Undeterred by the rain, a few kids play at an outdoor playground and soccer field, but most are exploring the indoor playroom, which has games, toys, art supplies and a staff that oversees these kids activities. At noon, free lunch will be served to any child who brings their own cup and spoon. Today it’s vegetarian pea soup. The city of Helsinki is footing the bill so kids and families have a reliable place to eat and play. 

Finland, like other Nordic countries, boasts generous benefits for families with children: access to free, high-quality prenatal care; an option to take up to three years of paid parental leave; heavily subsidized child care programs, which can be free for families up to a certain income threshold; and spaces like that provide play areas and free meals for families. This is in sharp contrast to the United States, which lacks a national child care infrastructure and has no federal paid leave policy. America leaves individual families responsible for arranging maternal health care, navigating parental leave benefits and sorting out child care decisions — and most of child care subsidies and meal programs are means tested and subject to political whims.

The collective-minded Finland and the individualistic United States have taken wildly different approaches to supporting families, but both leave a key population of caregivers struggling: stay-at-home parents. As seek solutions to address a declining birth rate, they may need to consider developing more support for parents who choose to stay home and care for their children.

Limited Benefits for Stay-at-Home Parents

Six months after giving birth, Virtanen went back to work as a lab technician. The decision was purely financial. She wanted to stay at home and care for her daughter, but she was the breadwinner, so her husband, Roope Jokinen took a year off from university, where he studies violin, to be their daughter’s primary caregiver. Shortly after returning to work, Virtanen cut back to part time hours so she could spend a day at home with her daughter each week, but the pay cut has been difficult for their family, especially with Jokinen still in school. Their arrangement allowed the couple to wait until their daughter was 18 months old to enroll her in a child care program, but even then, Virtanen said, it felt too soon. “It might have been easier if she was older,” she said. “She may have understood why we were taking her there.”

In Finland, stay-at-home parent benefits are primarily connected to paid family leave, meaning the time a parent can take from work to care for the birth or adoption of a child. Finland provides via Kela, a government agency that administers benefits under national social security programs. Eligible working parents who decide to care for their own children can apply to receive an income-related parental allowance based on their annual earnings. It has a sliding scale based on income and it decreases significantly after the first year. After a child turns 2 years old, this allowance ends but parents who choose to forgo paid work and care for their child at home can receive a fixed monthly child home care allowance until the child turns 3. And at any point from birth through age 3, a parent can opt for their child to attend a child care program and the cost is generously subsidized by the Finnish government. 

But even with the robust ecosystem of family policies in Finland, the economics of caregiving can create stress, especially for parents who want to stay at home to care for their children. For high earners, like Virtanen, the allowance would have been too significant a pay cut, which is why she opted to return to work. And while Jokinen qualified for the minimum allowance because he’s a student, it barely made a dent in the cost of raising a family. 

Many American families face similar pressures. While some American workers are eligible to take unpaid family leave through the (FMLA), and some states and private employers do offer a paid family leave benefit, many parents find themselves calculating the cost of care against their leave benefits and making decisions they may not view as ideal for child care. 

In the U.S., non-working parents who care for their children at home are ineligible for benefits, largely because the handful of child care policies the U.S. has implemented have had an explicit goal of boosting workforce participation. , for example, was a federally supported program that subsidized child care for working mothers during World War II. The tax policies designed to offset the costs of child care, such as the Child and Dependent Care Tax Credit, are only available to families in which both parents work. And even states like Vermont and New Mexico, which have generous and innovative child care policies, don’t provide benefits for parents who wish to care for their children.

An Evolving Policy, With Steps Toward Supporting Family Preferences for Child Care

In 2022, Finland took a step toward supporting family preferences. The , allowing them to to take up to six months of paid leave. Before that, the policy only applied to mothers. This change has challenged societal norms around gender and work, explained Miina Pakarinen. Pakarinen is currently on maternity leave with her second son, who won’t get his name until a non-religious naming ceremony in August. He goes by one of his many nicknames, including Paavo, which means pope, since he was born the day Pope Leo the XIV was elected. With her older son, who was born in 2021, Pakarinen spent 10 months at home, and had her mother care for him until he started a child care program at age 1. But with Paavo, Pakarinen is planning to return to work at an employment agency when he turns 6 months old, and then her husband will stay home for six months. 

“It’s making our society more equal,” she said of the paid leave split. “Both at home and at work, with who gets to take the time off.” Pakarinen is not interested in being a stay-at-home parent, but acknowledges that creating more choices for families is beneficial, and she’s looking forward to her husband being the caregiver when she returns to work. 

