Access to maternity care is decreasing across the country, leaving nearly seven million women of childbearing age and an estimated 500,000 babies with limited or no access to maternity care services, according to a report released October 11 by the March of Dimes, a nonprofit focused on maternal and infant health.
An estimated 36 percent of counties, mostly in the Midwest and South, are considered “maternity care deserts,” meaning they have no obstetric hospitals or birth centers and no obstetric providers. That’s a 2 percent increase from the 2020 report, which represents 15,933 women in more than 1,000 counties.
The data underscore the fact that the United States is still among the most dangerous developed nations for childbirth, especially in rural areas and communities of color, according to the report. Black and Native American babies were more likely to be born in counties with no obstetrician-gynecologist services or birthing centers compared with white babies.
“With an average of two women dying every day from complications of pregnancy and childbirth and two babies dying every hour, our country is facing a unique and critical moment as the infant and maternal health crisis continues intensifying,” said Stacey D. Stewart, the president and CEO of the March of Dimes, in a press release. “With hospital closures, inflation, and COVID-19 limiting access to care, the compounding issues of our time are bearing down on families, forcing them to extend themselves in new ways to find the care they need and ways to afford it,” she said.
“We know that when birthing people have difficulty accessing care, they have poor pregnancy outcomes,” says Kamilah Dixon, MD, an ob-gyn and an assistant professor of obstetrics and gynecology at the Ohio State University Wexner Medical Center in Columbus, who was not involved in compiling the report. “This report is alarming and important to highlight the challenges that many birthing people face in seeking the healthcare they need,” she says.
Loss of Providers and Obstetrics Care Worsened Access in Many Parts of the U.S.
Key findings from the 2022 report include the following:
- Two million women of childbearing age live in maternity care deserts and more than 146,000 babies are born in one.
- Five percent of counties have a worse designation in this report than in the 2020 report.
- Nearly seven million women are living in communities with no or limited access to maternity care.
- Women in maternity care deserts are more likely to have asthma or high blood pressure and to smoke cigarettes than women in counties with full access to maternity care.
- The loss of obstetric providers and obstetric services in hospitals were responsible for decreases in maternity care access in more than 110 counties between this report and the 2020 report.
“Our 2022 report confirms that lack of access to care is one of the biggest barriers to safe, healthy pregnancies and is especially impacting rural areas and communities of color where families face economic strains in finding care,” said Zsakeba Henderson, MD, the senior vice president and interim chief medical and health officer of March of Dimes, in the release.
Although there has been a slight increase in obstetric providers nationwide, that’s not translating into more providers serving rural areas, said Dr. Henderson. “In fact, only 7 percent of obstetric providers serve rural areas and, with more than 500,000 babies born to women living in these areas, families in rural areas are at higher risk for poor outcomes.”
Native American and Black Babies Are More Likely to Be Born in a Maternity Desert
Overall, one in eight babies were born in a maternity desert, with one in four Native American babies and one in six Black babies born in areas with no or limited access to maternity care services.
“We know that these groups unfortunately experience disproportionate rates of poor pregnancy outcomes, including increased rates of prematurity and maternal mortality,” says Dr. Dixon. “While there are many factors at play in these disparities, access to reliable care is certainly a factor. We also know that structural racism contributes to healthcare disparities, and the maternity deserts are an example of this at play,” she says.
Maternal Deaths in the U.S. Are On the Rise
The number of maternal deaths in 2020 jumped 14 percent from 2019, going from 754 to 861, according to a report from the National Center for Health Statistics (NCHS). All ages and all racial groups had increases in maternal mortality in 2020, though the overall rise was largely driven by Black and Hispanic women.
Black women had the highest maternal mortality rate of the three racial or ethnic groups included in the report, with 55.3 deaths for every 100,000 live births, an increase of 26 percent over the previous year.
Although the report didn’t investigate the reason behind the increase, some experts attributed the rise to COVID-19, and the interruption in care caused by stay-at-home orders during the pandemic is at least partly to blame.
Two-thirds of pregnancy-related deaths in the United States could be prevented, according to the Centers for Disease Control and Prevention (CDC).
Policy Change Could Help Improve Access to Care and Reduce Maternal Mortality
Policy changes are needed to ensure that all people receive the care and support they need before, during, and after pregnancy. The following key opportunities were among the recommendations made by the authors.
Give more people access to Medicaid. If states expanded eligibility for Medicaid to include individuals who fall at or below 138 percent of the Federal Poverty Level (FPL) it may improve the health of people of childbearing age and their children and help reduce racial disparities.
Improving access to Medicaid by raising the income eligibility threshold could also help low-income families access care.
Extend the Medicaid postpartum coverage period. Currently, the federal law limits coverage of postpartum services to 60 days; the report recommends extending that to 12 months. The American Rescue Plan Act of 2021, which began in April 2022, gives states the option to extend postpartum coverage to pregnant people to one full year. But Congress must now take the next step to make 12 months of postpartum coverage mandatory and permanent under all state Medicaid programs, the authors suggest.
Expand access to and improve integration of the midwifery model of care in all states. This can help improve access to equitable and culturally informed maternity care in under-resourced areas, lower costs, reduce unnecessary medical interventions that contribute to risks of maternal mortality and morbidity in initial and subsequent pregnancies, and improve the health of all moms and babies.
The World Health Organization (WHO) recommends midwives as an evidence-based way to reduce maternal mortality. According to a review published in The Lancet, midwifery-led care in women with healthy pregnancies can lead to lower maternal mortality and improved well-being of the mother.
Expand equitable access to doula services through reimbursement and workforce development. Doula support improves birth outcomes and may reduce maternal morbidity and mortality among women of color, wrote the authors. In some states coverage of doula services is provided under private and public insurance programs, including Medicaid, the Children’s Health Insurance Program (CHIP) and TRICARE, and reimbursement payment levels to doulas should be sufficient to support the care provided.
What Should Women of Childbearing Age Do if They Live in a Maternity Desert?
Short of moving to a new town, what’s a woman to do if she is expecting and lives in one of these deserts? That’s a challenging situation, says Dixon.
“I would advise that they work with the nearest healthcare system to see what services are available. Additionally, many can work with their insurance companies to see if there are resources for transportation and other support if they have to travel far distances for visits or delivery. With the growth of telehealth, I can see that this is an area where having access to these technologies can help provide care to birthing people in maternity deserts,” she says.
The March of Dimes also views telehealth as a tool that could improve care for some women. The organization is examining how lack of access to broadband prevents the expansion of telehealth in some rural areas.
At the Ohio State University, an initiative called Community Care Coach is now in place, says Dixon. The program features a mobile unit designed to provide reproductive health services in historically underserved communities as a way to decrease the barriers to care, she says.
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