by Rupa Palanki
The United States increasingly faces a crisis in maternal and infant health care. Over 2.3 million American women of reproductive age live in maternity care deserts — counties with little to no access to birthing centers and obstetric care. These deserts often result from rural hospital closures, health care provider shortages, and long-standing structural inequalities. The absence of accessible maternity services contributes to higher rates of preterm births and inadequate prenatal care, placing both pregnant individuals and their children at risk. Low-income and minority communities are especially vulnerable.
In Alabama, recent hospital and birthing unit closures have intensified local concerns about the state’s maternal health landscape. Today, over one-third of Alabama counties are maternity care deserts, and over a quarter of Alabama women have no birthing hospital within a 30-minute drive. With one of the nation’s highest maternal mortality rates, Alabama’s need for action is urgent. Below, I evaluate the strengths and limitations of three potential reforms aimed at addressing the Alabama maternity desert crisis.
Policy Solution #1: State Medicaid Expansion
Expanding Medicaid in Alabama could bolster the finances of rural hospitals, which currently bear the substantial costs of uncompensated care for uninsured patients. Many of these individuals fall into a “coverage gap”: they earn too much to qualify for Medicaid under current state guidelines, but too little to afford other insurance options. Medicaid expansion would cover at least 100,000 more Alabamians, enabling rural hospitals to receive reimbursement for previously unpaid care. This financial boost would help rural medical centers stay open and would support continued obstetrical services, which are often the first to be cut during budget crises.
However, Alabama’s political leadership remains resistant to Medicaid expansion. While Governor Kay Ivey has the authority to expand Medicaid without legislature involvement, she has repeatedly declined, citing concerns about long-term costs. This is despite the fact that Alabama would pay only 10% of expansion costs, with federal funding covering the rest. Without significant political pressure, Alabama Medicaid expansion is unlikely in the near future.
Policy Solution #2: the Rural Obstetrics Readiness Act
Unlike Medicaid expansion, the Rural Obstetrics Readiness Act has support from a bipartisan group of senators and representatives, including endorsement by U.S. Senator Katie Britt (R-AL). It has also been endorsed by the National Rural Health Association, the American College of Obstetricians and Gynecologists, the American College of Emergency Physicians, and other health advocacy groups. Introduced last spring in both chambers of Congress, this bill aims to improve emergency maternity care in rural facilities that lack a birthing unit. It proposes an obstetric emergency training program for non-obstetric providers, funding for necessary equipment, and support for teleconsultation services. If passed, this bill could improve health outcomes for pregnant individuals and their children by ensuring emergency room providers have basic maternity care training.
However, the bill’s viability is uncertain. The bill is sponsored by only six senators and eleven representatives. In contrast, the Maternal and Child Health Stillbirth Prevention Act of 2024 — a health care law that was successfully enacted this term — was sponsored by 21 senators and 63 representatives. This indicates that the broad political will necessary to pass the Rural Obstetrics Readiness Act by January 3, 2025, which is the end of the current Congress’s term, may not exist.
Furthermore, this bill addresses only immediate gaps rather than the root causes of maternity care deserts. Without broader structural changes, rural hospitals remain unlikely to have the financial resources to hire and retain OB/GYNS. Moreover, while intervention by non-specialist providers in emergency situations can save lives, it is not an effective replacement for the consistent OB/GYN care that many pregnant individuals require over the course of a pregnancy.
Indeed, even if the bill is reintroduced and passes next term, maternity care deserts are likely to worsen under a Republican-led presidency and Congress without further intervention. In particular, Project 2025 includes proposed cuts to Medicaid, restrictions on reproductive health services funding, and reduced investment in Title X centers. This will exacerbate OB/GYN shortages in rural and marginalized communities and drive community health centers out of business.
While the Rural Obstetrics Readiness Act provides a vital short-term policy solution, more comprehensive reforms are necessary to make meaningful progress in combatting the maternity care desert crisis.
Policy Solution #3: Covering Doula Care for Medicaid Recipients
Alabama may also consider covering doula services for Medicaid recipients, which is an optional benefit under federal guidelines. Doulas provide non-medical educational, emotional, and physical support to pregnant individuals and may improve delivery outcomes reduce health disparities, and increase health savings. Doula care coverage also potentially has bipartisan support. Twelve states and Washington DC had already implemented Medicaid coverage for doula services as of January 2024, and many other states are considering this measure. Moreover, the Alabama Department of Mental Health and the nonprofit BirthWell Partners are running the Community Doula Project in Birmingham as a pilot program.
As with the Rural Obstetrics Readiness Act, Medicaid coverage for doula care alone will not solve the Alabama maternity care desert crisis. Moreover, burdensome Medicaid certification processes and low reimbursement rates may reduce the willingness of doulas to accept Medicaid patients, which is an issue that has arisen in other states. Still, covering doula care for Medicaid recipients could provide a steady source of support for Alabama’s most vulnerable patients throughout the pregnancy, labor, and postpartum periods.
Conclusion
Ultimately, there is no single solution to Alabama’s maternity care desert crisis. Meaningful progress will require coordinated efforts from federal, state, and local health authorities, as well as prioritizing public health over political party.
Rupa Palanki is a law student (J.D. 2026), whose research interests include innovative medical technologies and chronic disease policy. She is a graduate of the University of Pennsylvania, where she studied Economics and interned for the U.S. Department of Health & Human Services and the Louisiana Department of Health. Prior to law school, she worked as an analyst at ClearView Healthcare Partners.
