When Eden G. Fromberg, DO, FACOOG, ABIHM, decided to start her own practice in 2005, she was taken aback by the expense of malpractice insurance for obstetrics. At $150,000-$200,000 per year, the cost was too high for her to be able to continue delivering babies. Since then, it’s increased to as much as $226,000 (or more) per year in some parts of the country.

Someone else had always paid for her malpractice insurance, said Fromberg, who had been working as an Ob/Gyn at a hospital in rural Upstate New York. “Reimbursed at $2000-$3000 per birth [at the time], you can do the math and see how many babies I would have needed to deliver before I could have paid for my insurance. And I also had to carry my office and staff,” she said.

To lower her costs, Fromberg decided to work part-time and divide her practice between Upstate New York and Manhattan. She would pay for office space and staff on a per diem basis, practice gynecology only, perform fewer procedures, and not take insurance.

Many of her colleagues came to similar conclusions. A few left medicine. Others sold their practices to work for hospitals or healthcare systems. Sometimes these institutions were subsequently taken over by larger companies, which then shuttered their labor and delivery (L&D) units. The hospital where Fromberg worked was among them. Now, women in her area need to drive at least 45 minutes to see an Ob/Gyn.

When L&D units shut down, Ob/Gyns must give up obstetrics or move.

Some are also opting to relocate due to the 2022 Dobbs v. Jackson Women’s Health Organization Supreme Court decision, which overturned Roe v. Wade. The number of MDs applying for Ob/Gyn residencies in states with abortion bans declined by 10.5% between 2022 and 2023, according to the Association of American Medical Colleges.

The upshot is that half of rural towns in the US lack even one Ob/Gyn, according to a 2025 paper in Obstetrics and Gynecology. As rural hospitals have closed or shuttered L&D units, “maternity deserts” are growing. Since 2020, more than 100 such units have closed. The American College of Obstetricians and Gynecologists projects the number of Ob/Gyns to keep falling. The rural Ob/Gyns who remain are forced to pick up the slack.

Rural Ob/Gyns Are in the Red: Low Earnings and High Costs

Maternity care is financed on the basis of volume, said Julia D. Interrante, PhD, MPH, research fellow and statistical lead, the University of Minnesota Rural Health Research Center, Minneapolis. “Providers are reimbursed for every birth that happens at their hospital. If there are fewer births [as in many rural areas], their income for that service line will be less.”

Making matters worse, reimbursement rates can be low. Half of rural deliveries are covered by Medicaid, which typically pays less than private insurance, Interrante added. In certain areas of the country, Medicaid covers up to 70% of all births.

Fixed costs are very high regardless of the number of births in maternity care, said Interrante, explaining that L&D units must be equipped and open 24/7.

“There is no other unit like it,” said Sarah N. Cross, MD, associate professor of obstetrics, gynecology, and reproductive sciences, Yale School of Medicine, New Haven, Connecticut. “We have our own ORs [operating rooms], anesthesiologists, nurses, surgical technicians, and pediatric providers,” she said. Even a relatively low-volume place needs dedicated staff. But it’s very expensive to run an L&D unit, and a lot of hospitals are forced to make tough decisions.

As Fromberg said, liability is a large part of these costs. Obstetrics is a litigious branch of medicine, said Cross. “There are a lot of emergencies, and sometimes a practice gets blamed when [the emergency] would have happened anyway.”

With high-risk pregnancies on the rise, complications and emergencies are even more likely. The growth of maternity deserts adds to the problem. More women are foregoing critical prenatal care and traveling greater distances to give birth, which increases the chances of complications.

In rural areas, non-Ob/Gyns often end up handling L&D. It is now much more common for a family physician to be the clinician attending a birth in a rural area. It can be a challenge to maintain those clinical skills when you have a low volume of births, said Interrante. “Some hospitals do simulation trainings in emergency birth situations. Still, we surveyed hospitals that had lost their Ob units, and 80% told us they did not have enough training and resources to handle emergency birth situations,” she said.

Data show that outcomes are worse in maternity deserts, said Michael Warren, MD, MPH, FAAP, pediatrician and Chief Medical and Health Officer, March of Dimes. “If patients lived in an environment where the system supported better access to care, their risk factors could have been addressed and some complications prevented.”

What Can Be Done?

“Maternity deserts are made by people and policy,” said Warren, who feels an overhaul of the system is sorely needed. With the recent passage of the H.R.1, the concern is that maternity deserts will increase as people lose access to care, he said.

The current reimbursement system does not work well in low-volume areas, said Warren. He recommended providers be compensated for maintaining maternity care infrastructure because “you still need a baseline state of readiness even when the birthing volume is low.” Perhaps such an alternative reimbursement model could fall under hospital designations that currently do not apply to maternity care, such as “critical access” and “rural emergency,” said Interrante.

It may help to “think about the whole complement of obstetrics and gynecological providers, not just Ob/Gyns,” said Warren. Nurse practitioners, family medicine physicians, and midwives can help compensate for dwindling Ob/Gyn numbers, as long as they receive robust training, he said.

Cross reported saying that her statements reflect her own opinions and do not necessarily reflect those of the organization for which she works. Fromberg, Interrante, and Cross reported having no conflicts of interest.