This step has helped Finland better support family choice, but the reality remains that even in a country with generous family policies and a strong child care infrastructure, the economics of child care is fraught. Heavily subsidized, high-quality child care may be a solution that works for most families, but there’s not a one-size-fits-all policy for families. And like the handful of child care policies in the U.S., most of the support requires outsourcing the care provided, with little support for families who opt to do it on their own. 

Addressing declining birth rates — a challenge Finland and the U.S. share — requires building a more robust, supportive child care system that takes into account family preferences for care. Both countries may need to consider developing family policies, tax credits and incentives that extend to parents who opt to stay home to bond and care for their babies and young children.

For Virtanen, staying at home isn’t in the cards for now. But she said she’d reconsider if she has another child, even if it comes with a financial cost. “I want to be the one caring for her,” she said. 

Nine months after Monroe County Hospital in rural South Alabama closed its labor and delivery department in October 2023, Grove Hill Memorial Hospital in neighboring Clarke County also stopped delivering babies.

Both hospitals are located in an agricultural swath of the state that’s home to most of its poorest counties. Many residents of the region don’t even have a nearby emergency department.

Stacey Gilchrist is a nurse and administrator who’s spent her 40-year career in Thomasville, a small town about 20 minutes north of Grove Hill. Thomasville’s hospital over financial difficulties. Thomasville Regional hadn’t had a labor and delivery unit for years, but women in labor still showed up at its ER when they knew they wouldn’t make it to the nearest delivering hospital.

“We had several close calls where people could not make it even to Grove Hill when they were delivering there,” Gilchrist told Stateline shortly after the Thomasville hospital closed. She recalled how Thomasville nurses worked to save the lives of a mother and baby who’d delivered early in their ER, as staff waited for neonatal specialists to arrive by ambulance from a distant delivering hospital.

“It would give you chills to see what all they had to do. They had to get inventive,” she said, but the mother and baby survived.

Now many families must drive to reach the nearest birthing hospital.

Nationwide, most rural hospitals no longer offer obstetric services. Since the end of 2020, more than 100 rural hospitals have stopped delivering babies, according to from the Center for Healthcare Quality & Payment Reform, a national policy center focused on solving health care issues through overhauling insurance payments. Fewer than 1,000 rural hospitals nationwide still have labor and delivery services.

Across the nation, two rural labor and delivery departments shut their doors every month on average, said Harold Miller, the center’s president and CEO.

“It’s the perfect storm,” Miller told Stateline. “The number of births are going down, everything is more expensive in rural areas, health insurance plans don’t cover the cost of births, and hospitals don’t have the resources to offset those losses because they’re losing money on other services, too.”

Staffing shortages, low Medicaid reimbursement payments and declining birth rates have contributed to the closures. Some states have responded by , by allowing the , or by encouraging urban-based obstetricians to open .

Yet the losses continue. Thirty-six states have lost at least one rural labor and delivery unit since the end of 2020, according to the report. Sixteen have lost three or more. Indiana has lost 12, accounting for a third of its rural hospital labor and delivery units.

In rural counties the loss of hospital-based obstetric care is associated with , studies have found. The share of women also increases in rural counties that lose hospital obstetric services.

And researchers have seen an — when a baby is born three or more weeks early — following rural labor and delivery closures. Babies born too early have higher rates of .

Births are expensive

The decline in hospital-based maternity care has been decades in the making.

Traditionally, hospitals lose money on obstetrics. It costs more to maintain a labor and delivery department than a hospital gets paid by insurance to deliver a baby. This is especially true for rural hospitals, which see fewer births and therefore less revenue than urban areas.

“It is expensive and complicated for any hospital to have labor and delivery because it’s a 24/7 service,” said Miller.

A labor and delivery unit must always have certain staff available or on call, including a physician who can perform cesarean sections, nurses with obstetric training, and an anesthetist for C-sections and labor pain management.

“There’s a minimum fixed cost you incur [as a hospital] to have all of that, regardless of how many births there are,” Miller said.

In most cases, insurers don’t pay hospitals to maintain that standby capacity; they’re paid per birth. Hospitals cover their losses on obstetrics with revenue they get from more lucrative services.

For a larger urban hospital with thousands of births a year, the fixed costs might be manageable. For smaller rural hospitals, they’re much harder to justify. Some have had to jettison their obstetric services just to keep the doors open.

“You can’t subsidize a losing service when you don’t have profit coming in from other services,” Miller said.

And staffing is a persistent problem.

Harrison County Hospital in Corydon, Indiana, a small town on the border with Kentucky, in March after hospital leaders said they were unable to recruit an obstetric provider. It was the only delivering hospital in the county, averaging about 400 births a year.

And most providers , a particular problem in rural regions that might have just one or two physicians trained in obstetrics. In many rural areas, family physicians with obstetrical training fill the role of both obstetricians and general practitioners.

