Rural California’s Birthing Desert

Thumbnail Source: Maternity care ‘deserts’ on the rise across the U.S., STAT News

Introduction

There are two pregnant women in CA: one lives in an urban city and drives less than 10 miles to her closest hospital to give birth, and the other lives in a rural county in the Central Valley and drives close to 100 miles. 

Rural California is facing a birthing desert. There are 8 rural regions in CA, including Shasta Cascade, North Coast, Central Valley, Gold Country, High Sierra, the Deserts, Central Coast, and the Inland Empire. With long geographical distances to hospitals, pregnant women and mothers in these rural areas face barriers to maternity care access, in addition to higher risks of pregnancy complications and infant and maternal mortality. 

Alternative to hospitals, birth centers exist throughout rural regions to provide prenatal, birth, and postpartum care for low-risk pregnancies outside a hospital setting. The problem is, they are closing. Low reimbursement rates from insurers like Medi-Cal, high operational costs, and inflexible licensing requirements contribute to the disappearing number of birth centers. Without these local and free-standing health care facilities, pregnant women and mothers are deserted in rural communities. 

Picture Source: Visiting High Sierras – A California Rural Region, Kirsten Alana

This maternal health crisis is rooted in a larger public health crisis in rural regions. Rural health experts featured on Tradeoffs, a nonprofit news organization, report that 80% of rural America is designated as medically underserved, with 44% of rural hospitals operating at a financial loss due to uninsured and underinsured patients, evidently contributing to uncompensated care. A vast shortage of primary care, high poverty rates, and a large elderly population further exacerbate this rural gap to affordable and quality health care. 

RHT Roll Out 

In 2025, under the One Big Beautiful Bill Act (OBBBA), the Trump administration rolled out a $50 billion investment for a Rural Health Transformation Program (RHT) to last until 2031.

Let’s break down how the dollars are distributed. 50% of the RHT funds will be distributed equally among approved States that submitted funding applications. The other 50% will be allocated “based on a variety of factors, including rural population, the proportion of rural health facilities in the State, [and] the situation of certain hospitals in the State,” under the authorization of the Center for Medicare and Medicaid Services (CMS).

Figure 1 Source: How States Can Access New Federal Funds to Improve Care in Rural Communities, The Commonwealth Fund

 Despite bipartisan enthusiasm for the RHT, health policy experts and some Democrats believe this $50 billion investment pales in comparison to the roughly $1 trillion in cuts to Medicaid and Obamacare, also enforced under the OBBBA. Furthermore, there is growing concern that the decisions behind RHT funding distributions will be heavily contingent on state adoption of White House policies. Understanding this federal funding landscape is crucial as the RHT begins implementation over the next 5 years. 

Medicaid Innovation

Returning to our maternal health crisis, how do we close the birthing desert with RHT funds? Well, it is not just dollars alone that will close this gap, but innovation. Numerous states have already implemented or created innovative ways to finance, deliver, and sustain care under Medicaid.

For example, Tennessee secured a CMS waiver to implement the TennCare Shared Savings program. This program is built upon a shared savings model between the federal and state governments to foster rural healthcare resilience in “targeted areas like preventive care, behavioral health, substance abuse treatment, mobile medical services, integrated care, care navigation, and transportation support.” The majority of these services aim to improve health outcomes of the rural maternal population, from prenatal to postpartum care.

Figure 2 Source: TennCare III: Unpacking Tennessee's New Medicaid "Block Grant" - The Sycamore Institute

The TennCare Shared Savings program is just one of many examples of Medicaid innovation that aligns incentives across multiple stakeholders to enhance health care access in rural America. This alignment will streamline efforts to solve the maternal health crisis, birth center closures, and to provide other resources like nutrition, mental health screenings, and breastfeeding consultations within rural communities. 

Rural Workforce 

Furthermore, rural workforce development is a crucial strategy to reopening and sustaining birth centers for the maternal population. The primary care providers in these facilities are midwives, nurses, and doulas. As mentioned in the introduction, a huge factor contributing to birth center closures is low reimbursement rates from insurers like Medicaid.

In California, Medi-Cal pays for 40% of births in California, but the reimbursement rates for birth centers are often insufficient to cover the actual costs of care. Therefore, many licensed midwives (LMs) do not accept Medi-Cal insurance from their patients and resort to out-of-pocket payments in cash. Figure 3 breaks down the reasons why, with almost 70% of LMs reporting that payments are not high enough to recoup the costs of providing care. 

Figure 3 Source: California’s Midwife Workforce: Who Midwives Are and Who They Serve: Snapshot, California Health Care Foundation 

Digital Health 

Digital health is beneficial for a variety of reasons. For example, the use of remote patient monitoring (RPM) tools prevents expensive emergency room visits and hospital readmissions by monitoring ongoing patient health data from their homes. RPM technology can close the geographical distance of rural patients to hospitals, while shifting away in-patient care burden from hospital systems. In order for RPM technology to be successful, patients and providers need to know how to use these devices. This is why digital health training is integral for rural health workforce development. 

Picture Source: Remote Fetal Monitoring and Maternal Health Outcomes

The integration of digital health is another target initiative for RHT funding allocation and implementation. However, challenges to consider are the lack of broadband connectivity and digital literacy in rural areas. Furthermore, the majority of the rural workforce, midwives and doulas in particular, have been locked out of the traditional healthcare model (i.e. hospital settings). This gap in care models has contributed to an increasing skepticism towards telehealth for midwives and doulas. 

“Midwives perceived disadvantages of telehealth for patients such as shorter visits with less time for patients’ concerns, financial barriers for those who lack internet access or devices, lack of privacy for patients, dangers of remote domestic violence and mental screening, and the creation of greater distrust for those already concerned about interacting with institutions or being recorded,” according to a 2024 systematic review of midwives’ experiences with telehealth. Integrating telehealth in rural areas would challenge the cultural norms of rural clinical practice and solutions are needed to improve midwifery relationship to telehealth and other remote patient monitoring tools that continuously track health data. 

Call to Action 

The geographical distance from home to hospital for pregnant women determines their chance of a healthy delivery or high-risk complication. Rural CA is facing a birthing desert, but we can close this gap of care. This will require Medicaid innovation, a sustainable workforce, and digital health integration. The time to invest in rural birth infrastructure is now. There is already existing momentum across a multitude of states to tackle this rural health gap amidst upcoming RHT implementation. The innovations are ready, what we really need is the political will and aligned incentives to implement and sustain it. 

To stay informed on rural health transformation matters, sign up for California Department of Health Care Access and Information’s Rural Health email listserv. The emailing list will send upcoming webinars, surveys, and engagement opportunities to share your ideas. When subscribing, select “Rural Health” under the Healthcare Workforce category to ensure you receive updates.