Lost In The Maternity Care Desert: The Worsening Crisis In Rural Obstetrics Care

The U.S. has long lagged behind other developed nations in a range of critical health outcomes, including infant mortality. But the maternity care disparities for rural American women—particularly those of color—are especially acute.

The often-overlooked crisis of rural obstetrics disparities stems from the ongoing attrition of rural maternity care clinicians and capacity, a trend that has fueled an expanding matrix of maternity care deserts across a third of the United States. 

What are maternity care deserts?

The term ‘maternity care desert’ refers to counties with no hospital staff trained to provide care for pregnant women and no specialists or certified nurse midwifes to deliver babies. 

More than a thousand such counties—about one-third of the U.S. total—now exist, primarily in the South, Great Plains, and Inter-Mountain West. Approximately 7 million women of child-bearing age live in maternity care deserts and roughly half-a-million babies are born there annually, accounting for 1-in-8 American childbirths. 

Predictably, the absence of readily accessible rural maternity care, combined with high rates of social determinants of health that can further compromise pregnancy and childbirth, lead to significantly higher risks for complications and death among rural mothers and babies.

Economics, demographics reducing access to rural maternity care

Multiple factors are driving the rural maternity care crisis. Chief among these has been the ongoing closure of rural hospitals and obstetrics units. Between 2005 and 2021, approximately 170 rural hospitals closed nationwide, including 19 during 2020, the first year of pandemic. Another 600—30% of all rural facilities—are at risk of closure in the near future. Many rural hospitals that have remained open shuttered their obstetrics capabilities during the first two decades of the century. 

High rates of uninsured patients, large amounts of uncompensated care, and inadequate commercial and government payer reimbursements have been identified as the primary causes of rural hospital closures. At the same time, the rising costs of fully staffing obstetric units, including providing anesthesia and nursing coverage, difficulties attracting clinicians to rural areas, and reduced demand due to an aging, shrinking population, all have combined to make it increasingly untenable to sustain rural maternity care.

Fewer family doctors providing rural obstetrics care 

Michael Kennedy, MD, AAFP, a professor emeritus in the Department of Family Medicine and Community Health at the University of Kansas School of Medicine and former Associate Dean for Rural Health Education, says the maternity care desert predicament has been exacerbated by fewer numbers of family physicians stepping up to provide obstetrical services.

“Family doctors in rural areas traditionally were expected to include obstetric care in their practice,” he said. “But that’s changed. Twenty-five or 30 years ago, about 30% of family docs nationwide were doing deliveries. Now it’s down to 6-to-9%.”

Malpractice premiums that are twice as high for family physicians providing obstetrics care versus those that do not have been a major factor in the decline, he said. Significantly, however, evidence indicates the higher rates aren’t driven by a greater incidence of adverse outcomes among family doctors, but simply reflect the inherent risks and litigious environment surrounding obstetric care.

And while routine delivery and C-section competency are well-established components of family medicine training and must be maintained through ongoing certification, declining delivery volume necessarily translates into less real-world experience. Over time, this can contribute to a physician’s decision to step away from obstetrics care. Finally, the rate of retiring baby boomer family docs has outpaced the number of new rural physicians coming into the field.

Kennedy, who himself practiced medicine in rural Kansas for a decade and delivered about 30 babies a year, says the shortage tends to feed on itself as the number of family doctors falls. Those that remain face ever greater patient loads and call demands and many are compelled to give up obstetrics to preserve a semblance of work-life balance. 

Maternity deserts drive enhanced risks for rural women and babies  

Under the best of circumstances, being pregnant in a maternity desert means driving often-considerable distances for necessary prenatal care, delivery and follow-up. Lengthy travel time necessarily translates into higher risks for missed or foregone appointments, incomplete or non-existent pre- and post-natal care, undetected conditions, delivery complications and ultimately a higher danger of illness and death. Consider the following effects of rural maternity care disparities: 

• Rural maternal mortality was 61% higher in the most rural of counties (those with less than 50,000 residents) when compared to metropolitan areas with more than 1 million residents.
• Infant mortality rates were 20% higher in the most rural counties versus large urban counties.
• Rural mothers have lower rates of prenatal care initiation during the first trimester compared to suburban areas. 
• Rural hospitals report higher rates of postpartum hemorrhage and blood transfusions during labor and delivery than do urban hospitals.
• Across both rural and urban settings, black and American Indian women are three times more likely to die from pregnancy-related causes than white women. 
• About 6% of rural births are pre-term, but only 40% of these births occur in a hospital with a NICU. 
• Rates of non-indicated labor inductions, including caesarean sections (and the complications that can potentially accompany them), rose faster in rural area than urban areas, presumably because rural mothers seek to avoid the risk of going into labor far from a hospital.  

Higher rural maternal care risks tied to social determinants of health 

Compounding the dangers facing rural women are health risks tied to social determinants, including higher levels of smoking, obesity, and, in some areas, heavy alcohol use. Rural women also face an increased danger of death or injury from automobile accidents, given the greater distances they must travel for care. A September, 2021 article published by the Commonwealth Fund raises this case in point: In New Mexico, one in three women who die during pregnancy or in the weeks following childbirth lose their lives in auto accidents (slide 33).

Meeting the rural maternity care challenge 

Like other entrenched health disparities, solutions for stabilizing and ultimately enhancing maternity care access in rural America are complex and necessarily linked to a host of underlying social determinants. Addressing issues like limited rural employment opportunities, poverty, population loss, racial disparities, lack of broadband internet and other factors are essential to a long-term fix. Nonetheless, a wide range of initiatives are underway in support of critical strategies and tactics that can help ease the maternity care desert crisis. Key goals include: 

• Expanding the rural maternity care workforce, using OB/GYNs, family practitioners and midwives
• Increasing maternity care training opportunities for family physicians and incentivizing employment in rural America
• Expanding the scope of practice for nurses and midwives to enable them to provide more services without physician supervision
• Increasing incentive opportunities for providers who deliver OB care and/or participate in maternity care bundle programs in rural areas
• Expanding access to care in addition to reimbursement for telehealth and other digital support services to improve connectivity between clinicians and rural pregnant women. An example might be a nurse line operating 24/7 to answer clinical questions so a determination can be made if travel to care is necessary
• Improving both commercial and government payer reimbursements to rural hospitals generally and for labor and delivery services specifically

Kennedy, the retired Kansas rural medicine educator and former country doctor, says the crisis around rural maternity care has reached a tipping point. 

“It’s a very dangerous situation, and if something isn’t done in the next five years, it may be irreversible and maternity deserts may become expansive,” he said. “There are several initiatives being pursued, but much more needs to be done, especially in the area of ensuring the financial viability of essential rural hospitals. To me, that’s the key.”

Address the health inequities faced by women living in maternity care deserts

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