More than half of U.S. counties no longer have hospital-based labor and delivery services, according to a new report on maternity access released Tuesday by the March of Dimes, and in the counties where those units have closed, midwives are increasingly the clinicians families see.
The 2026 edition of the organization's Nowhere to Go report finds that more than 52 percent of counties lack hospital-based obstetric services, and that nearly 35 percent, roughly one in three, qualify as maternity care deserts, meaning they have neither birthing facilities nor obstetric clinicians.
Alabama is one of the states where that arithmetic is most visible in daily practice. Midwives there are covering distances that would have been unusual a decade ago, and the operational question they face is what to do when a transfer that once took 20 minutes now takes an hour or more.
More Than Half of U.S. Counties Lack a Delivery Unit
The headline figures describe two overlapping problems. A county can have obstetric clinicians but no hospital unit where a birth can occur, or it can have neither.
Michael Warren, chief medical and health officer for the March of Dimes, told NPR that the situation "goes beyond a mere inconvenience," adding that women living in maternity care deserts are more likely to have bad pregnancy outcomes.
The scale is specific. Warren said those counties are collectively home to 2.4 million women of reproductive age and account for about 150,000 births per year, and that travel from affected counties for appointments, treatment, or emergencies takes three times as long on average. In 2024, one in four women did not receive prenatal care during the first trimester.
The practical translation is time. Obstetric emergencies, including hemorrhage, placental abruption, cord prolapse, and eclampsia, are measured in minutes, not hours. Distance does not cause these complications, but it changes what can be done when they occur.
One nuance deserves attention. The overall national picture held mostly steady compared with the organization's 2024 report, so this is a persistent condition rather than a sudden deterioration. MedicalDaily previously reported on the accelerating pace of closures and the payment structures driving them.
Longer Transfers Change What Clinicians Can Do
Midwives currently attend about 12 percent of births nationwide, an increase of 4 percentage points over the past decade, according to the report.
In counties without a nearby hospital unit, that shift is not primarily a philosophical preference. It reflects who is available. Nadia Gramby, a licensed and certified professional midwife based in Chelsea, outside Birmingham, founded her practice in 2018 partly to reach women in maternity deserts. She recently drove 302 miles in a single day for prenatal appointments in Anniston, Montgomery, Helena, and Alabaster.
Longer transfer times reshape clinical decision-making in specific ways. Risk assessment during pregnancy carries more weight because a patient identified as high risk may need to plan to relocate closer to a hospital before labor rather than rely on transfer. Clinicians carry medications and equipment for stabilization that would otherwise be a hospital's responsibility. And the threshold for transferring earlier rather than later moves down, because the drive itself has become part of the calculation.
Midwives are medically trained to perform many of the same functions as physicians in low-risk births, and research shows midwife-attended births are associated with lower rates of cesarean section and complications. Insurance coverage for midwifery care varies by plan and state, affecting whether the option is financially available even where a midwife practices.
The closures themselves are driven mainly by finances rather than demand. Obstetric units incur high fixed costs because they must be staffed around the clock regardless of the number of deliveries, and low-volume rural units frequently lose money on every birth. More than 500 hospitals closed maternity wards between 2010 and 2022, and the March of Dimes says closures usually involve a county's only birthing facility.
Licensing Fights Are Playing Out in Court
The regulatory environment is contested. Midwives have filed lawsuits against several southern states, and in Alabama the litigation concerns licensing requirements the plaintiffs describe as restrictive.
State health officials have argued that physicians should always be involved in the birthing process to protect health and safety. Critics of expanded midwifery practice raise questions about the safety of home births, particularly when emergencies develop and immediate surgical capability is not available.
The March of Dimes is advocating for policies allowing midwives to practice independently and prescribe medication, and the new report calls for expanded hospital privileges for them.
These are positions in an unresolved policy dispute, not settled conclusions. The litigation has not produced final rulings, and readers should treat the arguments on each side as arguments. What is documented is the access gap; what remains contested is the appropriate regulatory response to it.
Steps for Families Living Far from a Birthing Hospital
For people who are pregnant or planning a pregnancy in a county without obstetric services, several practical steps apply regardless of how the policy debate resolves.
Identify the nearest hospital with an operating labor and delivery unit early in pregnancy rather than late, and confirm it is still operating, since closures have occurred with limited notice. Drive the route once. Knowing the actual travel time at different hours is more useful than a mapping estimate.
Discuss risk factors with a clinician early. Conditions including high blood pressure, diabetes, prior cesarean delivery, multiple gestation, and placental abnormalities may warrant a delivery plan built around proximity to a hospital, including temporary relocation near the delivery date for some patients.
Warning signs that warrant immediate care at any point in pregnancy include heavy vaginal bleeding, severe abdominal pain, severe headache with vision changes, sudden swelling of the face or hands, fever, decreased fetal movement, or fluid leaking before term. These are emergencies where distance matters most, and calling 911 is appropriate rather than driving.
Medicaid covers a large share of births in rural areas, and most states have extended postpartum coverage to a full year. Patients uncertain about coverage should confirm with their state Medicaid office rather than assuming. Local health departments can identify prenatal care options where hospital-based obstetrics is unavailable.
Doulas are a distinct role worth understanding on their own. They provide labor support but are not clinicians and do not deliver babies, and a growing number of state Medicaid programs now cover doula services. In areas without local obstetric care, some families combine a doula for continuous support with a relationship with a clinician at a more distant facility.
Whether the pace of closure slows depends largely on reimbursement policy. The March of Dimes says last year's federal budget law creates additional barriers by cutting Medicaid funding and allowing enhanced Affordable Care Act premium subsidies to lapse, a characterization that reflects the organization's policy position rather than a settled finding.
Key Questions Answered
What does the new report find? More than 52 percent of U.S. counties lack hospital-based labor and delivery services, and nearly 35 percent are maternity care deserts with no birthing facilities or obstetric clinicians.
What is a maternity care desert? A county with no hospital or birth center offering obstetric care and no obstetric providers.
How many people are affected? Those counties are home to 2.4 million women of reproductive age and account for roughly 150,000 births a year, according to the March of Dimes.
How large a role do midwives play? They account for about 12 percent of U.S. births, an increase of four percent over the past decade.
What is the Alabama litigation about? Midwives are challenging state licensing requirements they describe as restrictive. State health officials argue that physicians should be involved in births.
What should families far from a hospital do? Identify the nearest operating labor and delivery unit early, drive the route, and discuss risk factors and a delivery plan with a clinician.
Which symptoms require emergency care? Heavy bleeding, severe abdominal pain, severe headache with vision changes, sudden facial or hand swelling, fever, decreased fetal movement, or leaking fluid before term.
