More than one-third of U.S. counties are now considered maternity care deserts. In 2023, the national maternal mortality rate hit 18.6 deaths per 100,000 live births. For Black women, that climbs to 50.3 deaths per 100,000, more than double the national average.
What we’re missing is policy alignment, sustainable funding, and important culture changes that align maternal care teams beyond the current boundaries of what high quality and reliable maternal care looks like. And we can’t afford to wait.
The Economics of Abandonment
A labor and delivery unit handling a handful of births each week can’t absorb the fixed costs of 24/7 staffing and specialized equipment. Medicaid pays for most rural births but reimburses below cost.
In a recent conversation with Carrie Cochran-McClain, Chief Policy Officer of the National Rural Health Association, she stated, “Access to obstetric services in rural areas has historically been challenging, and in the last several decades has grown more and more limited. We have over half the counties in this country where you do not have access to obstetric services and labor and delivery services.”
But readiness costs money that rural hospitals don’t have. And even the best-trained emergency physician can’t replicate the safety net of a staffed obstetrics unit with immediate surgical backup.
Belinda Pettiford, Title V MCH Director, Section Chief at NC DHHS, Division of Public Health, put it plainly when we last spoke, saying, “Rates of infant and maternal mortality are much higher for Black infants and mothers than for non-Hispanic white infants and mothers. Our three primary goals of this effort are addressing economic and social inequities, strengthening families and communities, and improving healthcare for all people of childbearing age.”
The Medicaid Mirage
Extending postpartum Medicaid coverage from 60 days to 12 months was supposed to help. On paper, it’s progress. In practice? Coverage alone doesn’t ensure access if providers can’t sustain services.
Budget uncertainty makes the situation worse. When state budgets stall, clinics delay hiring, remaining staff face burnout, patients lose continuity, and families wonder whether to start care now or wait. That hesitation can be fatal when managing fast-moving conditions like preeclampsia or gestational diabetes.
What’s Working on the Ground
State maternal health programs supported through Title V are piloting approaches that extend beyond hospital walls: community-based doula programs, enhanced care coordination for high-risk pregnancies, and targeted interventions addressing the social drivers of health that shape maternal outcomes long before the first prenatal visit.
Rural health systems are adapting too. Where labor and delivery units have closed, some facilities have shifted focus on emergency preparedness. Standard protocols for obstetric hemorrhage and hypertensive crises create consistency despite staffing turnover. Drills that account for real transport times turn rare events into practiced responses.
Cross-training strengthens small teams when volume can’t keep skills sharp. The American Hospital Association flags these approaches as critical for reducing preventable harm to both parent and child.
And for those who may still lack access to in-person visits, technology can extend reach when effectively integrated into workflows. Remote monitoring can flag rising blood pressures earlier. Virtual consults bring specialist expertise to isolated providers. But both require clear escalation plans and realistic pathways to in-person care, not vague instructions to “seek care later.”
These innovations work. But they’re patches on a system that’s hemorrhaging capacity. Without policy and funding alignment, they can’t scale fast enough to maintain the gains and match the pace of closures.
The Policy Window Is Open, but Closing Fast
Major federal funding opportunities are on the table right now. The Rural Obstetrics Readiness Act (S.380) has bipartisan support and would authorize $15 million through 2029 for grants to rural hospitals, critical access hospitals, and telehealth programs. The Rural MOMS program is offering grants up to $1 million for collaborative improvement networks. Not to mention Title V program renewals are coming up.
The question is whether states and policymakers will move them strategically and keep the foundational components funded from one administration to another. High-quality maternal care should be bipartisan. The policy fixes we need are straightforward:
Rural hospitals shouldn’t be penalized for keeping obstetric care available. Stable funding must cover staffing, equipment, and training regardless of birth numbers. Blended payment models can sustain obstetrics before more units close.
Providers, public health agencies, rural hospitals, and training resource groups each hold part of the solution. Coordinated partnerships can standardize protocols, expand training, and advocate for sustainable funding.
Recent disruptions to the CDC’s PRAMS program leave a dangerous gap in data, which is the cornerstone of demonstrating and documenting improvement in maternal health. The surveillance systems must be reinstated.
What Needs to Happen Next
We already know the solutions: stable funding for rural obstetric readiness, Medicaid coverage that ensures access, evidence-based training for all providers, and coordinated postpartum care that closes racial gaps in outcomes.
But knowledge alone isn’t enough. Policymakers who claim maternal health as a priority must fund the infrastructure and partnerships that make it real. Aligning federal and state policy to sustain rural maternity care is the next step.
About Lora Sparkman
Lora Sparkman has been a nurse for over 37 years, leading patient safety and improvement work for over 22 years, specifically using software and technology to advance healthcare improvement. For the past eight years, she has served as a clinical strategic leader at Relias. Most recently, Sparkman led a team at Relias with academic partners developing a VR application applying adult learning principles and human factors to improve infection, prevention, and control.
The views and opinions expressed in this article are solely those of the author and do not necessarily reflect the official policy, position, or endorsements of Relias LLC or its affiliates. The author is speaking from their personal, expert perspective, and this content should not be interpreted as representing an official statement from Relias LLC or its affiliates.
