Maternity care deserts have remained unchanged over the past decade. But Medicaid cuts could further threaten access.
So finds the latest March of Dimes report (PDF), which found that one in three U.S. counties are considered maternity care deserts, a share virtually unchanged since 2016.
Most of these are rural counties. Nearly two and a half million women of reproductive age live in these regions and must travel three times longer, on average, to reach labor and delivery services. An additional 3.4 million women live in counties with low or moderate access to maternity care.
“When we know we’re among the most dangerous countries in the world for giving birth, we have got to figure out a way to do better,” Michael Warren, M.D., chief medical and health officer at March of Dimes, told Fierce Healthcare.
A maternity care desert, per the report, is defined as a region with zero birthing facilities (hospitals or birth centers) and zero OB clinicians (including OBGYNs, midwives and family physicians).
Though the topline figure for maternity care deserts has remained unchanged, one in five counties has changed its access status since 2016. “That’s really remarkable, because it points to how dynamic this situation is,” Warren explained, meaning accessibility may fluctuate within a given community over time.
Over half of U.S. counties lack a hospital with labor and delivery services. At least 96 labor and delivery units have closed since 2024 alone. “Whatever we can do to try to keep labor and delivery units open or birth centers open, for that matter, in these communities would be beneficial,” Mark Simon, chief medical officer of OB Hospitalist Group (OBHG), told Fierce Healthcare. OBHG sponsored the report but was not involved in its creation.
From 2016 to 2024, Texas saw the largest expansion of maternity care deserts (16 additional counties). Iowa and Nebraska both saw measurable declines (five additional counties each). On the flip side, Louisiana made gains in access (six counties moved out of care desert status). Nevada and Montana also saw some gains (two and five counties reversed status, respectively).
One of the drivers of OB clinician shortages is recruitment and retention challenges. Med students who train in rural areas are more likely to practice in those settings, Warren said, highlighting the importance of continuing to expand rural residencies. Another important consideration is loan repayment for clinicians.
Clinician shortages are also affected by restrictions on midwives and family physicians. Family docs have historically been involved in OB care and can play a crucial role in closing care gaps. Though they represent less than 6% of the overall OB workforce, they make up over a quarter of OB clinicians in rural counties. But family docs have fewer opportunities to receive OB training in residency and, for a variety of reasons, may not have admitting privileges at hospitals, meaning they cannot support labor and delivery. These are opportunities for innovative policymaking, Warren and Simon agree.
When it comes to midwives, who can safely manage low-risk pregnancies and support deliveries, the report said 16 states have expanded the scope of midwifery practice. In 2024, 11.6% of hospital births were attended by midwives, up from 8.4%, representing “meaningful growth.” Midwifery care is associated with higher rates of vaginal delivery, lower rates of C-sections and higher rates of patient satisfaction. “Certified nurse midwives have to be a part of the solution,” Simon said.
Insurance rates have improved due to Medicaid expansion, per the report. Nearly all states have also extended postpartum Medicaid coverage through 12 months.
“Insurance access matters. We know that if you’ve got access to insurance, it is easier to be able to get that prenatal care, to get that postpartum care,” Warren said. In 2024, a quarter of women didn’t get prenatal care in their first trimester, a crucial time to identify risk, manage chronic conditions and get preventive services.
However, Medicaid cuts in the One Big Beautiful Bill Act may reverse gains in insured status.
“Medicaid cuts have the potential to be devastating here,” Warren said. Because states will have less federal funding to work with, they may be forced to cover fewer people, cut what services they reimburse for or cut reimbursement rates (or some combination). If hospitals start getting less for deliveries, that could be a real hit to their bottom line—especially for rural hospitals that already see a disproportionate number of Medicaid patients.
California is testing the idea of allowing hospitals in rural regions to have standby perinatal services. This would mean staff would not be required to be physically on call 24/7, the costs of which can add up. This “might make sense in these rural communities that don’t have a ton of deliveries,” Simon said.
Other strategies include leaning into technology. Telehealth and remote patient monitoring (RPM) have “potentially a very bright future in this,” Simon said. “If you can allow a mother to have a prenatal visit when she is still at home, … that’s still better than nothing,” he said.
The Rural Health Transformation Fund is a promising avenue for expanding tech-enabled care, particularly in behavioral health, per Warren. “Fifty billion dollars is not enough to plug the hole and solve the maternity care access crisis, but at the same time, it’s an important opportunity,” Warren said.
The report noted that reimbursement parity between Medicaid and commercial plans is needed for these digital approaches to scale. Investment in broadband expansion is also crucial, and must be accompanied by digital literacy programs. Clinicians also need to have expanded interstate licensing to practice across state lines.
Reimbursement changes are coming very soon to maternity care. The American Medical Association is moving away from the decades-old global maternity bundle in its CPT codes starting January 2027. The shift will allow providers to bill for discrete services delivered across various settings, more closely reflecting the collaborative care women receive today, per the AMA.
While clinicians and medical societies have praised the move, conservative lawmakers are concerned it will be inflationary and increase healthcare costs. The CMS is considering preserving the current global maternity coding and payment structure, which groups like the American College of Obstetricians & Gynecologists and OBHG oppose, arguing it would create administrative complexity and undermine unbundling.
“I believe that the old model that CMS is trying to resurrect is antiquated. It was based on an era when you have one physician [provide all care],” Simon said. "Unbundling allows for seamless billing, appropriate billing, of those services when they occur.” Additionally, unbundling provides transparency and insight into who is providing services and where, which could serve to expand care in communities that need it most, he said.