Nearly seven million women of childbearing age have low or no access to basic obstetric services in their county of residence, according to the March of Dimes “Maternity Care Deserts Across the U.S.” biannual report.
The long-term decline in maternity services throughout the U.S. has continued this year, specifically in rural settings, which has expanded the number of “maternity deserts.”
A maternity desert is a county without a hospital providing obstetric services or a birthing center, and one in which there is not a licensed obstetrician/gynecologist or a certified nurse midwife in the county.
Today, 36% of U.S. counties meet the definition of a maternity care desert. This means that 2.2 million women of childbearing age are without access to basic obstetric services in their county, and countless others have a minimum level of services.
Unfortunately, this is nothing new. The trend goes back decades and is linked to the closing of rural health services.
A 2017 study published in Health Affairs revealed that 9% of rural counties lost hospital obstetric services between 2004 and 2014, leaving almost half of rural counties without services. As a result, women must travel 45 minutes or more to access these basic health care services, including the delivery of a child.
We are also seeing a tremendous rise in maternal mortality rates across the U.S.
In 2020, 861 women died due to pregnancy-related issues (up from 752 in 2019), according to the Centers for Disease Control and Prevention. In addition, around 50,000 women experience significant pregnancy-related complications or morbidity each year, according to the National Institutes of Health.
In 1987, the Centers for Disease Control and Prevention initiated its Pregnancy Mortality Surveillance System. The program initially found that there were 7.2 pregnancy-related deaths per 100,000 live births every year. In 2017, that rose to 17.2, and by 2020 it was 23.8.
Currently, according to the latest CDC data, the maternal mortality rate among Black women is 55.3 per 100,000 live births, compared to 19.1 among white women and 18.2 among Hispanic women.
The leading causes of pregnancy-related deaths are cardiovascular conditions, infection, cardiomyopathy and blood loss. None of these are typically racial factors for young pregnant women.
Pregnancy-related deaths are on the rise for Black, white and Hispanic mothers. The Black community is paying the highest price for the lack of maternal health care, but the impact extends to all demographics and the problem is three-fold.
First, we are doing a poor job of caring for pregnant women in this country. The MOD report illustrates this problem. A growing number of rural and poor communities are struggling to maintain access to essential services for women.
Second, 50% of births in the U.S. are paid for by Medicaid. Poor, rural states like Arkansas (67% of all births), Louisiana (65%) and Mississippi (64%) are the most dependent on the program.
Unfortunately, Medicaid does not pay as well as commercial insurance. For example, in 2013, the average employer-based insurance company paid on average $18,329 for maternal and newborn care, while Medicaid only paid $9,131. In some states, the Medicaid reimbursement rate is less than the actual cost of the care, leaving hospitals to cover the difference.
Therefore, to stay solvent, many hospitals align themselves in order to have a higher percentage of commercially insured patients or they initiate cost-saving measures. This encourages the consolidation of services in larger centers in order to offset overhead and/or the closing of smaller centers that cannot financially sustain themselves.
While it is another topic for another day, many rural communities only have access to a faith-based hospital, which can decline to provide certain treatments – including family planning services. It is a catch 22 in which we need faith-based (often Catholic) health care systems to bail out small, rural hospitals, but many are concerned with added control to reproductive rights.
In the end, rural and poor communities are left in the cold, with minorities bearing the brunt.
Third, the lack of obstetric services negatively impacts prenatal care, and the majority of maternal deaths are preventable through quality prenatal care. The MOD report is a barometer of the problem.
Lack of facilities and services translates into infant and maternal deaths and morbidity. Therefore, we need to start by looking at how we fund the full spectrum of maternal care from pre-conception to six months after delivery.
Hospitals need to step up and be willing to provide services in difficult places, but they also need to be able to at least break even. Otherwise, they won’t be able to buy supplies, rent equipment, pay the nurses and keep the lights on.
Next, we need to push public officials to develop strategies to provide grants to hospitals in remote locations to enable them to continue operating. Laboring mothers, heart attack victims and trauma patients should not have to drive hours to get to health care providers.
Finally, local communities need to conduct strategic surveys designed to identify obstacles to access. Do mothers need transportation? Are they concerned about cost? Is culture and language getting in the way of access? Might there be trust issues between the at-risk demographics and providers?
Our current system is shameful. We are functionally telling millions of women and babies that there is no room in the inn.
Senior Staff Chaplain and Clinical Ethicist at the Baptist Health Medical Center in Little Rock, Arkansas.