I knew that it just wasn't something I could legally consider.
Across the American landscape, a quiet emergency is unfolding in the space between a pregnant woman and the care she needs. More than a third of U.S. counties now lack any obstetric services, a collapse shaped by hospital economics, provider flight, and the downstream consequences of abortion restrictions — all converging on the most vulnerable moment in a human life. The United States, one of the wealthiest nations on earth, now records maternal mortality rates that rival far less resourced countries, with Black women bearing the sharpest edge of that failure. What is happening is not simply a healthcare shortage; it is a reckoning with which lives a system has quietly decided to protect.
- Women in rural Texas and Alabama are driving hours in medical crisis, being transferred to wrong hospitals, and undergoing emergency surgeries in the hands of strangers — because the nearest obstetric unit has already closed.
- The U.S. maternal mortality rate has reached 32.9 deaths per 100,000 live births, infant mortality rose at its steepest rate in two decades, and Black women die from pregnancy complications at three times the rate of white women.
- Abortion bans are accelerating the provider exodus — OB/GYN residency applications dropped 10.5% in near-total ban states — leaving the very regions with the most restrictive reproductive laws also the most medically abandoned.
- Midwifery expansion and telemedicine offer partial lifelines, but state regulations are actively blocking both: Alabama's new licensing rules would effectively shutter most freestanding birth centers, and some states refuse to reimburse virtual prenatal visits.
- Lawsuits, court rulings, and Medicaid extension proposals are inching forward, but closures are outpacing solutions — three more Alabama maternity units shuttered in recent weeks alone.
Ellie was thirty-seven weeks pregnant when her blood pressure began spiking and her body signaled danger. She lived in southern Texas, an hour from the nearest obstetric hospital. When she drove to the closest facility, she found a birthing unit that had closed months earlier. Doctors there transferred her — not to the Houston hospital where her own obstetrician practiced, but to an unfamiliar facility where she underwent an emergency cesarean for preeclampsia. "It was incredibly traumatic," she said afterward. Her story is not exceptional. It is the system working exactly as it has been allowed to work.
According to a 2023 March of Dimes report, more than one-third of all U.S. counties are now maternity care deserts — places with no hospital, no birth center, and no obstetric providers. In Texas, nearly half of counties have no obstetric services at all. The causes are interlocking: rural hospitals closing under financial pressure, only seven percent of obstetric providers choosing to work in rural areas, and now, the accelerating departure of OB/GYN physicians and residents from states with abortion bans. Medical school applicants are actively avoiding residencies in those states, and providers already there are questioning whether to stay.
The human cost is written in mortality statistics. The U.S. maternal death rate stands at 32.9 per 100,000 live births — among the highest in the developed world. Infant mortality rose three percent last year, the steepest climb in twenty years. Black women die from pregnancy complications at three times the rate of white women. In Alabama, where nearly a third of women are Black and abortion is nearly entirely banned, maternal mortality ranks among the nation's worst. A certified nurse midwife there described feeling unwelcome in her own state, even as she chose to stay for her family.
After her emergency birth, Ellie developed postpartum depression. Texas Medicaid covered sixty days of postpartum care — the federal minimum — and she managed one therapy session before her coverage lapsed. She could not afford to continue. The state has since announced plans to extend that coverage to a year, a step dozens of states have already taken.
In North Dakota, the nation's most desert-dense state, free clinics offer pregnancy tests but not comprehensive care. In Minnesota, one OB/GYN serves a region spanning three Native American reservations after four labor and delivery units closed in five years. She is trying to expand telemedicine, but some states won't reimburse it. In Alabama, new regulations would require freestanding birth centers to meet hospital licensing standards and sit within thirty minutes of a hospital — a threshold nearly ninety percent of rural Alabama women cannot meet. Three more maternity units closed there in recent weeks. Midwives and physicians are suing the state health department, and a judge has allowed licensed birth centers to operate while the case proceeds. But the closures are not waiting for the courts.
Ellie was thirty-seven weeks pregnant when her body began to fail her. Shortness of breath. Chest tightness. A home blood pressure monitor showing numbers that terrified her. She lived in southern Texas, in a place where the nearest hospital with obstetric care was an hour away, and she had no idea what would happen if she made that drive.
When the symptoms worsened, she drove to a nearby hospital—one that had closed its birthing unit just months earlier. The doctors there took one look at her spiking blood pressure and knew she needed transfer to a facility with obstetric providers. She asked to go to Texas Children's Pavilion for Women in Houston, where her own obstetrician had guided her through the entire pregnancy. Instead, she was taken to the wrong hospital. There, in an unfamiliar place with unfamiliar doctors, she underwent an emergency cesarean section for preeclampsia. "It was incredibly traumatic," she said later. "The stress of the transfer and being at the wrong hospital and sudden preeclampsia, it was very intense."
Ellie's ordeal is not an outlier. It is the visible consequence of a maternity care system in collapse. According to a 2023 report by the March of Dimes, more than one-third of all counties in the United States lack either a hospital or birth center offering obstetric care, or any obstetric providers at all. These are called maternity care deserts. In Texas, the figure is worse: 46.5 percent of counties have no obstetric services. In rural Texas, 28.4 percent of women live more than thirty minutes from a birthing hospital. In urban areas, that number drops to 3.8 percent. The disparity is stark and deliberate—a function of where hospitals choose to invest and where they choose to close.
