More than a third of U.S. counties are now widely considered ‘maternity care deserts’: places without a hospital, birth center, or obstetric provision. That coverage gap affects over 2.3 million women of reproductive age and means roughly 150,000 births a year miss out on local care.
Driven by ongoing rural hospital closures and clinician shortages, the rising number of U.S. maternity deaths is causing real harm: higher rates of preterm birth, dangerous complications (such as preeclampsia and postpartum hemorrhage), and preventable deaths for both mothers and babies.
This Birth Injury Lawyers Group study will look closely at the problem to uncover the key associated issues and measure the true scope of the maternity care crisis.
The Scope of the Maternity Care Crisis
In 2024, 3,628,934 babies were born in the United States. The general fertility rate was 53.8 births per 1,000 women aged between 15 and 44. Childbearing rates fell among women aged between 15 and 34, stayed at the same level for those aged between 35 and 39, and rose among women in their early 40s, continuing a consistent, long-term shift toward later motherhood. (The average age at first birth rose to a record 27.6.)
Fertility rates declined unevenly across different racial groups. Rates fell 4% among American Indian/Alaska Native (AIAN) women (to 46.8 per 1,000); they also fell for Asian women (to 46.3) and Black women (5%, to 50.9). Among Native Hawaiian/Pacific Islander women, the rate was essentially unchanged (72.4).
At first glance, fewer births, later motherhood, and declining teen pregnancy rates might suggest a maternity care system with more capacity. Instead, the infrastructure needed to support births in the U.S. is collapsing at a faster pace than the birth rate.
March of Dimes research defines a maternity care desert as follows: a county with no hospital (or birth center that provides obstetric care) and no practicing OB provider, including physicians, certified nurse midwives, or nurse practitioners. Counties classified as ‘low access’ lack a full-service birthing hospital or an adequate supply of local maternity clinicians.
Although more than one in three U.S. counties (just over 35%) are now considered maternity care deserts, the trend is getting worse. Since the last official count, more than 100 additional counties lost access to maternity care due to obstetric care closures. And when one facility is lost, the nearest alternative must then accommodate the displaced patients, putting extra strain on a provider that may already be struggling to meet demand.
Although around 2.3 million women of childbearing age live in counties with no maternity care access, another 3.3 million live in counties with severely limited access.
If we combine those numbers, that’s 5.6 million women with little option but to deal with their pregnancy and ready themselves for childbirth without reliable, local obstetric care. 35% of those women are women of color, with the AIAN communities bearing the brunt of the burden: around 1 in 5 AIAN women face pregnancy and birth in counties lacking full maternity care access.
The women who give birth to 150,000 babies every year in maternity care deserts face significant risks. They include a 13% higher risk of preterm birth, a 1.3-times higher rate of pre-pregnancy hypertension, and up to a 2.5-times higher risk of an unplanned out-of-hospital birth when travel times to the nearest hospital or birth center are especially long.
Maternity care deserts are not just a problem in isolated rural areas. They span the Great Plains, rural South, and parts of Appalachia. Put simply, they are now a structural feature of the U.S. maternity care system. And in some areas, the problem is particularly acute.
Maternity Care Deserts: Where Are They?
In some U.S. states, women must deal with a notable scarcity of maternity care options.
By a distinct margin, North Dakota ranks worst: 71.7% of its counties offer no maternity care and 43.8% of the state’s women of childbearing age live more than 30 minutes away from a birthing hospital (about 69,900 women).
South Dakota follows (56.1% of its counties lack maternity care options, while 23.7% (40,700) of its potential mothers suffer extensive travel distance). Oklahoma features 53.2% of its counties with no maternity care access; 12.8% (105,200) of its women live over 30 minutes from a maternity care facility. Nebraska and Mississippi round out the top five.
Although for both Alaska and Montana half of their counties are classified as deserts, their distance burdens differ sharply. 7.8% of Alaskan women (about 11,500) live more than 30 minutes from a birthing hospital, compared with 18.4% in Montana (roughly 39,200 women).
49.1% of West Virginia’s counties are maternity care deserts, with 22.2% (69,600) of its women hampered by long travel distances to a maternity facility. 47.1% of Nevada’s counties are classed as maternity deserts. While only 10% of its women of childbearing age suffer travel limitations, that’s still around 64,600 women due to its larger population.
Kentucky (45.8% of counties) features the worst distance-to-care numbers outside North Dakota: 31.3% of its 878,135 women of childbearing age live over 30 minutes from a birthing hospital. That works out to about 275,000 women, the largest raw number of any state.
At the other end of the spectrum, New York features the nation’s lowest maternity desert rate (3.2%), followed by Maryland (4.2%), New Jersey (4.8%), Arizona (6.7%), and California (6.9%). Vermont (7.1%), Pennsylvania (7.5%), Oregon (8.3%), South Carolina (13%), and Ohio (14.8%) round out the ten best-performing states.
Vermont demonstrates why county-level desert rates can be misleading: despite only 7.1% of its counties qualifying as deserts, 29.4% of its women still live over 30 minutes from a birthing hospital.
