On nearly every metric, rural mothers already fare worse. Maternal mortality—death during pregnancy, childbirth, and the first six weeks after delivery—averaged 81 percent higher in rural areas than in urban ones from 2016 to 2019. During that same period, rural women had a roughly 14 percent higher risk than urban women of needing treatment in an intensive-care unit during or after delivery; they are almost twice as likely to require transfer during or after birth to another hospital because a needed treatment is not available where they are.

These figures reflect the dismal state of rural-health-care infrastructure, which is particularly acute in maternity care. Since 2005, 109 rural hospitals have closed outright. Of those that remain, many have been closing down their labor-and-delivery units. Most rural hospitals no longer offer labor-and-delivery services, and in the past five years, an average of more than two rural hospitals a month have closed these units. As of 2023, 60 percent of rural counties had no hospital-based obstetric care. With few options available, rural women are less likely than urban women to receive prenatal care; this in turn makes them and their babies more susceptible to preventable complications.

Several related factors have contributed to these closures. Labor-and-delivery units have high fixed costs (physician and nurse salaries, birthing beds, fetal warmers), making them a financial liability if they are not operating at or near capacity. As fertility has declined, more units have gone into the red because they have too many empty beds. But even a steady flow of patients is not always enough: A rural hospital’s labor-and-delivery unit can struggle economically despite full beds because pregnant rural women are less likely than pregnant urban women to be enrolled in the commercial insurance plans that have high reimbursement rates. Instead, rural women are more likely to be enrolled in Medicaid, which has lower reimbursement rates, or to have no insurance at all.

As dire as this situation already is, public policy is about to make it worse. Prior to the second term of President Trump, rural areas were trying to make up for health-care-professional shortages through the H-1B visa program. The proportion of practicing physicians from other countries who are on an H-1B visa is almost twice as high in rural areas than in urban ones. Last September, Trump issued an executive order dramatically increasing the cost of H-1Bs to $100,000, which will surely have an effect on how many people can come to the United States with this status.