Ashley O’Neil’s first pregnancy took an unexpected turn one Sunday night in May 2016. When she started bleeding, she headed to her local emergency room in rural southern Maryland.
“All of the major hospitals (that) could provide the care that I needed were two hours away. I should have been flown out, but the weather was terrible, and it wasn’t safe to fly,” she says.
Twelve hours later, her son was born four months early at 21 weeks gestation. Sadly, he did not survive.
“I think about that night often and wonder if the outcome would have been different if the weather was nice and I was able to be flown to the next hospital, or if the first hospital had been equipped to handle cases like mine,” she says.
Events seemed to be repeating themselves two years later when her second son, Kolin, was born at 25 weeks at her local hospital and needed a neonatal intensive care unit. Kolin waited an hour until a flight team arrived, all the while being given manual breaths because the staff couldn’t get a breathing tube into such a tiny baby.
O’Neil had to wait until the following day to be transported because she needed to receive approval from her insurance first.
Kolin spent six months at the level 4 NICU, a two-hour drive from their home. Although he’s now a happy 5-year-old, he has many medical issues, including cerebral palsy.
“I couldn’t get the care that (my sons and I) needed locally. It’s hard not to wonder what his life would look like had he been born at a hospital with a level 4 NICU, if he had been born at a place where they could have intubated him as soon as he was born,” O’Neil says.
O’Neil’s story is becoming all-too familiar for those who live in rural areas across the United States where there is limited to no access to maternity care.
In fact, millions of women live in maternity care deserts, a term used to describe counties without a hospital or birth center and without any obstetric providers. According to a 2024 March of Dimes report, more than 1 in 3 U.S. counties (35%) are maternity care deserts, leaving more than 2.3 million women of reproductive age without access to critical, life-saving maternity care.
[READ: Checklist for Choosing a Maternity Hospital.]
Less Prenatal Care in Care Deserts
The U.S. continues to have the highest maternal mortality rate among high-income countries in the world, but the situation for women is becoming even more dire. As the March of Dimes reports, approximately 1 in 25 obstetric units closed nationwide in 2021 and 2022 due to financial constraints, limited reimbursement from insurance providers and staffing shortages. Over half of counties in the U.S. now do not have a hospital that provides obstetric care.
To make matters more dangerous, recent Supreme Court decisions to overturn Roe v. Wade led to a mass exodus of doctors fleeing states, such as Texas, where they may be criminalized for providing emergency care under restrictive abortion bans.
Women in maternity care deserts or low access counties, where there are limited obstetrics care and clinicians, get less prenatal care and have higher rates of preterm birth, with worse outcomes for Black and indigenous women.
“In Aurora, we are now the only OB provider in town, which means our schedules are often full, and patients might have to wait longer than normal to book an appointment,” says Dr. Chibuike Anokwute, a family medicine and obstetrics physician at Mercy Hospital Aurora, a 25-bed facility in the Ozarks of southern Missouri.
Mercy Hospital Aurora was designated as a Maternity Access Hospital in U.S. News & World Report’s 2025 Best Hospitals for Maternity Care. This recognition is given to facilities that provide outstanding care in what would otherwise be a maternity care desert.
[READ What Is Advanced Maternal Age?]
What Patients in Maternity Care Deserts Can Do
Unfortunately, it falls to pregnant people in maternity care deserts to navigate the increasingly difficult health care landscape to get good maternity care.
Here’s what you can do:
1. Get prepared for pregnancy
For planned pregnancies, make sure you are as healthy as can be prior to getting pregnant to reduce the risk of complications, which your local hospital might not be able to handle.
If you have high blood pressure or diabetes, make sure both are controlled and you closely track your readings.
You can ask a general practitioner, family physician or primary care provider in your area about how to address any overall health issues you’re dealing with. These doctors will be able to advise you on how to get your body ready for pregnancy.
[READ: What Is TFMR? Termination of Pregnancy for Medical Reasons.]
2. Establish care ASAP
Less prenatal care can mean more unexpected complications that small hospitals aren’t always equipped to handle, so it’s important to find and establish care as soon as you can.
Once you’re pregnant, locate a pregnancy care center, which might include a community health center or clinic, to ensure you have all the resources you need and know what resources are available in your community. Be sure to check your local hospitals because you might not realize they provide pregnancy services.
“Because patients don’t know we offer these services, they often forgo care,” Anokwute says. “That often means those patients lack appropriate prenatal care or don’t catch something concerning.”
Many family practitioners in rural areas also deliver babies, so ask your regular doctor if they can treat you or know another local doctor who can. Ask family, friends and online groups for local moms who they’ve gone to for care.
Other ways to find care include:
— Federally funded health centers. These organizations combine many different types of care in one place, including pregnancy, for underserved communities around the country.
— March of Dimes. March of Dimes Mom & Baby Mobile Health Centers provide health care access to women and children in counties with limited or no access to maternity care.
— Insurance providers. Your private insurance, Medicaid or Children’s Health Insurance Program (CHIP) can give you a list of participating providers in your area that cover prenatal care.
— FindHelp.org. Put your zip code into FindHelp.org, which partners with large health systems, nonprofits and government agencies to create a directory of community-based organizations that provide free or reduced-cost resources including health care, food and housing.
[Read: Everything You Need to Know About Prenatal Vitamins.]
3. Use health resources
There are various federal and state programs and insurance plans that offer services for pregnant women, including:
— Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Apply for WIC, a federal program to help low-income pregnant and postpartum women, infants and children with food and health care referrals. Your state might have additional programs, so contact your local health department.
— Marketplace insurance. Through the Affordable Care Act, all Marketplace insurance plans — and many others — must provide certain free services to pregnant women.
— Department of Health and Human Services. The federal office of Health and Human Services also provides a phone number, 1-800-311-BABY, to help you find free or reduced prenatal care services in your area.
