Wednesday's Signal told you the physicians are leaving and the replacements are not coming. Today's Briefing maps the data and names the levers — the specific federal and state tools that could begin to rebuild the obstetric workforce in the places that are losing it.
The numbers
Let me make the scale of this concrete.
As of 2024, 1,104 U.S. counties — 35.1% of all counties — are classified as maternity care deserts by the March of Dimes.[2] That means no hospital with obstetric services, no birth center, no OB/GYN, and no certified nurse-midwife. Not underserved. Zero.
116 rural hospitals have ended labor and delivery services between 2020 and 2025 (CHQPR tracking).[1] 27 of those closures occurred in 2025 alone — one of the highest annual totals in five years. Only 41% of rural hospitals still offer L&D.
Nearly 80% of rural counties had no practicing OB/GYN by 2021–2022.[3] In the counties that do have OB coverage, the average provider is older, closer to retirement, and less likely to be replaced when they leave.
In Idaho — the leading indicator — 31.8% of counties are classified as maternity care deserts.[2] Two hospital L&D units (Bonner General in 2023, Valor Health in 2023) permanently ended services. Idaho's Maternal Mortality Review Committee was dissolved in 2023 and operated as the only state without one for over a year before being reinstated via HB 399 in 2024. And a 2025 study documented that approximately 35% of Idaho's obstetric physicians — 114 of 268 — stopped practicing in the state between August 2022 and December 2024.[4]
The workforce that staffs the operating room in 2032 is the workforce that, in 2024, decided where to apply for residency.
AAMC data shows the residency pipeline echoing the exodus. In the 2023 cycle, OB/GYN applications to programs in ban states declined 10.5% (vs -5.3% in legal states). In the 2024 cycle, ban-state applications declined 6.7% while legal states rose 0.4%.[3] Each of those application declines is a physician who will not practice in that state in 2036. The pipeline is twelve years long. The decisions being made today about where to train are the workforce reality of the 2030s and 2040s.
What a maternity care desert actually means
I need to make sure this is not an abstraction.
When the last OB/GYN leaves a rural county and the hospital closes its L&D unit, here is what happens to the pregnant woman who lives there.
Her prenatal care — if she can get it — requires driving to the next county. That might be thirty miles. It might be ninety. She needs time off work, childcare for her other children, gas money, and a car that runs. She does this monthly for the first two trimesters, then biweekly, then weekly. Each appointment is a half-day project.
When she goes into labor, she drives. Or she calls an ambulance that drives. After a rural hospital closure, median inpatient travel distance increases from 3.4 to 23.9 miles (GAO general-inpatient data).[5] For obstetric emergencies specifically — placental abruption, eclamptic seizure, postpartum hemorrhage — those extra miles are measured against the clinical clock.
When she delivers, she delivers in a hospital that does not know her. Her records may or may not have transferred. The OB on call has never seen her. If she needs an emergency C-section, she needs an anesthesiologist — and the hospital she is delivering in may not have one in-house at night.
That is a maternity care desert. It is not a policy label. It is the operational reality of having a baby in a county that the workforce has left behind.
The levers that still exist
Here is the part that matters. There are specific, named, existing tools that could begin to rebuild this. None of them are hypothetical. All of them have bipartisan precedent. Whether they are used is the question.
- National Health Service Corps (NHSC). The NHSC is the federal program that exchanges medical-student debt for years of practice in federally designated Health Professional Shortage Areas (HPSAs).[7] The program already exists. The mechanism is proven. The lever is expanding the number of NHSC slots targeted to HPSAs that overlap with maternity-care-desert counties. The economics are simple. A medical student graduating with the AAMC's 2024 median debt — approximately $205,000, with the private-school average closer to $228,000[6] — will practice in a rural county for four years if the federal government pays off that debt. That is not altruism. That is math. The NHSC is the tool that converts the math into the workforce.
- Teaching Health Center GME (THCGME). Teaching Health Centers are community-based residency programs — as opposed to the traditional academic-medical-center model. They train residents in the communities where they are needed, which means the geographic-stickiness effect works in favor of underserved areas instead of against them. The THCGME program is funded through HRSA. Funding has historically been extended via continuing resolutions and health-extender packages (most recently extended through Sept 30, 2025 in H.R. 1968; subsequent FY26 HHS appropriations carried it further).[7] The reauthorization decision recurs every cycle, and the funding level — not the appropriations calendar — is the lever. More slots in community-based programs in underserved areas means more physicians who train there and stay there.
- Conrad 30 J-1 visa waivers. For thirty years, international medical graduates on J-1 visas have been disproportionately concentrated in rural and underserved-area OB coverage. The Conrad 30 program allows each state to sponsor up to thirty J-1 waivers per year for physicians who agree to practice in HPSAs, Medically Underserved Areas, or for Medically Underserved Populations for three years.[8] The post-2017 contraction of the J-1 program — under both the first and second Trump administrations — has constrained the recruitment pipeline those counties relied on. The Conrad State 30 and Physician Access Reauthorization Act (S. 709 / H.R. 1585, 119th Congress, introduced February 2025) is the legislative vehicle for restoring it.[9] The lever is restoration to pre-2017 levels plus expansion of allowable specialties to include obstetric-specific placements.
State-level postpartum and workforce protections. States have their own levers. The forty-nine states that adopted the twelve-month postpartum Medicaid extension can protect it through state legislation. States can also use their own workforce incentive programs — loan repayment, tax credits, scope-of-practice expansions for midwives and advanced practice providers — to partially compensate for the physician losses.
The challenge is that the states losing the most physicians are the states least likely to use these levers. The states with the most restrictive abortion bans are, with few exceptions, the states with the weakest state-level workforce protections. That is not a coincidence. It is the structural expression of the same political environment that produced the bans.
The Closer
The workforce crisis in maternal healthcare is not a shortage. It is an exodus — driven by policy, accelerated by Dobbs, and compounding through a twelve-year pipeline that cannot be refilled on a political timeline.
The tools to begin rebuilding exist. They are funded. They have bipartisan support. They sit in reauthorization queues. The question is not whether we know how to fix this. The question is whether the people who can pull the levers will pull them before the pipeline empties out entirely.
The Manufactured Healthcare Crisis
The workforce exodus is one front in a fifteen-month dossier. The whole picture — counters, named actors, the five-phase chronology — is published in our long-form visual essay.
manufactured.laboracollective.comThe Architecture of Harm: The State of Women's and Children's Health in the United States — Dr. Connor's fourteen-chapter flagship report — is forthcoming.