recruitment, according to Iowa Public Radio.
Why Liability and Economics Keep Squeezing OB Units
An Iowa OB-GYN has linked rising liability costs to OB-GYN departures, including in rural communities. Federal policy adds another wrinkle: the Rural Emergency Hospital designation, implemented in 2023, offers struggling facilities enhanced Medicare reimbursement, but only if they eliminate all inpatient beds, ending inpatient obstetrical care; REHs may provide low-risk labor and delivery and may conduct emergency deliveries, per the Rural Health Redesign Center.
Travel distance is only part of the burden once a mother reaches a hospital that can deliver her baby. Iowa communities are not mandated to provide ambulance services, and the state faces a shortage of EMS volunteers, the same gap that factors into the closures documented in 3 News Now's reporting. Iowa Code Chapter 422D, paired with Senate File 615 passed in June 2021, lets counties ask voters to approve a local tax levy to fund ambulance operations, but the system still depends on individual counties choosing to act, according to UnityPoint Health.
EMS Gaps Raise Stakes for Postpartum Emergencies
Jenny Sharrick, director of public health services for Firefly, which serves young families with lower incomes, said EMS shortages create concerns about timely transport for postpartum patients experiencing hemorrhage. She told 3 News Now that EMS delays could contribute to maternal mortality, and that shortages of OB-GYNs, birthing centers, and EMS compound the long travel distances families already face.
MacLeod-Kozal said she advises her patients about precautions to take and when to seek care, a reflection of how much responsibility falls on individual providers in communities with thin obstetric coverage. Medicaid plays an outsized role in propping up what access remains: pregnant women in Iowa with household incomes up to 215% of the federal poverty level qualify for coverage that extends through 12 months postpartum, according to the Iowa Department of Health and Human Services. The department's guidelines, effective October 2025, also shifted Iowa Medicaid to an unbundled maternity billing structure, reimbursing prenatal, delivery, and postpartum visits separately rather than through a single global payment.
The pressures documented around Shenandoah echo a pattern seen just across the border, where Hoodline previously reported on a Nebraska mom forgoing hospital birth after maternity care deserts left her with few nearby options. For now, families around Shenandoah are left relying on a single full-time OB-GYN, a homegrown ambulance service, and an overnight nurse-midwife to hold together care that, elsewhere in Iowa, has already disappeared.
