Between the passage of the "Big Beautiful Bill's" $1 trillion-plus cuts to Medicaid, which covers nearly half the births across the country, and the restrictive laws interfering with obstetricians' ability to do their jobs, this country is experiencing a serious maternity care crisis.
This article was made possible because of the generous support of DAME members. We urgently need your help to keep publishing. Will you contribute just $5 a month to support our journalism?
Twenty years ago, in the midst of a multi-day labor with my son, I asked the labor and delivery (L&D) nurse when I might expect to finally deliver. She smiled, squeezed my hand in between contractions, and told me, “The baby will come when he is ready to. These things don’t happen on a schedule!”
That lack of a schedule makes running a L&D unit a challenge for hospitals of all sizes. Unlike a typical outpatient surgery center, where each procedure is scheduled weeks, if not months, in advance, maternity wards have no idea when patients might arrive for care. That means, despite having to keep the department fully staffed 24/7, 365 days a year just in case a patient shows up, they are only reimbursed on an episodic basis. Whether the department delivers 30 babies per month, or none at all, their costs remain the same. But the amount of money they take in can vary widely. And, as most L&D care teams are legally required to have an obstetrician (OB), two nurses, and an anesthesiologist or nurse-anesthetist available at all times, it means that maternity care, unlike other healthcare service lines, is far from a profitable enterprise. At least, on a numbers basis.
Even hospitals that do a brisk birthing business still tend to operate at a loss. Medicaid is the single largest payer of birthing in the United States, covering more than 40 percent of births across the country. It’s well known that Medicaid tends to pay less than private insurance for a wide range of healthcare services. But a 2022 analysis from the Health Care Cost Institute estimates that, on average, hospitals receive about $8,700 more for all deliveries from employer-sponsored health insurance per patient — and as much as $11,000 more for Cesarean sections. When you average those differences across hundreds, if not thousands, of births each year, is it any wonder that so many L&D departments operate at a significant loss?
And with the passing of the so-called “Big, Beautiful Bill” to slash Medicaid funding by more than $1 trillion over the next ten years, it is unclear who will take responsibility for childbirth-related reimbursements. The Congressional Budget Office estimates this law will lead to more than 11 million people losing their insurance — and, no doubt, many of them pregnant people.
Then there’s the matter of restrictive laws interfering with obstetricians’ abilities to provide the highest quality care to their patients. Thanks to the Supreme Court’s Dobbs vs. Jackson Women’s Health Organization decision, which overturned Roe v. Wade, physicians now find themselves unsure of what practices are legal, because they change from day to day, and state by state. The uncertainty has led many medical students to shy away from specializing in obstetrics. And now, many established providers are choosing to leave the field altogether or move to states without restrictive abortion bans.
The end result is what Kasey Rivas, National Director of Strategic Partnerships at the March of Dimes — a nonprofit, non-partisan organization focused on improving the health of mothers and babies, calls significant growth of maternity-care deserts. Between 2021 and 2022, the March of Dimes noted that 1 in 25 obstetric units closed across the United States between 2021 and 2022, with many of these deserts in rural areas.
“There’s over 3,000 counties in the United States and Puerto Rico and over 1 in 3 of those is a maternity-care desert,” Rivas said. “You see counties in middle America, the southeastern area of America, are all areas that are at most risk when it comes to access to care. It’s no coincidence that those are the areas with the worst maternal health outcomes.”
The combination of L&D closures, with a dwindling OB-GYN provider pipeline, means that in the future, pregnant people will have to travel great distances to receive care — if they can access it at all. We stand at a precipice when it comes to safe, high-quality maternal care. And it begs a vital question: Who is going to help deliver babies in the future?
Christy Turlington Burns, founder of Every Mother Counts, a nonprofit organization dedicated to making childbirth safe and equitable for every mother, everywhere, said the U.S. has been in a crisis state for some time — and it is only growing with the rollbacks on abortion access.
“It’s shocking that more than half of all U.S. counties don’t even have a hospital that provides any obstetric care at all,” she said. “It’s surprising how similar we are to parts of rural sub-Saharan Africa, especially as you consider the distances people have to go to get to hospitals and facilities now.”
When you add these factors together, you see the United States is at a crossroads. With millions losing their own source of insurance, we will see a domino effect across maternity care, losing more of an already dwindling number of obstetric providers as well as the hospital L&D department that employ them, especially in rural and medically underserved areas.
How do we respond? Unless these forces are countered in some positive manner, more closures will happen, maternal complications and mortality will increase, and we, as a nation and society, will see untold losses in our families and communities.
Sadly, more than half our congressional representatives did not fight to protect Medicaid. In fact, the Senate actually increased cuts to this vital healthcare safety net before this catastrophic bill was signed into law. This means that all we can do at this point, especially given the fecklessness of the current administration, is to find new ways to advocate for safe, compassionate childbirth at the community level.
First and foremost, we each need to discuss what is happening, especially those of us who live in states that have curtailed reproductive rights and childbirth funding. Let people, especially your local and state representatives, know that these cuts will have knock-on effects that will affect families of all kinds across the nation. Get involved with grassroots legislative initiatives to expand midwifery and doula-supported care, like the Oklahoma Birth Equity Initiative or the American College of Nurse-Midwives. They can use your donations, as well as support during advocacy events.
Fight when you can against local hospital, health center, and L&D department closures. This is not an easy task, as they need adequate Medicaid funding to operate. While the new budget law does provide $50 billion for rural healthcare, most experts argue it is not enough. But your voice can help. Join protests. Reach out to state and local legislators. Ask questions and demand answers about such closings at town halls. Remind the powers-that-be that families lives — in particular, the lives of women and children — depend on it.
Finally, you can also lend your voice at the state level to protect abortion access (and bring clarity to the different laws surrounding it). Let your representatives know that you want doctors to be able to practice medicine without having to first consult the hospital attorney. And, of course, vote. The midterms are less than a year and a half away. It is entirely possible that, with a new slate of legislators, we can undo some of the damage done with this abomination of a budget bill.
We need to honor and protect childbirth. It should not have to be a profit generator for our government and communities to work together to make it as safe and equitable. It’s time we work together to affect some change before more families and children needlessly suffer particularly in underserved medical communities, as the number of OBs dwindle down to zero.