When the Lights Go Out: What Hospital L&D Closures Teach Us About CON

I’ve delivered babies at 3 AM. I know what it means when a community loses its labor and delivery unit — not as a policy abstraction, but as the physician who gets the call, drives through the dark, and catches what’s coming whether the system is ready or not.

So when Maine’s legislature recently debated whether to require hospitals to give 120 days’ notice before closing an L&D unit, I had thoughts. Most of them impolite.

Here’s what I want physicians — and anyone who cares about rural healthcare access — to understand about this conversation. Because it’s coming to your state too, and the way it gets framed will determine whether we get real reform or another well-intentioned rule that accomplishes nothing except giving people more time to be afraid.

Since 2020, more than 120 rural hospitals have stopped delivering babies or announced they will before the end of 2026. That’s a 12% reduction in rural L&D units in five years. In Maine alone, a string of maternity wards has closed over the past decade. MaineHealth’s Waldo Hospital in Belfast closed its unit in April 2025. Communities that spent generations assuming their local hospital would be there for the most consequential moments of a family’s life are finding out, often with inadequate warning, that it won’t be.

The reasons are familiar: Medicaid underpays. Birth rates are declining. Staffing is brutal. The math doesn’t work. None of that is new, and none of it is dishonest. Hospitals closing money-losing services are doing exactly what any rational institution does when the numbers don’t pencil out.

But here’s what gets left out: the regulatory environment that made these hospitals the only option in the first place.

Maine’s DHHS has had voluntary guidance since 2022 asking hospitals to give 120 days’ notice before closing L&D units. Some complied. Some didn’t. The recent commission on healthcare regulatory oversight recommended making it statutory.

Let’s be honest about what 120 days actually accomplishes: it gives communities more time to panic in an organized fashion. It does not create another option. It does not lower the regulatory barriers that made independent birth centers prohibitively difficult to open. It does not address the Certificate of Need laws that, in states like Maine, require government permission before any new healthcare facility can be established — effectively guaranteeing that when a hospital decides the math doesn’t work, there is nothing else.

Worse, it may actively harm communities by triggering months of anxiety over a closure that hasn’t happened yet, while doing nothing to change the outcome. A family planning a birth doesn’t need 120 days of dread. They need another place to go.

Notice of closure is not a substitute for competition. It’s the sound of a door closing slowly instead of slamming — and somehow we’re supposed to be grateful for that.

Here is the policy truth that the closure notice debate consistently obscures: in states with active Certificate of Need laws, hospital L&D closures create access vacuums that the market cannot fill — not because there’s no demand, not because independent practitioners couldn’t serve the need, but because CON laws require a lengthy, expensive, and often futile approval process before anyone can try.

Maine’s CON threshold for a new healthcare facility is $3 million — set in 2012 and never inflation-adjusted. A free-standing birth center, an independent surgical center, a new primary care clinic built to serve a rural community: all of them face the same gauntlet. Apply to the state. Document public need. Demonstrate you won’t hurt existing facilities. Wait. Pay lawyers. Wait some more. Discover that the incumbent hospital system — the one that just closed its L&D unit — has filed comments in opposition.

This is not hypothetical. This is the structure of healthcare regulation in more than 35 states. And it means that when a hospital closes a service, the regulatory architecture that was supposed to protect the community actively prevents the community from replacing it.

The regulatory burden in healthcare falls hardest on independent practitioners and small organizations, not on systems. A large health system absorbs a CON application the way it absorbs the cost of a new MRI — as a line item. A small group practice, a community birth center, a rural clinic trying to fill the gap left by a closed hospital unit: they don’t have that infrastructure. For them, CON isn’t a bureaucratic inconvenience. It’s a locked door.

If we want communities to have actual options when their hospital closes a service, we need to make it possible for new practitioners and facilities to enter. That means CON reform. Not closure notice requirements. Not statewide health planning committees. Not 120 days to find out you’re alone.

The closure notice debate is a symptom. Certificate of Need is the disease. And treating a symptom while ignoring the disease doesn’t make anyone healthier — it just makes the decline more visible.

When the next rural hospital closes its L&D unit, the question shouldn’t be “did they give enough notice?” It should be “why is there nothing else?”

We already know the answer. The question is whether we’re willing to say it out loud.