For decades, Americans have migrated toward urban areas seeking opportunities, emptying out large swaths of countryside. In their wake, they have left shrinking communities that struggle to support multiple businesses, schools and hospitals.
This is a common theme in the Midwestern state of Iowa, whose population has grown by less than a million people in the past century. As family farms have consolidated into megafarms run by large corporations, rural residents have moved to cities like Des Moines, the state capital, or left the state altogether.
Shrinking rural America
The northwest region of Iowa has been hit especially hard, forcing those who remain to drive farther and farther for things like groceries, education and health care.
At its peak, the town of Mallard hosted several grocery stores and restaurants, four churches, a cinema and two schools, one of them private. Today, its population of about 265 supports little more than a gas station and a couple of bars. The 100-year-old Catholic Church closed last summer, and the public school will close next year, forcing students to ride on buses to a neighboring town.
Kayla Lanning, a former horse training assistant, takes it all in her stride.
“We’re used to it. It’s not any big deal to us to have to travel a little ways,” she said. In her case, “a little ways” can mean a two-hour drive.
When Lanning learned she would be giving birth to twins, she was told that she could either schedule a cesarean section at her nearest hospital, about 20 kilometers (12 miles) away, or travel to a better-equipped hospital 135 kilometers (85 miles) away. She and her husband, John, chose to make the long drive and avoid the C-section.
Luckily for the Lannings, the drive to the hospital was uneventful, aside from a police officer pulling them over for speeding. The babies were delivered in the hospital, but prematurely; that meant being transferred to yet another hospital, even farther away.
Lanning admits to being a little “irritated” by the distances involved, but accepts it as the part of the trade-off for staying in Mallard.
But not everyone is able to make it to a hospital with a proper obstetrics unit.
“It’s not uncommon for me to get a call from an ER (emergency room), where they say, ‘We have a patient. She started bleeding, she’s 28 weeks along, and she came in here’” to a hospital with no such unit, said Dr. Neil Mandsager, who specializes in high-risk pregnancies.
Many hospitals don’t even have an ultrasound machine to check the status of a baby, said Mandsager, the medical director of obstetrics at Mercy Medical Center in Des Moines. As a result, he travels about 865 kilometers (540 miles) each month to pay weekly visits to patients in rural health care centers.
The problem isn’t isolated to Iowa, which ranks 36th among the 50 states in terms of population density. According to a University of Minnesota study published earlier this year, “18 million reproductive-age women live in America’s rural counties, but over half of these counties have no hospital” where a woman can give birth.
Mandsager said Iowa “does a pretty good job of creating a system that works as best as it can for the pregnant woman, but there’s still definitely some gaps, and these gaps are getting bigger as these small hospitals close.”
Typically, obstetrics services in one to three maternity hospitals or obstetrics units close in Iowa each year, but this year, the number has spiked.
“I can’t remember a year when eight [obstetrics units] closed. That’s a pretty high number,” he said.
Mandsager, along with Stephanie Trusty, a nurse clinician at the Iowa Department of Public Health, attributes the closings to concerns over quality of care, malpractice insurance, profitability and low patient volume. They say it’s also difficult to attract and retain physicians.
“In rural Iowa, delivering babies is not scheduled. If they’re a single practitioner in a rural area, then they’re on call 24 hours a day, seven days a week. You know, that’s hard,” Trusty said.
In addition, there is the worry that so few deliveries can impact a physician’s and nurse’s ability to keep up their skills. Trusty said she looked at the maternity records of the eight hospitals that closed their obstetrics units or shut down altogether this year and found that three of them averaged less than one birth per week.
New mothers surveyed
The Iowa Department of Public Health for years has used a survey given to new mothers as a way to assess concerns. The patient survey collects data on issues such as distance traveled and quality of care received. Trusty said the survey has had an extremely high response rate. Of the 40,000 yearly births in the state, the department receives about 20,000 survey responses.
Surprisingly, she said, those responses haven’t reinforced their fears.
“We asked ‘did they have trouble getting prenatal care,’ and very few were refused care, and most people said it was still easy to get access,” Trusty said. “On how many miles they drove? The data didn’t change for years and years, so we took it off our survey.”
That was five years ago. Because of the large number of maternity ward closings this year, Trusty said they will reintroduce the question about “distance traveled” in next year’s survey.
As for whether couples may be dissuaded from settling in smaller towns because of these longer commutes, Lanning said it didn’t factor into her decision.
“We are so grounded here. John grew up here, and everything we know and do is here. So yeah, that doesn’t affect that,” she said.