The U.S. is in the midst of a worsening crisis in maternity care. More than 500 hospitals discontinued their obstetric care from 2010 to 2022, leaving millions of Americans—especially in rural areas—without access to essential care, according to a new study.

This is not just a rural crisis, but a national one, with urban areas increasingly affected as well, according to the first national data compiled since 2018.

The Trend: Hospitals Abandon Services for Childbirth

From 2010 to 2022, a total of 238 rural and 299 urban hospitals lost their obstetric services while only 138 hospitals, mostly in urban locations, added them. By 2022, more than half of all rural hospitals (52.4%) no longer offered obstetric care, up from 43.1% in 2010. Urban hospitals were not spared either, with 35.7% lacking obstetric services by 2022, compared to 29.7% a decade earlier

“I worry the trend will continue, based on history. But this isn’t affecting every state and every community in the same way—rural communities are disproportionately affected,” said LDI Senior Fellow Sara Handley, Assistant Professor of Pediatrics at the Perelman School of Medicine and a neonatal specialist at Children’s Hospital of Philadelphia.

As more hospitals shutter these critical services, maternal mortality could continue to rise. “The loss of hospital-based obstetric services can adversely affect access and outcomes,” the study noted.

Handley and her colleagues published the research in two parts: first in a January 14, 2025 research letter in JAMA, presenting summary data and a broad overview of the study, followed by a more comprehensive state-level analysis in the July 7 edition of Health Affairs. Researchers examined all U.S. hospitals providing obstetric and maternity care from 2010 to 2022, using data from the American Hospital Association annual surveys, CMS Provider of Services Files, and manual verification. The primary outcome was the presence of basic obstetric services, while the secondary outcome focused on closures or losses of these services.

Taken together, the data show a troubling picture of declining access, potential delays in vital services, and a shortage of specialized providers.

Not Just a Rural Problem—Urban Communities Are Suffering Too

The crisis affects different states in wildly different ways. Seven states experienced losses of 25% or more of their hospitals with obstetric services: Iowa (33.3%), West Virginia (30.0%), the District of Columbia (28.6%), Rhode Island (28.6%), Pennsylvania (27.7%), South Carolina (26.9%), and Oklahoma (26.2%). Rural counties in Pennsylvania lost nearly half of their obstetric services during the study period (46.2%).  “People forget how rural a state Pennsylvania is,” Handley noted. Over 25% of counties in the state are rural or highly rural, particularly in the central part of the state, making hospital care difficult to reach.

The situation is even more dire elsewhere. By 2022, eight states were without obstetric services in more than two-thirds of their rural hospitals: Florida, North Dakota, West Virginia, Alabama, Illinois, Oklahoma, Mississippi, and Nevada. These losses coincide with areas already experiencing higher maternal and infant mortality rates, according to Handley.

However, the problem isn’t confined to traditionally rural states. Urban areas in Kansas, the District of Columbia, Rhode Island, Oklahoma, and Hawaii all saw more than 25% of their obstetric hospitals lose these services, highlighting how the problem affects diverse communities. Yet, some data surprised the team. Delaware, Utah and Vermont experienced no obstetric service losses between 2010 and 2022. More work needs to be done to determine why.

Financial Pressure and Staffing Shortages Drive Closures

Despite multiple policy efforts by many administrations to address this issue, the trend is continuing. A complex web of financial pressures makes obstetric services particularly vulnerable—including high fixed costs for maintaining services, lower patient volumes, and a higher proportion of Medicaid patients with lower reimbursement rates. Workforce shortages further complicate the scenario, as rural areas struggle to attract and retain qualified obstetricians and specialists.

It can be tough to find obstetric specialists regardless of location, Handley said, noting that “our malpractice environment is really unfavorable here in the obstetric and perinatal space.”

Unlike many hospital services, obstetric care requires 24/7 staffing regardless of birth volume. Hospitals must maintain multiple specialists on call around the clock, creating substantial fixed costs that can’t be reduced when patient volumes are low. This staffing model becomes financially untenable when combined with the lower reimbursement rates typically associated with rural hospitals’ higher Medicaid patient populations.

“Maternity Deserts” Are Market Failures—Not Inevitable Realities

Hospital closures affect the entire continuum of maternal care. “If you’re losing obstetric-based hospital services, you’re quite possibly losing obstetric-based outpatient services, too,” Handley warned. This means fewer prenatal visits and postpartum support. It also impacts emergency obstetric care, as ambulances must travel greater distances to reach facilities equipped to handle crises.

Handley also pointed out that the term “maternity care desert” is misleading. “Areas without maternity care are not naturally occurring; they are created by market forces,” she said. This distinction emphasizes that these are policy-driven problems requiring targeted solutions.

Global Lessons Offer Hope—but U.S. Solutions Must Be Local

Other countries provide valuable models for maintaining obstetric services. Handley cited Finland and Portugal, which have strategically kept smaller obstetric units in remote areas. Western Australia employs triage systems to direct high-risk patients to larger hospitals while allowing low-risk deliveries to occur locally.

In the U.S., provider-to-provider telehealth programs are emerging as promising solutions. In Southern Minnesota, rural providers can consult with neonatal specialists at larger medical centers, enhancing the quality of acute care and supporting rural clinicians who might otherwise feel isolated.

To ease this crisis, solutions must be coordinated and tailored to meet the specific needs of affected communities, according to Handley. State-level initiatives could include establishing perinatal collaboratives that focus on lower-volume hospitals, expanding regional support beyond single health systems, and developing workforce strategies like loan forgiveness and exchange programs for rural providers.

With one in five Americans living in rural areas, it’s vital that policymakers act soon. “We need targeted, individualized efforts to ensure that people have access to essential childbirth care,” Handley stressed.

The data show that America’s maternal health system is at a tipping point. It’s a critical public health challenge that requires both urgent intervention and long-term strategic planning, according to Handley. “We need to be intentional and take a comprehensive view of how to fit the system together.”

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The study, “Obstetric Care Access Declined In Rural And Urban Hospitals Across U.S. States, 2010–22” was published July 7, 2025 in Health Affairs. Authors include Katy Backes Kozhimannil, Julia D. Interrante, Caitlin Carroll, Emily C. Sheffield, Alyssa H. Fritz, Alecia J. McGregor, Sara C. Handley.

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