In a recent video released by March of Dimes, a pregnant mother named Claudia declares that she will likely give birth in a car. The nearest hospital is a thirty minute-drive from her home. Claudia recalls giving birth to her first child on a farm, her second in a car, and how she made it to the hospital to deliver her third just in time. Like so many others in Texas’ Ward County, Claudia lacks close, convenient access to a physician or gynecologist in her area to provide obstetrics care.
Her story is not the exception, but largely the norm for people from rural areas of the United States. According to the American Hospital Association, 89 obstetrics units have closed in U.S rural hospitals between 2015 and 2019. More than half of rural hospitals, already few and far in between, did not offer obstetrics care in 2021. Women in rural areas have all different challenges and needs, but have collectively experienced the effects of hospital closures due to underfunding and lack of care.
Ashley Stoneburner is a data science manager at March of Dimes, a nonprofit organization that works to improve health outcomes for mothers and babies. Stoneburner told The Politic that today, “there are 5.6 million women who live in counties with no or limited access to maternity care services.” March of Dimes defines maternity care deserts as areas where there is limited or no access to birthing hospitals, birth centers offering obstetric care, or obstetrics providers. For those who live in maternity care deserts, “some rural residents have to travel as far as almost two hours to reach the nearest hospital with obstetrics services. That was the outlier, but that is the substantial burden,” said Dr. Peiyin Hung, a professor at the University of South Carolina who specializes in geographic disparities in healthcare.
Lack of obstetrics care is just one of the issues pregnant people face in rural areas. “More than 20% of rural residents do not have the internet to access a lot of resources or know how to leverage existing community resources,” said Dr. Hung. “Only looking at the most underserved communities leaves behind a lot of disadvantaged populations that have, on average, some resources—but who are still outliers compared to other communities.”
As maternity care deserts continue to expand in rural areas, the maternal mortality rate has risen.
Maternal mortality refers to the death of a birthing person due to pregnancy-related health issues during childbirth or within 42 days postpartum, as defined by the World Health Organization and the Center for Disease Control. From 2011 to 2013, the maternal mortality rate was 17 deaths per 100,000 births in the United States. Even though the U.S. has the highest healthcare spending per person in the world, the maternal mortality rate rose to 32.9 deaths per 100,000 live births by 2021. Black and American Indian/Native Alaskan (AI/AN) women are among the most vulnerable to complications—before, during, and after pregnancy. Notably, the maternal mortality rate for Black women is 69.9 per 100,000 births, and AI/AN women are 4.5 times as likely than non-Hispanic white women to die from their first delivery.
March of Dimes is currently partnering with Surgo Venture, a privately funded action tank, to measure the Maternal Vulnerability Index, which identifies where U.S. residents are most vulnerable to poor maternal health outcomes. The data from this report shows that people in states with a majority of rural counties—Alabama, Mississippi, Georgia, Texas, Arizona, Arkansas, and Oklahoma—are the ones most susceptible to maternal mortality.
Maternal deaths can be prevented if a woman meets with an obstetrician early and receives regular care. This not only improves the chances of a healthy pregnancy but also helps prevent common risks women face during and after birth, including hypertension, heart disease, stroke, and preeclampsia. Yet this support is not a reality for women who cannot quickly access obstetrics care or other resources efficiently.
Even programs such as Critical Access Hospitals, created by the Centers for Medicare and Medicaid Services (CMS) in response to over 100 rural hospital closures in the 1980s, do not include obstetrics care in their services. These Medicare-run institutions, which are either nonprofit or public, are intended to provide care in rural areas that are 15-to-35 miles from the nearest hospital or medical facility. These hospitals have at-most 25 acute care inpatient beds and do not offer care past 96 hours. Although this program has relieved some healthcare burdens in rural communities, it still leaves behind vulnerable populations of pregnant people.
Maternity care deserts arise mainly as hospitals struggle with staffing shortages, low patient volume, reimbursement, and funding to cover the cost of providing care. According to Christine Morton, PhD, a medical sociologist and author, “40 to 45% of all obstetric births are covered by Medicaid.” But hospitals serving patients with Medicaid coverage often receive lower reimbursement rates, Morton continued. “Unfortunately, you have this perfect storm—where you have the most vulnerable women and other pregnant people who are in these low-resource areas and do not have access to care.”
Many hospitals’ leading concern is to generate greater revenue. “Hospitals, even if they are not for profit, are looking to increase margins of profitability, and obstetrics is not seen as a revenue generator in healthcare—unlike the NICUs, [which] generates a lot of income,” Morton said.
In 1965, the U.S. federal government established Medicaid to improve health coverage for low-income people in all fifty states and U.S territories. The program plays a critical role in rural areas where families may not have jobs that provide healthcare or are underinsured, making it difficult to cover the care they need. While Medicaid is a vital resource for many women and families in rural areas, it does not pay or reimburse hospitals or clinics as much as private insurance does. The program is additionally limited because it was unequally expanded under the Affordable Care Act (ACA), which provided states the option to expand Medicaid coverage to childless adults and people who originally earned too much to qualify for Medicaid in the past. Due to a Supreme Court ruling in 2012, not all states are required to expand Medicaid, because of the increase in cost to cover a larger group of people. Now, the security of even having insurance may be taken away from many rural families. Legislation passed in 2022 that allocated billions of dollars to Medicaid expansion, in return for limiting states from dropping people from Medicaid rolls, will end next year.