Seven additional states (Connecticut, Delaware, Hawaii, Maine, Massachusetts, New Hampshire, and Rhode Island) use a different ‘full-access county’ framework and so are excluded from the ranking for comparability. (That said, their reported figures suggest they would likely rank among the stronger maternity care performers.)
The gap between New York’s 3.2% and North Dakota’s 71.7% is about 22-fold. Such a disparity underscores how extremely varied maternity access often is from one state to the next.
Though the crisis mainly affects rural, Southern and Great Plains states, geography alone doesn’t determine how many women are affected. The percentage of a state’s counties without care and the number of women who face long travel times can tell very different stories.
And although we’ve touched upon the subject of racial disparities in maternity care, the level of the disparity changes depending on the state in question.
Maternity Care: Racial Disparities at State Level
The demographic makeup of America’s worst maternity care deserts compounds the issue of who bears the heaviest burden. American Indian and Alaska Native (AIAN) women account for a far larger share of births in several maternity desert states than their roughly 1% national birth share: 17% in Alaska, 12% in South Dakota, 8% in Oklahoma and Montana, and 6% in North Dakota.
These are also among the states with the highest maternity care desert rates, making AIAN birthing people disproportionately likely to live in areas with the lowest levels of obstetric access. In Alaska, 8% of babies born to Alaska Native women were born in a maternity care desert.
Mississippi presents a different pattern: Black births represent 38% of all births, more than five times the average share across the ten worst desert states.
Combined with a 51.2% county-level desert rate and a 15% preterm birth rate (the highest in this analysis), the state’s burden is particularly pronounced. In Nevada, Hispanic births account for 40% of births (the highest Hispanic share among the top ten maternity desert states).
By contrast, White births account for 75% in Kentucky, 89% in West Virginia, and 80% in Montana, underscoring the fact that maternity deserts affect racial groups differently depending on the state.
Racial disparities are also an issue in prenatal care. AIAN women were 1.4 times more likely to receive inadequate prenatal care in high-vulnerability areas (North Dakota and Nebraska) and 1.9 times more likely in Kentucky. Asian/Pacific Islander women were 2 times more likely to receive inadequate prenatal care in South Dakota and 1.9 times more likely in Montana.
Hispanic women were 1.1–1.7 times more likely to get inadequate prenatal help in Mississippi, West Virginia, and Nevada. In North Dakota, 16.5% of BIPOC women in high-vulnerability areas received inadequate prenatal care, over four times the rate in low-vulnerability areas.
Combined, the data confirms the extent to which racial and geographical factors often compound one another. States with the least maternity access are often home to groups who already face elevated risks of poor maternal care, potentially leading to a state-level crisis shaped by geography, demographics, underinvestment, and policy.
Black Women and Pregnancy Complications
In 2024, Black mothers died of maternal causes at a far higher rate than White mothers, and this gap persists regardless of income or education. Research among college-educated mothers found the pregnancy-related mortality ratio for Black women was five times higher than for equivalently educated White women.
In New York City, college-educated Black women were over twice as likely to suffer severe childbirth complications as White women who hadn’t completed high school.
Approximately 80% of the difference regarding severe maternal morbidity between Black and White women is attributed to preexisting health conditions. The remaining disparity is linked to differences in how some conditions are treated, including within the same hospitals (and even by the same physicians), which points to underlying bias and inconsistent care quality.
And the disparity extends beyond Black women. AIAN, Native Hawaiian/Pacific Islander, Asian, and Hispanic women are also subject to elevated rates of ICU admission during delivery compared with White women.
Pregnancy-Related Deaths
Federal maternal mortality review data confirms that among pregnancy-related deaths with known timing, 53% occurred between 7 and 365 days after birth, a period during which mothers are often thought to be medically recovered and often receive less intensive care.
Cardiomyopathy and untreated mental health conditions (including postpartum depression and substance use) are some of the causes disproportionately associated with deaths during this period. A single six-week postpartum visit cannot identify risks that can emerge or continue for months.
This means the 12-month Medicaid postpartum coverage extension is much more than a symbolic policy. If over half of pregnancy-related deaths occur after the initial six-week period, maintaining support and access during the first year covers the period when much of the preventable risk remains.
The Hidden Toll: Illness and Injury
When maternity care isn’t available, the consequences measurably manifest in increases in illness, injury, and death. A 2025 study of Medicaid recipients discovered that women in maternity desert states faced a 34.2% greater risk of maternal mortality, an 18.3% greater risk of infant mortality, and an 8.9% greater risk of low birthweight than women in areas with better maternity care access.
A separate 2025 study found maternal mortality rates of 32.25 per 100,000 live births in desert counties compared to 23.62 in full-access counties, as well as higher rates of severe maternal morbidity, including transfusion and unplanned hysterectomy.
Among mothers who gave birth in 2024, 10.4% (around 377,000 women) developed gestational hypertension, up 73% from 6% in 2016. Untreated hypertension can lead to preeclampsia, which may subsequently cause a stroke, a seizure, or a preterm delivery. The CDC notes that such cases may be undercounted as birth certificates don’t capture every case.
