A pregnant woman in rural America may have to drive two hours — sometimes more — to reach a hospital that can deliver her baby. If labor comes early or complications arise, that distance becomes dangerous.
This is happening in the United States in 2026 — not because we lack medical knowledge or technology, but because we have failed to train and place the physicians where they are most needed.
The crisis seems paradoxical. The U.S. fertility rate has declined by 23% over the past two decades. Fewer babies should mean less strain on the system. But that is not what is happening. In many parts of the country, especially rural communities, access to maternity care is shrinking, not expanding.
Consider South Dakota. It has one of the highest fertility rates in the nation. Yet more than half of its counties are classified as maternity care deserts — areas with no hospital or birth center offering obstetric services and no obstetric clinicians, as defined by the March of Dimes.
Despite this need, South Dakota has no obstetrics and gynecology residency program to train physicians. The state relies on importing doctors trained elsewhere — a strategy that is increasingly difficult to sustain. Physicians who do not train in rural settings are less likely to practice there long term.
This is not just South Dakota’s problem. It is a national design flaw.
Nearly half of U.S. counties lack a practicing obstetrician or gynecologist. Rural hospitals have steadily closed labor and delivery units, citing financial losses, staffing shortages, and the high cost of malpractice insurance. The remaining providers are stretched thin, and patients are traveling farther for care — often delaying prenatal visits or arriving in labor without adequate support. For instance, a patient may arrive at the hospital only to find insufficient physician coverage.
We often frame this as a physician shortage. But that is only part of the story. The deeper issue is a training bottleneck — and a misalignment between where doctors are trained and where they are needed.
In the United States, the number and location of residency positions — the training programs physicians must complete after medical school — are largely determined by federal funding through Medicare — but that doesn’t help pregnant women. These positions are concentrated in urban academic medical centers, reflecting historical patterns rather than current population needs.
The Association of American Medical Colleges has repeatedly warned that this system contributes to workforce shortages in underserved areas. Doctors tend to practice near where they train. When training programs are absent, so too is the long-term workforce.
South Dakota’s lack of an OB/GYN residency is not an oversight. It is the predictable result of a system that reinforces existing infrastructure instead of building new capacity where it is most needed.
Even when demand is high, creating new residency programs is not straightforward. Training requires more than patient volume. It depends on faculty, facilities, and a range of clinical experiences that many rural hospitals — already operating on narrow margins — cannot provide on their own.
The consequences are measurable and severe. Women in rural areas face higher rates of maternal morbidity and mortality, particularly among low-income communities and Black and Indigenous women — disparities documented by the Centers for Disease Control and Prevention. Delayed care, longer travel times, and fragmented services all contribute to worse outcomes.
And the absence of local training programs perpetuates the cycle. Without a pipeline of physicians rooted in these communities, shortages persist and deepen.
Fixing this problem does not require reinventing medicine. It requires aligning our training system with our national needs.
First, federal funding for residency positions should be tied more directly to geographic and specialty shortages. Expanding obstetrics and gynecology training slots — particularly in rural tracks — would begin to correct the imbalance. Targeted programs have demonstrated that where physicians train influences where they practice. But these efforts remain too limited in scope.
Second, we need to rethink what a residency program looks like. Rural states do not necessarily need traditional, stand-alone programs. Regional, distributed models — linking hospitals across state lines — could provide the necessary clinical experience while allowing trainees to live and work in underserved areas. Accreditation standards should evolve to support these models, rather than favoring large urban centers by default.
Third, financial incentives must support long-term commitment. Loan repayment programs and rural subsidies are often short term and fragmented. If we want physicians to build careers in underserved communities, we must offer stability — not just recruitment bonuses.
Finally, we cannot ignore the role of malpractice risk. Obstetrics is one of the highest-liability specialties in medicine. For small hospitals, the financial burden of maintaining obstetric services can be prohibitive. Without addressing this, even well-designed workforce solutions will remain fragile. We need a cap on how much patients can sue for malpractice. Some states, for example, have a $250,000 limit for pain and suffering.
Some will argue that expanding residency training is too expensive or too slow to be effective. But the cost of inaction is already evident: more emergency transfers, worsening maternal outcomes, and widening health disparities.
If a state with one of the highest fertility rates in the country cannot sustain a single OB/GYN training program, the problem is not demand. It is design.
We have built a system in which need does not drive capacity. Until that changes, maternity care deserts will continue to expand — and the distance between patients and care will continue to grow.
Jocelyn Mitchell-Williams, MD, Ph.D., is associate professor of obstetrics and gynecology and senior associate dean for medical education at Cooper Medical School of Rowan University, and a practicing OB-GYN for nearly 30 years. Vijay Rajput, MD, is professor and chair of the department of medical education at Nova Southeastern University’s Dr. Kiran C. Patel College of Allopathic Medicine, and an internist and medical educator. This article represents the opinions of the authors and does not necessarily reflect the views of their institutions.
