A majority of Pennsylvania’s rural hospitals don’t deliver babies, mirroring a nationwide trend that leaves expectant mothers to the fate of long drives to a suburban maternity ward.

Pennsylvania has 42 rural hospitals; of those, 60% of them (25) operate without labor and delivery services, according to an analysis from the Center for Healthcare Quality and Payment Reform. Pregnant women in rural areas need to drive almost 40 minutes to reach a hospital that can assist them during birth.

Of the 17 rural hospitals that still have maternity wards, financial troubles could force cuts. In recent years, 35% of them reported financial losses on patient services.

Rural depopulation and fewer patients to serve have been an issue, but so have reimbursement rates — both from private insurance and public health care programs.

Though low Medicaid payments and uninsured patients can make the financial picture for rural hospitals tricky, private health insurance covers 40% of birth in rural communities, the analysis noted, which also covers less than the cost of services in some cases.

Those low rates have put rural hospitals in a bind.

“The smaller the hospital, the more likely it is that private insurance plans pay them less than the cost of the services,” Harold Miller, the center’s president and CEO, said. “In some cases, it’s because the health plan pays the hospital less than it pays a larger hospital, but it can also be because it pays the same amount as a larger hospital, even though it costs more to deliver the same service at a rural hospital.”

The problem stems from the fixed costs of having a maternity ward with low use. The center’s analysis found that rural hospitals only get paid for provided services. Facilities can go days without any births, meaning reimbursements and other revenues don’t cover mandatory staffing costs.

While talk in the General Assembly and the federal government for health care reform has touched on telehealth and expanding the care that nurse practitioners can give, neither would address maternity care. Nurse practitioners can’t offer some types of care that pregnant women could need during birth.

“The problem isn’t just the amount of payment, but whether and when the health plan pays,” Miller said. “Prior authorization requirements, claims denials, and delays in payments hurt rural hospitals as much as low payment amounts.”

In recent years, more than a dozen rural hospitals have shuttered. Five facilities have closed since 2006 in Philipsburg, Ashland, Peckville, Ellwood City, and Sunbury. Another eight either closed or merged in Bradford, Hastings, Towanda, Pottsville, Clearfield, Saint Marys, Wellsboro, and Titusville.

Stemming the tide of closures, Miller argued, starts with reforming payments. Requiring insurance plans to cover the actual cost of rural maternity care and creating annual “standby capacity payments” from Medicaid and private insurers to cover fixed costs instead of service-based fees could improve hospitals’ finances.