A new study in the American Journal of Preventive Medicine found that as hospitals shut down obstetric units, particularly in rural areas, far fewer women now live within a reasonable driving distance of maternity care. As a result, they face longer travel times, making it harder to obtain prenatal services and respond quickly to emergencies. According to the University of Pennsylvania’s Leonard Davis Institute of Health Economics, more than 500 hospitals have closed their obstetrics units between 2010 and 2025.
A Becker’s Hospital Review report explains that many hospitals are closing their obstetric units because they are costly to run, difficult to staff, and often financially unsustainable, especially when birth volumes are low.
As hospital-based obstetrics contracts, improving access will depend on removing regulatory barriers that limit midwives and prevent new birthing centers from opening.
Currently, 25 states and the District of Columbia allow Certified Nurse-Midwives (CNMs) to practice autonomously. In many states without full practice authority, nurse midwives can still attend home births, but only if they secure a physician supervision or collaboration agreement. In other words, they’re licensed to provide maternity care—including deliveries—but their ability to practice depends on finding a doctor willing to sign off. However, in many states, physicians won’t collaborate, rural areas lack OB/GYNs, and hospitals discourage affiliations, leaving midwives technically permitted but practically unable to offer services.
Certified Professional Midwives (CPMs) are a distinct clinical profession from Certified Nurse-Midwives (CNMs). CNMs are medically trained clinicians embedded in the health care system who can practice across settings, while CPMs are specialized in out-of-hospital births and are often the main providers in home and birth center settings—but face more variable and restrictive state regulation. As of January 2026, 33 states and the District of Columbia license CPMs. Several states offer no formal pathway to licensure, and CPMs practice in a legal gray area. Other states, such as Illinois, Iowa, Massachusetts, and Michigan, only license CNMs.
No state outright bans home birth, but many states restrict who can attend them by refusing to license midwives, requiring physician supervision, or limiting acceptable credentials—leaving home birth legal in theory but often inaccessible in practice. For example, Nebraska prohibits CNMs from attending home births.
Just as scope-of-practice rules limit who can provide care, certificate-of-need (CON) laws restrict where that care can be delivered by making it more difficult to open new birthing centers. Freestanding birthing centers are increasingly popular alternatives to hospital delivery, typically staffed by nurse-midwives. In some areas, like rural Alabama, they offer women, especially African-American mothers, a more familiar and patient-centered setting, while also reducing the burden of long travel distances in a state where roughly 28 percent of women lack a hospital within a 30-minute drive.
Of course, birthing centers are not a substitute for hospital care in high-risk pregnancies, but they can safely serve low-risk patients and free up hospital capacity for more complex cases. They also tend to be significantly less expensive than hospital deliveries, offering a lower-cost alternative in a system already strained by rising maternity care costs.
According to research by the Pacific Legal Foundation, roughly a dozen states require a certificate of need to open a freestanding birthing center, forcing providers to obtain state approval and often run the gauntlet of opposition from incumbent hospitals—effectively giving competitors a veto and creating a direct barrier that can delay or block new centers even in underserved areas.
But CON laws are only part of the problem. The Pacific Legal Foundation report finds that most states impose additional restrictions, such as requiring transfer agreements with nearby hospitals, mandating physician oversight, or adding complex licensing and facility requirements that mirror hospital standards. These barriers can be just as limiting, especially in rural areas where hospitals may refuse to cooperate or physicians are scarce. As a result, even states without CON laws often make it difficult to open and operate birth centers, helping explain why 17 states had no operating birth centers as of 2025.
In summary, as hospitals withdraw from providing obstetric services, policymakers are not only failing to replace the lost capacity—they are actively blocking viable alternatives from emerging.
The answer is not to double down on a shrinking, hospital‑centric model but to let alternatives develop. That starts with dismantling regulatory barriers that prevent midwives and birthing centers from filling the gaps hospitals leave behind.