Ripple effects

Even before Harrison County Hospital suspended its obstetrical services, some patients were already driving more than 30 minutes for care, the Indiana Capital Chronicle . The closure means the drive could be 50 minutes to reach a hospital with a labor and delivery department, or to see providers for prenatal visits.

Longer drive times can be risky, resulting in more scheduled inductions and C-sections because families are scared to risk going into labor naturally and then facing a harrowing hourlong drive to the hospital.

Having fewer labor and delivery units could further burden ambulance services .

And hospitals often serve as a hub for other maternity-related services that help keep mothers and babies healthy.

“Other things we’ve seen in rural counties that have hospital-based OB care is that you’re more likely to have other supportive things, like maternal mental health support, postpartum groups, lactation support, access to doula care and midwifery services,” said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health, whose research focuses in part on maternal health policy with a focus on rural communities.

State action

Medicaid, the state-federal public insurance for people with low incomes, pays for nearly half of all births in rural areas nationwide. And women who live in are more likely to be covered by Medicaid than women in metro areas.

Experts say one way to save rural labor and delivery in many places would be to bump up Medicaid payments.

As congressional Republicans debate President Donald Trump’s tax and spending plan, they’re considering to help pay for the bill’s tax cuts. Maternity services aren’t on the chopping block.

But if Congress reduces federal funding for some portions of Medicaid, states — and hospitals — will have to figure out how to offset that loss. The ripple effects could translate into less money for rural hospitals overall, meaning some may no longer be able to afford labor and delivery services.

“Cuts to Medicaid are going to be felt disproportionately in rural areas where Medicaid makes up a higher proportion of labor and delivery and for services in general,” Kozhimannil said. “It is a hugely important payer at rural hospitals, and for birth in particular.”

And though private insurers often pay more than Medicaid for birth services, Miller believes states shouldn’t let companies off the hook.

“The data shows that in many cases, commercial insurance plans operating in a state are not paying adequately for labor and delivery,” Miller said. “Hospitals will tell you it’s not just Medicaid; it’s also commercial insurance.”

He’d like to see state insurance regulators pressure private insurance to pay more. More than 40% of births in rural communities are covered by private insurance.

Yet there’s no one magic bullet that will fix every rural hospital’s bottom line, Miller said: “For every hospital I’ve talked to, it’s been a different set of circumstances.”

is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

Black women experience in maternal care, including . The medical racism that Black women experience contributes to disproportionately high rates of maternal mortality. Just look at the stats: Black women are -related causes than white women according to the Centers for Disease Control and Prevention (CDC). Shockingly, the CDC also reports that of pregnancy-related deaths are preventable.

Numerous studies show that . While their roles are different, both doulas and midwives offer vital support before, during and after birth that can combat the Black maternal health crisis. Midwives are trained medical professionals who provide prenatal care, monitor physical and emotional health, and perform labor and delivery in a variety of settings including hospitals, homes and birthing centers. The midwifery model of care is holistic and client-centered, and . Doulas are advocates that ensure clients’ needs are respected, and they make active, informed decisions about care. Doulas can create birthing plans, offer techniques for pain management during labor, and provide continuous physical and emotional support. Their presence is proven to improve maternal health outcomes and .

Being paired with a birth team that is reflective of background, values and culture is important, and helps to build trust and contribute to more equitable care. For Black women, that connection can be lifesaving. Yet, and according to some estimates .

Niambi Bloom (LSW) is one of only two Black birth doulas in Colorado Springs. She first discovered this maternal care desert while searching for her own doula during her first pregnancy. She found only one Black doula based in Denver, more than an hour away. Ultimately, she chose a local doula and had what she describes as a “textbook home birth” where she was surrounded by a midwife and a doula who she felt genuinely cared about her. Bloom chose to become a birth doula to help positive birthing experiences like her own become the norm. She also wanted to give other Black women what she did not have, care from a Black doula. Bloom now helps to lead training sessions about maternal health disparities to new groups of prospective doulas. It was during one of these sessions that Bloom met a Black woman who was training to become a doula in Colorado Springs. Now, the two work together but still have not found other Black birth doulas in the area. According to Bloom, “It’s just us.”

Building a more diverse maternal care workforce is essential to providing more equitable care, and it’s a necessary component to combating Black maternal health disparities, but there are barriers that prevent both recruitment and retention of Black birth workers. Tyla Leach, a labor and delivery nurse and childbirth educator, believes a major barrier is the sheer amount of money, time and energy it costs to become trained and remain in practice. A found that almost all doulas find their work to be emotionally fulfilling, but few consider it to be financially rewarding. According to Jazmin Williams, a full spectrum doula and the Founder of , “Birth work is not a revenue-based service. It is not a revenue-based profession. We aren’t getting rich off supporting our community…But we know the necessity of having a doula that is reflective of your background, reflective of your culture that knows how to become an advocate with you… to amplify your voice rather than talk over for you.” She added, “We do provide a lot of sliding scale assistance and I’m pro bono, but we also have families of our own and that’s how we came into practice, so we really have to look at our care pricing that is also sustainable for us.”

