In Rural America, Maternity Care Is Anything but Equal

Driving to the hospital while in labor can be a scary experience for anyone. For people who live in maternity care "deserts," this drive is often hours long, sometimes through winding roads with hazardous conditions, depending on the time of year.

An uptick of hospital closures, staffing shortages and financial barriers are responsible for these deserts—counties with limited or nonexistent access to maternity care.

"I have seen the effects of these closures personally," said Anne Banfield, M.D., vice chair of the West Virginia section of the American College of Obstetricians and Gynecologists (ACOG).

"My practice is located in the mountains of West Virginia, and because of closures that have happened in the past 15 years, going south, the next closest hospital with birthing facilities is two and a half hours away," Banfield said. "That two and a half hours is in good driving conditions, which often don't exist in the winter. Many of our patients face challenges related to consistent transportation, and when you add in these long distances, getting care often isn't possible."

The landscape of maternity care deserts

According to March of Dimes, maternity care deserts exist either through lack of services or barriers to a person's ability to access care. A county deemed a desert does not have a single hospital with obstetric care, birth centers or obstetric providers.

More than 2.2 million women of reproductive age live in maternity care deserts. Rural areas are the most affected.

At the University of Minnesota Rural Health Research Center, Carrie Henning-Smith, M.S., M.P.H., and a team of researchers found higher rates of obstetric closures and a higher prevalence of maternity care deserts in less-populated rural counties, generally with a population center of 10,000 people or less.

"We have also found higher rates of obstetric unit closures in rural counties with a higher percentage of Black residents and in states that have not expanded Medicaid," Henning-Smith said.

More than 2.2 million women of reproductive age live in maternity care deserts. Rural areas are the most affected.

Maternity care deserts also severely affect Indigenous people who face an already increased risk of maternal death and childbirth complications.

"Of the 5.2 million people who identify as Indigenous, 40 percent live in rural areas on and off tribal lands," Banfield said.

Fewer than 10 percent of obstetric providers practice in rural areas, according to a 2020 report from March of Dimes. In 2017, about half of the 3,139 U.S. counties lacked a single obstetrician.

According to Henning-Smith's research, 179 rural counties, about 1 in 10, lost hospital-based obstetric services from 2004 to 2010. The number of hospital closures has continued to rise since then.

The burden of living in a maternity desert

Access to quality care ensures better maternal health outcomes. The United States has the highest maternal mortality rate among developed countries. Further, Black women are two to six times more likely to die from pregnancy complications than white women. Living in a maternity desert only compounds these already stark inequities.

In a 2018 retrospective study published in the Journal of the American Medical Association (JAMA), of nearly 5 million births in rural counties, researchers found the loss of obstetric care in rural counties was associated with increases in preterm births and births in hospitals without obstetric units.

A 2021 study, published in the journal Women's Health Issues, looked at Louisiana maternity deserts and found the risk of death during pregnancy and one year postpartum was significantly elevated among women in maternal deserts as opposed to those with greater access to care.

"Anecdotally, I have certainly seen situations when patients' outcomes may have been different had they had care available closer to home," Banfield said.

The reality of living more than a 30-minute drive to an obstetric ward causes higher rates of delayed prenatal care, pregnancy-related hospitalizations, low-birth-weight infants and infant mortality, Banfield continued.

When someone requires specialized, high-risk care, it's available almost two hours from Banfield's office. Poverty only compounds the struggle to access care, afford gas, transportation, time off work and child care. Banfield reinforced that this is an all-day trip, not a quick appointment someone can schedule before a 9 a.m. shift.

There is also the mental stress. Living farther from a hospital with an obstetric unit can compound the stress of a high-risk pregnancy, when someone is more likely to need frequent doctor's visits. It's well-documented that stress can have detrimental effects on pregnancy and lead to various adverse outcomes, such as preterm labor and delivery, low infant birth weight, shortened gestational length, preeclampsia and gestational diabetes.

In filmmaker Elizabeth Arledge's documentary series, "Remote Chance: Rural Health Care in America," about maternity deserts in rural Georgia, obstetrician Joy Baker, M.D., noted that Black women are twice as likely to screen positive for depression and anxiety during or after pregnancy.

The effects of maternal deserts on overall health are widespread but not equal.

"Those poor outcomes are not equally distributed, and rural and BIPOC [Black, Indigenous, people of color] residents experience an inequitable share of maternal and infant mortality and morbidity," Henning-Smith said.

Why rural obstetric units are closing

It takes more than an obstetrician to run a labor and delivery ward.

"Staffing beyond just obstetrician-gynecologists is also a factor," Banfield explained. "If you do not have adequate nursing or anesthesia staff, you cannot have a functioning obstetrics unit, because these are essential team members."

Once a unit closes, recruiting OB-GYNs to practice in those areas becomes more challenging, Banfield said.

A variety of factors contribute to obstetric wards shutting down.

"Some of the biggest contributors include workforce shortages, low volume of care, low reimbursement rates and the high overhead costs involved in providing services," Henning-Smith said.

From 2010 to 2019, nearly 100 rural hospitals closed, the Commonwealth Fund reported.

Many rural hospitals face vulnerability to closure for financial reasons. The COVID-19 pandemic only exacerbated these vulnerabilities and increased stress on finances, hospitals, communities and staff.

Replenishing maternity deserts

The Commonwealth Fund, a philanthropic organization that promotes high-quality health care, has a comprehensive list of recommendations for replenishing care in maternity deserts. Some of these recommendations include:

• Enlisting nonclinical partners, such as doulas
• Training more rural obstetricians
• Widening telemedicine's reach
• Expanding Medicaid coverage for up to one year postpartum
• Investing in midwives

ACOG's recommendations for aiding maternity deserts include promoting state initiatives that offer financial incentives to rural obstetric healthcare practitioners. Another initiative is to encourage graduates of OB-GYN residency programs to participate in loan repayment programs that require practicing in rural locations for a specific length of time.

Widening access for rural women to contraceptive methods, emergency contraception and safe abortion services are also on ACOG's list of suggestions. Continuing research on how poverty disparities impact rural women's health is imperative.

"Expanding Medicaid and increasing reimbursement rates would help, as would addressing workforce shortages through financial incentives and rural-focused training programs," Henning-Smith concluded. "But we also need to address some of the underlying causes, such as structural racism and disinvestment in rural areas."