When speaking to The Politic Usha Ranji, associate director for Women’s Health Policy at KFF, explained, “one thing I hear from clinicians is that patient volume is really important for maintaining high quality care. In some communities, particularly the most rural communities, populations tend to be small. So it can be really hard to maintain the volume that you need to really maintain high quality, good clinical care.”
The more practice a physician receives in maternal care, the better they can serve and identify certain needs of women in these rural communities who already face so many risks. In 2016, the University of Wisconsin opened the nation’s first—and so far only—program for OB-GYN residency in rural areas. Laura McDowell, MD, became the first resident to graduate from the program, in 2021. She explained to NBC News in an interview that she was inspired to enter the program because of her desire to combat inadequacies in rural healthcare. “Women shouldn’t have to think twice about getting good quality health care in their small rural town,” McDowell said.
McDowell’s work is a part of a movement to boost recruitment of doctors to rural areas, especially as hospitals around the country struggle with staffing shortages. Since 2020, one in five healthcare workers have quit their jobs, while 47% of healthcare workers plan to leave their jobs by 2025. “One strategy we are starting to see is more federal dollars going towards supporting more training of healthcare professionals in rural areas,” said Ranji. It can be hard to draw people there, but if you start building the workforce from people who already live in these communities, then they are more likely to stay.” To address the staffing shortages afflicting hospitals in rural areas requires the effective reallocation of healthcare funds, in order to pay physicians more and stop punishing patients for being low-income.
“The implementation is the fight.”
The struggles in maternal healthcare extend to the healthcare mothers receive—or do not receive—after giving birth. Postpartum, or what is sometimes considered “the fourth trimester,” is a vital time for mothers to receive care. The recent rise in postpartum depression and suicidality makes postpartum care especially crucial.
The ACOG advises expecting mothers to meet with their obstetrician several times during a period of 12 weeks after giving birth. However, many of these women living in rural areas likely will not have adequate postpartum care for more than sixty days, in states that have not adopted Medicaid expansion under ACA.
Sarah Benatar is a principal research associate for the Urban Institute who emphasized long-term maternal care in an interview with The Politic. “A lot of the issues we observe in terms of the care [received by] pregnant individuals, especially low-income pregnant people, is really just [lack of] continuous care and other structural barriers to being as healthy as you possibly can be,” Benatar said. “We can’t really expect that just nine months of care is going to solve everybody’s problems.”
There has been some progress on this front, though. President Biden’s American Rescue Plan Act of 2021 provided financial incentives to expand Medicaid and postpartum coverage to one year. While this expanded option initially went through just 2027, it was made permanent in Congress’s Consolidated Appropriations Act of 2023. “In the past several years, the Biden administration has really invested in maternal health, equity issues, and disparity issues,” said Dr. Hung.
While there are many policy solutions to solving maternal healthcare deserts in rural areas, women need access to resources now, and telemedicine may be the most efficient, realistic answer. Telemedicine provides a variety of health-related services through live video, remote patient monitoring, and electronic consultations. These services provide care, education, intervention, and monitoring assistance to patients and clinicians who are long-distance.
Since 2003, the University of Arkansas for Medical Sciences has worked with a community of hospitals through broadband networks to provide services. This was initially in response to the poor health outcomes that have plagued the state for decades. In 2019, Arkansas was ranked number 49 regarding women and infant health outcomes, according to America’s Health Rankings. Arkansas has also expanded use of the 24/7 obstetrical nurse call center model, which utilizes a staff of full-time nurses, patient service coordinators, and appointment center staff to talk with patients and provide guidelines that are evidence-based to support high-risk patients.
There are many initiatives that March of Dimes hosts involving telehealth. “Policy solutions around telehealth can address the limited access to maternity care in the U.S., expanding accessibility and providing more options for healthcare delivery,” Stoneburner said. “The Tech to Save Moms Act will make a difference for families by investing in and promoting telehealth and digital tools that can be used by families in areas of the country with few or no maternity care providers. As a country, we need legislation like the Tech to Save Moms Act so that families do not need to extend themselves to access the high-quality maternity care they need and deserve.”
Telemedicine, especially in predominantly rural states like Arkansas, can be a model for expanding access to more rural counties. But it is not always the most viable option to serve all rural communities—especially when many of them still struggle with internet access.
“The implementation is the fight,” Dr. Robert Bullard noted. Investing in telehealth, expanding Medicaid, and creating more rural OB GYN programs like that at the University of Wisconsin is more vital than ever. There is no single solution to this nation-wide crisis. “We all have a role to play in prioritizing maternal health here in the U.S.,” said Stoneburner. “Everyone can do their part so that all moms and babies have the best possible start, right in their local communities.”