The New Landscape of Rural Births

Published: May 19, 2026

By Mara Johnson-Groh

5 min read

When Erin Samel was pregnant for the second time, she knew she didn’t want to give birth via caesarean again, given the risks of having the invasive procedure twice. But that meant her best option for delivery was Dartmouth Health’s Dartmouth Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire, a two-hour drive away from her home in Gorham, New Hampshire.

“For some of my prenatal appointments that were just five-minute visits, I had to travel four hours round trip,” says Samel, who is now a mother of four. “So that was me taking an entire day off work for a few minutes of care—something not everyone can afford to do.”

The challenges Samel faced in her pregnancy are not unique in New Hampshire. Over the past 25 years, nearly half of labor and delivery units across the state have closed because of financial issues, staffing shortages, and a decline in births. These closures are especially acute in rural areas, such as the most northern reaches of New Hampshire. As a result, receiving care close to home in the North Country is increasingly difficult.

With populations across rural areas in decline, these challenges aren’t likely to ease, according to a 2022 policy brief published by Dartmouth researchers. So in 2023 a group at DHMC applied for a federal grant to improve access to pre-and perinatal care in New Hampshire. Now halfway into their four-year Rural Maternity and Obstetrics Management Strategies (RMOMS) grant, DHMC has made huge strides in increasing care in the region through the formation of the North Country Maternity Network (NCMN), which unites disparate programs across the region to transcend the limitations of what individual service providers can offer due to its unique structure and funding.

Already, NCMN has improved maternal care infrastructure by partnering with local hospitals, creating a doula/community health worker program, providing training for obstetric nurses, and more.

“The North Country is a rural area with a lot of economic challenges,” says Daisy Goodman, DNP, MPH, a grantee co-applicant and a certified nurse-midwife at DHMC. “With the help of the RMOMS grant, we have already made huge steps in improving connections to and continuity of care here and are already beginning to see improved outcomes.”

High Costs

The challenges local hospitals and providers face stem in part from underfunding. Under Medicaid, births are reimbursed in a lump sum. This means a hospital receives the same amount for a birth regardless of how many visits or how much extra care a patient might need.

In North Country hospitals with obstetric units, nearly 1 in 4 births are covered by Medicaid, according to the 2022 policy brief. As a result, birthing units can bankrupt hospitals. The hospitals that closed their units had an even higher percentage of births under Medicaid: 39%. One North Country hospital lost a million dollars in one year on maternity care services, Goodman says. Though no providers want to close labor and delivery wards, sometimes they have no choice.

two women look at pregnancy ultrasounds — The Doula CONNECT program provides free support to anyone who is pregnant in the North Country before, during, and up to one year after birth. *Credit: Kata Sasvari*

NCMN has partnered with several local providers to help find ways to offset these high costs of care.

The RMOMS grant is also helping by enabling NCMN to offer obstetric-focused emergency readiness training for local ambulance crews who may need to assist births in regions far from hospitals with labor and delivery wards.

$1M

loss suffered by one NH hospital in one year on maternity care services
28

obstetric unit closures in NH, VT, and ME since 2000
1 in 4

births in the North Country covered by Medicaid

Other programs offer more targeted care to those giving birth. NCMN has been working to facilitate telehealth visits to reduce transportation burdens on rural patients, and in 2025, a new program to provide better access to doulas—trained, nonmedical professionals who provide guidance through childbirth—was launched by one of NCMN’s partners, North Country Health Consortium (NCHC).

Doula-ing it All

Traditional doulas sometimes only attend the birth itself. By contrast, doulas with NCHC’s Doula CONNECT program provide free support to anyone who is pregnant in the North Country before, during, and up to one year after the birth. This support ranges from facilitating conversations with doctors to supporting breastfeeding and screening for postpartum depression.

“There’s a lot of research and evidence that says having a doula improves outcomes like the baby’s birth weight and mother’s mental health, and it lowers the chance of preterm labor and needing a cesarean section,” says Rebecca Hill-Larsen, CHW, Doula CONNECT coordinator.

In its first year, the fully grant-funded program has already helped 36 clients, including attending a dozen births. The doulas hired by the program are also cross trained as community health workers, which provides them with the skills to tackle related problems such as insurance and food security. The doulas often assist with problems unique to rural areas, such as providing advice on transportation.

“Being healthy in pregnancy and through postpartum is more than just about physical health,” Hill-Larsen says. “Our doulas help support all aspects of health, including things like, does a patient have a way to get to appointments, do they have enough food?”

Unlike some programs for maternity services, the doulas’ care follows the pregnant individual—not the baby. So in traumatic cases where the baby dies or is taken away by the Division for Children, Youth and Families, doulas can still support their client.

“An Endless Maze”

A resource such as this would have been game-changing for Lisa Coulombe following her first pregnancy. When she became unexpectedly pregnant in 2016, Coulombe was addicted to opioids and struggled to receive proper care. The closest methadone recovery clinic was too far to access, and the drugs a doctor prescribed to treat opioid use disorder made both Coulombe and her baby girl sick. When her baby was born, she was taken away by the Division for Children, Youth and Families.

“I was so scared. All I wanted was to be able to care for my baby,” says Coulombe, who is now a community health worker herself, and who has been drug-free since 2021. Seeking to regain custody of her daughter, Coulombe recently discovered she has been adopted. “The support I desperately needed was unavailable to me then. I diligently sought out resources, and it was like going through an endless maze.”

Along with the doula program, other services are available to people in rural New Hampshire, such as the Ask Petra warm line, which provides one-on-one help for anyone with substance use disorders. NCMN also follows a model for universal screening of substance use conditions, and a tiered pathway for intervention.

“We have clients who are struggling with substance use disorder, and a relationship with a doula has really helped them feel supported and be better able to advocate for themselves as they navigate pregnancy,” Hill-Larsen says.

With the work of NCMN, things are looking up for maternity care in the North Country. As Goodman reflects on the accomplishments of NCMN so far, she’s most proud of the work of bringing together service providers across the North Country.

“We’re really excited for what this future of working together can hold in the coming years,” she says. “This type of collaboration is especially critical given the increasing challenges faced by rural maternity care providers and rural healthcare in general.”

Download This Issue