The for their work. Most private insurance providers and Medicaid programs do not cover doula care, which often means clients can pay up to thousands of dollars out of pocket for these services. The CDC, estimates that over . Failure to include Medicaid coverage for doula care makes a vital resource to combat maternal mortality largely inaccessible for those who are most at risk. A growing number of states are pushing for Medicaid reimbursement for birth doulas to address the problem. According to , “the goal of Medicaid coverage of doula care [was] threefold, according to advocates: support people who are giving birth, provide culturally congruent care and compensate doulas fairly for their work.”

Necessary Policy Change: How They Did It

In 2022, Washington lawmakers passed to establish birth doulas as a health profession in Washington state, creating a process for state certification and thus a pathway for Medicaid reimbursement. The success of HB 1881 is as a national model for how legislators should directly involve and advocate with birth workers.

• The , a Queer, Trans, Black, Indigenous and People of Color-led (QTBIPOC) organizing group bolstered by , was instrumental in the creation of the bill and worked in lockstep with legislators to lobby for its passage. Members of the Coalition shared their perspectives to ensure the bill combats harm, addresses community concerns, and that the certification process does not shut out doulas who are already practicing.
• They were instrumental in creating a certification process that is voluntary, meaning doulas who choose not to become certified are still able to practice and support their communities.
• They also advocated for a competency-based model for certification and training that values ancestral knowledge, and differs from courses offered at large certification organizations that have historically .

Sage Maenad Kissiah-Grove, a member of the Coalition, and a birth and postpartum doula, credits HB 1881 with establishing and opening up the certification process “for people who come from all kinds of backgrounds in birth work, people who have been trained ancestrally, people who have self-trained and people who have not trained through these big organizations.” She added, â€œFor their training to be from people who look like them and who have their same experiences is huge.”

Washington State Senator T’wina Nobles, a Black woman and mother of four, worked alongside the Doulas for All Coalition to rally support for the legislation and to create a clear pathway for its passage in the State Senate. She believes that doulas “really are the leaders” in this work, and that people who are most impacted and most connected to birth work deserve their voices to be heard. Nobles sees herself as an amplifier who focuses on “allowing the experts, the doulas and midwives and folks who do the birthing work, to lead and let me know what they need.”

This year, Nobles plans to introduce legislation that builds on the success of HB 1881 with Senate Bill 6172, which will allow birth doulas up to $4500 in Medicaid reimbursement rate, the highest in the country.

What’s Next?

Federal Way Birth Center celebrated its grand opening in November. For Faisa Farole, it is just the beginning. She envisions a future in which FWBC will serve as a community hub and provide support beyond childbirth. â€œI want the center to be not just a place where we are providing mentorship to aspiring Black midwives, but also a place where the community can come and get lactation education and childbirth education,” said Farole.

She added, “I want it to be something that the community is using, and not a place where the doors are closed.” She also sees the center working in collaboration with nonprofit organizations who support BIPOC (Black, Indigenous and People of Color) communities, and she already has spoken with the about teaching in the space.

Farole is also the founder and executive director of (GPS), a nonprofit that provides free community-based doula services for Black, immigrant and refugee families. She also has trained more than 100 doulas who combined speak more than 17 different languages. She sees her own nonprofit working closely with the center, and offering GPS clients the option to give birth at the center if they choose. Farole is optimistic about the future of her center, as well as other initiatives that will help more Black women “answer the call” and provide vital support for their communities.

Jazmin Williams was fortunate to be on a Black birth team with a Black birthing person, Black midwife, Black doula and a Black pediatrician. “It’s rare to have an entirely Black birth team…It’s an incredible experience and one that I’m thankful for,” said Williams. “It fills my heart to know that is possible, and that we can do that.”

All Black women deserve a birthing experience where they feel respected, their choices are honored, and their lives are protected. There is beauty, joy and strength in birth, and those experiences should be the norm. What is happening in Washington is cause for celebration and hope. We can support Black birth workers and center them in legislative advocacy. We can build a more diverse maternal care workforce and ensure doulas and midwives are paid living wages. We can save the lives of Black women and create safe, healthy birthing experiences that are rooted in empowerment instead of trauma.

The Federal Way Birth Center is the first Black owned freestanding birth center in Washington state. It is the first of its kind, but hopefully it will not be the last.