The crisis has multiple causes, all reinforcing each other. Hospital closures are accelerating. Provider shortages are severe: only seven percent of obstetric providers work in rural areas, even though two-thirds of maternity care deserts are rural counties. And now, following the Supreme Court's decision to overturn Roe v. Wade, abortion restrictions are making the problem worse. Medical schools are reporting a 10.5 percent drop in OB/GYN residency applicants from states with near-total abortion bans. Some providers are leaving those states entirely. Others, like Kim Taylor, a certified nurse midwife in Alabama, are staying but feeling unwelcome. "How much pain do I really want to go through and endure?" she asked. "I want to be here. I want to be in Alabama where my family is … and I'm being treated like I don't belong here."
The human cost is measured in deaths. As of 2021, the maternal mortality rate in the United States was 32.9 deaths per 100,000 live births—a rate that makes the U.S. one of the most dangerous developed nations for childbirth. Infant mortality rose three percent last year to 5.6 deaths per 1,000 live births, the largest increase in two decades. One in three pregnancy-related deaths occurs in the postpartum period, and the majority are preventable. The burden falls heaviest on Black women, who are three times more likely than white women to die from pregnancy complications. In Alabama, nearly one-third of women are Black, and the state has one of the highest maternal mortality rates in the country.
After Ellie gave birth, she developed postpartum depression. Texas Medicaid covered her care for sixty days postpartum—the current federal minimum—but she could only see a therapist once before her coverage expired. The demand for mental health services was too high; she could not afford to pay out of pocket. She remains untreated. Meanwhile, the state has announced plans to extend postpartum Medicaid coverage to a year, a change dozens of states have already made.
In North Dakota, which has the highest proportion of maternity care deserts in the nation and a strict abortion ban, the Dakota Hope Clinic offers free pregnancy testing and ultrasounds but cannot provide the full range of care women need. In Minnesota, near the North Dakota border, Dr. Johnna Nynas has watched four labor and delivery units close in five years. She is one of only a few OB/GYN providers serving a region that includes three Native American reservations, where women face particularly high rates of maternal mortality and pregnancy complications. She is working to expand virtual care, but some states will not reimburse for telemedicine appointments. "You're just continuing to close the door to access," said Dr. Elizabeth Cherot, CEO of the March of Dimes.
The system is tightening. In Alabama, new regulations would require freestanding birth centers—facilities where midwives guide low-risk patients through labor—to meet hospital licensing requirements and be within thirty minutes of a hospital. But 27.9 percent of Alabama women do not live within that distance, and nearly ninety percent of women in rural areas of the state do not. Three more maternity units have closed in Alabama in recent weeks. Medicaid covers half of all births in the state, and hospitals are reimbursed less for Medicaid births than private insurance births—a significant force behind closures nationwide. Midwives and doctors are suing the Alabama Department of Public Health, backed by the ACLU. In early October, a judge ruled that birthing centers meeting national standards could be licensed while the lawsuit continues. But the regulatory pressure remains, and the closures continue.
Notable Quotes
It was incredibly traumatic. The stress of the transfer and being at the wrong hospital and sudden preeclampsia, it was very intense.— Ellie, a pregnant woman in Texas who was transferred to the wrong hospital during an obstetric emergency
States that have highly restrictive abortion laws also tend to have the largest swath of maternity care deserts and also don't really invest in maternity care.— Dr. Bhavik Kumar, medical director for primary and trans care for Planned Parenthood Gulf Coast
The Hearth Conversation Another angle on the story
Why does it matter that Ellie ended up at the wrong hospital? Couldn't the doctors there have handled her emergency?
They could have, technically. But she had spent her entire pregnancy with one obstetrician, who knew her history and her body. Being transferred to a stranger in crisis, especially with a condition like preeclampsia that can deteriorate fast, meant losing continuity of care at the moment she needed it most. The trauma wasn't just medical—it was the loss of the one person she'd built trust with.
The story mentions that abortion bans are making the maternity care crisis worse. How are those two things connected?
States that restrict abortion tend not to invest in maternity care either. It's not coincidence. If you're banning abortion, you're not signaling that you value women's reproductive autonomy or comprehensive care. Medical students see that. They don't want to train in those states. And providers who are already there—like Kim Taylor—feel the hostility. So you end up with fewer doctors and midwives in exactly the places where more pregnant women will be forced to carry pregnancies to term.
What's the actual barrier to telemedicine? It seems like it would solve some of these distance problems.
It could, but some states won't reimburse for virtual appointments. So even if a woman in rural North Dakota could see a doctor over video, her insurance won't pay for it. The door stays closed. It's a policy choice, not a technical limitation.
You mention that Black women are three times more likely to die from pregnancy complications. Is that a biological difference or a care difference?
It's a care difference, rooted in systemic racism and implicit bias within health care itself. Dr. Nynas, who works in Minnesota, named it directly: generational trauma, systemic racism. Black women in vulnerable areas are less likely to receive adequate prenatal care. They're more likely to live in maternity care deserts. And when they do access care, they often encounter providers who don't listen to them or take their symptoms seriously. The biology is the same. The treatment is not.
What does Ellie's story suggest about what happens next?
It suggests that without major intervention—more funding for rural obstetrics, removal of regulatory barriers to midwifery, expansion of telemedicine reimbursement, and serious reckoning with how abortion restrictions compound the crisis—more women will have experiences like hers. More will be transferred to wrong hospitals. More will go without postpartum mental health care. More will die from preventable causes. The system is closing doors, not opening them.