Gestational diabetes has also risen among groups affected by maternity deserts. Among AIAN mothers, the rate reached 136.7 per 1,000 births in 2024, a significant rise from 113.2 in 2016. Managing gestational diabetes requires regular glucose monitoring and frequent prenatal visits, complicating treatment for patients who travel long distances for care.
Postpartum hemorrhage remains one of the most time-sensitive obstetric emergencies. It requires immediate access to blood products and a surgical team: the kind of resources maternity deserts usually lack.
Maternal Care Infrastructure
Meanwhile, the care infrastructure continues to shrink. Twenty-one rural labor and delivery units closed in 2024, with a further 27 closing in 2025 (the total number lost between 2020 and 2025 was 116). Only 40% of U.S. rural hospitals (950 of 2,396) still deliver babies. Just 5.6% of rural hospitals feature an onsite NICU, while 56.2% are more than 60 miles from the nearest NICU.
The effects extend beyond pregnancy and childbirth. A 2025 Medicaid study found that people in maternity desert states were 14% less likely to get timely prenatal and postpartum care (while living in areas with 30% fewer mental health providers and 36% fewer pediatricians).
The resulting compounding cycle of distance, delayed monitoring, and untreated conditions increases the possibility of complications and preventable issues.
In 2024, the U.S. infant mortality rate was 5.52 per 1,000 births, with maternal complications of pregnancy among the five leading causes of infant death. For counties with no maternity access, the rate was 6.5 per 1,000.
The disparity was greatest among postneonatal deaths, occurring after the first month but before the first birthday: 2.6 deaths per 1,000 in maternity desert counties versus 1.8 in full-access counties. This suggests the effects of maternity deserts extend beyond childbirth, with reduced access to pediatric follow-up and emergency services also being factors.
What’s Being Done?
States and the federal government are increasing their direct targeting of maternity care deserts, as opposed to treating them solely as a rural-health issue.
Louisiana passed legislation in 2025 that required Medicaid to fund obstetric access so that no resident lives over 30 miles from obstetric provision.
In May 2025, eight states joined a policy academy that specifically focused on maternity deserts, exploring measures like Medicaid reimbursement for midwives and doulas, mobile maternity units, and regional care models for areas deemed too small to support full-service hospitals.
Mobile care has already produced results. Following a 2024 report that found 18 of Florida’s 21 rural hospitals no longer offered obstetric services, a mobile OB/GYN clinic was subsequently launched in February 2025. By the end of 2025, it had provided prenatal care, postpartum care, and gynecological screenings to 194 women during 616 visits. This clearly shows that interventions directly targeting maternity deserts can reach patients in a matter of months.
In May 2024, a national recommendation proposed Comprehensive Maternity Care Centers: team-based facilities run by midwives and supported by OB-GYNs and doulas, providing obstetric, lactation, mental health, and pediatric services to counties without maternity care.
This model can now utilize a share of a $50 billion fund for rural-health support. In Kentucky’s case, an award of around $213 million included funding for maternal access.
Some states are also changing their Medicaid payments, linking obstetric reimbursement to outcome levels rather than volume to help keep existing services financially viable. A federal bill reintroduced in 2026 would further expand access to maternal care, specifically targeting communities that have lost hospital-based obstetric provision.
The remaining challenge is a matter of scale. Recent initiatives include a goal of one state mandate, eight states in a policy academy, fewer than 200 women served by one mobile clinic during its first year, and center-based funding (that must also compete with other state priorities).
While these won’t resolve maternity desert issues, such initiatives are a move in the right direction: desert-specific tools now exist, are funded, and in some cases are already serving patients. The real test will now be the extent to which they prevent new maternity deserts from emerging, and whether they merely replace access lost elsewhere in the state.
The Maternity Desert Crisis: The Immediate Future
The U.S. is experiencing declining birth rates and later parenthood while maternity care access deteriorates, with more than 35% of counties now classified as maternity care deserts. That leaves roughly 5.6 million women without (or with severely limited) obstetric care.
The crisis is concentrated in rural, Southern, and Great Plains states and disproportionately affects some racial groups; it also contributes to higher risks of maternal and infant mortality, preterm birth, and severe complications. Although states and the federal government are beginning to fund targeted solutions, the scale of current interventions remains insufficient.
Overall, maternity care access is disappearing faster than demand for it, meaning a woman’s location is a major driver of subsequent maternal and infant health outcomes.
Better future results will depend not only on the creation of new state/county maternity programs, but also on how quickly and widely they can be scaled to prevent more counties from losing care.
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The birth of a child is a life-changing event. However, when something goes wrong, it can turn a family upside down and cause immense pain. When a preventable mistake injures your newborn, the future you envisioned for your child can disappear. And you may also become overwhelmed by bills and caretaking duties.
The national birth injury lawyers from Birth Injury Lawyers Group dedicate their time to helping parents of injured children fight for their rights. We offer hope and possible financial compensation to families who have been harmed by a medical professional’s mistake.