— Temporary Assistance for Needy Families (TANF). Another federal program, TANF may also be able to help.
4. Ask all the questions
Although providers may be limited, those that are available are dedicated and want you to have a good experience, so don’t be afraid to discuss anything that’s on your mind. After all, they are there to help.
Questions to ask at your first prenatal appointment include:
— How often will my appointments be, and where are they located?
— What testing, such as ultrasounds and 20-week anatomy scans, are included in the appointments?
— Will I always see the same doctor?
— What are my delivery options?
— What are the hospital’s cesarean section rates?
If you’re high-risk, discuss if you would need a maternal-fetal medicine specialist (MFM), and if so how far away one is located. Even if you have an uncomplicated pregnancy, you should find out what the plan would be in an emergency, such as where a NICU is located if your baby needs it.
5. Plan for transportation
Due to poverty levels in rural areas, lack of transportation and travel costs are the most common barriers Anokwute sees to accessing maternity care.
“If patients think they have to drive 40 minutes … for prenatal care, they might not be able to afford that and will skip it,” he says.
If transportation is an issue for you, work with your OB-GYN to schedule your appointments all the way through your due date.
“This way you can plan ahead and make arrangements for transportation,” Anokwute says.
6. Attend prenatal classes
Check with your local health department to see if they have any maternity programs at community centers or clinics. Classes can help you prepare for labor and delivery, as well as the postpartum period.
If there are no options for in-person classes in your area, you can access one virtually. Many health systems — such as UnityPoint Health, which serves the Midwest — have free videos for patients, so check out ones in your area (or even elsewhere). Additionally, many baby websites, such as BabyCenter, offer free online childbirth classes.
7. Use a midwife
If you’re low risk and planning on a vaginal delivery, using a certified nurse-midwife may help you access care, says Andrea Hedrick, a certified-nurse midwife at St. Joseph Regional Medical Center in Lewiston, Idaho, which was designated by U.S. News as a Maternity Access Hospital.
Trained to provide reproductive care, including during pregnancy, labor and delivery, a CNM may deliver babies at other locations besides hospitals, such as clinics and health centers.
“We actually don’t need most births to occur in hospitals,” says Diana Mason, senior policy service professor for the Center for Health Policy and Media Engagement at George Washington University School of Nursing, who has studied maternity care deserts.
U.S. News provides a directory of certified midwives to find a CNM near you.
Be sure to discuss with them what the plan would be if you or your baby needed more intensive care, such as an emergency C-section or NICU.
8. Find a doula
Doulas are birthing helpers who can advocate for you during labor and delivery, when you may not be able to advocate for yourself. O’Neil suggests checking if your insurance will cover one; if so, check the list of participating doulas in your area.
Doulas can provide one-on-one emotional support, which is associated with better labor outcomes. As a result, there is less chance of needing special care at a faraway hospital.
9. Know the signs of emergencies
Educate yourself on the signs and symptoms of preeclampsia, preterm labor and other potential pregnancy complications, O’Neil says. If you’re aware of what to look out for, you can get care quicker, especially if that means transporting you to a bigger hospital farther away.
Warning signs that require urgent care include:
— A headache that won’t go away or gets worse
— Dizziness or fainting
— Changes in vision
— Fever
— Extreme swelling in hands or face
— Trouble breathing, chest pain or fast heartbeat
— Bleeding or fluid leaking during pregnancy, or very heavy bleeding postpartum
— Severe belly pain
10. Advocate for yourself
Hedrick says it’s her job to empower women, encourage them to be their own advocate and help them be able to say what they need. This goes for both during pregnancy, and during labor and delivery.
“Don’t be afraid to advocate for yourself and your unborn baby. If something doesn’t feel right, communicate that to your health care providers,” O’Neil says.
The sooner any issues are addressed, the better the outcome may be — and when you’re far away from care, time is of the essence.
[SEE: What to Pack in Your Hospital Bag When You’re Expecting.]
Why Are Maternity Care Deserts Increasing?
A 2022 government report found the number of rural hospitals providing obstetric care has been on the decline since 2014. Causes for this include:
— Financial strain. Many rural hospitals that once provided obstetrics services are closing due to financial and logistical challenges, says Nicki Gamet, vice president of regional operations for Mercy Springfield Communities, which operates Mercy Hospital Aurora. Those that remain open often discontinue their OB services. More than 700 rural hospitals are currently at risk of closing, Mason says.
— Insurance reimbursements. Hospitals are seeing a decrease in reimbursement rates from Medicaid, and a significant portion of rural pregnant patients are covered by Medicaid, which makes it incredibly difficult to sustain these services.
— Lack of providers. Burnout and the pressures of rural health care make providers wary of practicing in these areas. The challenges recruiting physicians and nurses to these communities put a greater burden on existing doctors.
— High liability. Obstetrics is also one of the highest-risk medical specialties, and many physicians are unwilling to enter the field due to the high costs of liability insurance and the risk of malpractice claims. This risk is often compounded for rural hospitals, which might not have the resources to cover substantial liability expenses associated with providing OB services.
— Restrictive laws. States that have restrictive laws around abortion are losing obstetric providers who don’t want the risk of jail time in order to treat patients with complicated cases or emergency situations that might require terminating a pregnancy.
Bottom Line
Maternity care deserts are an increasing problem that will be up to hospital systems, insurance companies and government programs to fix. In the meantime, patients have to take it upon themselves to search out ways to access care and advocate for their needs with providers.
The good news is that doctors, midwives, nurses and other health care workers in rural areas are extremely committed to their jobs because they want their patients to have the best care possible in a less-than-ideal setting.
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10 Ways to Find OB-GYN Care in a Maternity Care Desert originally appeared on usnews.com
