Maternity Care Deserts: Key Drivers of the National Maternal Health Crisis

• Health Policy
• Maternal Health
• Maternity Care Desert

On June 24, 2022, in the wake of its first-ever Maternal Health Day of Action, the White House released a strategic national action plan proposal titled “White House Blueprint for Addressing the Maternal Health Crisis.”¹ The brainchild of Vice President Kamala D. Harris, the “Blueprint” outlines a sustained multi-year effort by several governmental agencies to address the national maternal health crisis as well as the racial, ethnic, and rural challenges thereof.¹ The “Blueprint” makes special mention of the adverse impact of “maternal care deserts” which it defines as “counties without hospitals providing obstetric care, freestanding birth centers, or even any individual obstetric providers, including obstetricians or licensed midwives.”¹ Note is also being made of the reality that “women who live in rural America - where there are many maternal care deserts - are about 60% more likely to die.”¹ The aforementioned concerns were recently reinforced and expanded on by a newly released March of Dimes (MOD) report titled Where You Live Matters: Maternity Care Deserts and the Crisis of Access and Equity.² It is the objective of this Commentary to delineate the role of maternity care deserts in the national maternal health crisis as well as explore the requisite federal and state actions for the potential remediation thereof.

Recently released data by the Division of Vital Statistics of the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC) are consistent with the view that the United States is in the throes of a maternal health crisis.³ In a summary of calendar year 2022, the most recent year for which data were available, the CDC reports that a total of “817 women died of maternal causes in the United States compared with 1205 in 2021 [and] 861 in 2020.”³ Stated differently, the maternal mortality rate for 2022 was 22.3 deaths per 100,000 live births, compared with a rate of 32.9 in 2021 and 23.8 in 2020.³ Note was also made of the fact that while the maternal mortality rates in 2022 for all categories improved compared with 2021, the rate for Black women (49.5 deaths per 100,000 live births) was still 2.6 times the rate for White women (19.0).³ Other CDC data from 2011 to 2016 (the most recent analysis available) show that, “in the most rural counties (which includes areas with populations of less than 50,000 residents), the maternal mortality ratio was 23.8 deaths per 100,000 live births compared with 14.6 in large metropolitan counties (areas with a population over 1 million).”⁴ Viewed globally, these observations affirm the conclusion that the United States is home to the “highest maternal mortality rate of any high-income nation.⁵ As noted by Vice President Harris, more women die in the United States “before, during and after childbirth… than any other developed nation in our world.”¹ Vice President Harris went on to state that “In the US an average of 2 women die every day from complications of pregnancy and childbirth.”¹

It is against the aforementioned backdrop that maternity care deserts were the subject of recurring reports of the MOD in recent years.² In its most recent report, the MOD designates “36% of all US counties as maternity care deserts…counties where there is a lack of maternity care resources, where there are no hospitals or birth centers offering obstetric care and no obstetric providers.”² The MOD report goes on to state that “low access to appropriate preventive, prenatal and postpartum care is likely to affect those who live in counties with few hospitals or birth centers (1 or fewer) providing obstetric care, few obstetric providers (fewer than 60 per 10,000 births) or a high proportion of women 18 to 64 without health insurance (10% or more).”² All told, the MOD report finds that “2.2 million women of childbearing age live in maternity care deserts” and that “more than 146,000 babies were born in maternity care deserts.”²

The MOD report goes on to state that “2 in 3 maternity care deserts are rural counties (61.5%)” and that “counties with low access to telehealth were 30% more likely to be maternity care deserts.”² “Over 500,000 babies were born to women who reside in rural counties, while only 7% of obstetric providers practice in rural counties.”² Hospital closures have exacerbated the problem: since 2005, 181 rural hospitals have closed across the country; 19 rural hospitals closed in 2020 alone.² Among the explanations cited for closing hospital obstetrics units was the shortage of obstetricians and family physicians. “In addition, 50% of women who live in rural communities, as compared with 7% of women in urban areas, must travel greater than 30 minutes to reach an obstetric hospital.”² In the nature of a summary, the 2022 MOD report notes that the last 2 years witnessed an “increase in counties that are maternity care deserts… that is 1,119 counties and an additional 15,933 women with no maternity care.”²

Though hardly lacking in federal attention, the challenges presented by the maternity care deserts remain unresolved. It was 2019 when an issue brief by the Centers for Medicare & Medicaid Services recommended that “federal, regional, state, local agencies and communities work together to improve access to high quality maternal health services in rural communities.”⁶ Since that time, comparable calls for collaborative action were issued by the Health Resources and Services Administration, the US Commission on Civil Rights, the Assistant Secretary for Planning and Evaluation, and the Medicaid and CHIP Payment and Access Commission. The clearest articulation yet of the challenges of rural obstetric care was afforded by the Government Accountability Office (GAO) in its study titled Availability of Hospital-Based Obstetric Care in Rural Areas.⁷ As noted by the GAO, the 2 most important factors in “affecting the availability of obstetric care in rural areas” were Medicaid reimbursement rates and the challenge of recruiting and retaining providers.⁷ It is against this backdrop that the GAO recommended increasing Medicaid reimbursement, increasing remote consultations through videoconferencing or phone calls, and establishing regional partnerships with a larger hospital for care coordination and for the provision of training and other resources.⁷

Congressional interest in maternity care deserts was recently restated during the 117^th Congress (2021 to 2022) in connection with the introduction of the bipartisan BABIES Act (Birth Access Benefiting Improved Essential Facility Services Act) [S.1716/H.R.3337]. According to the bill’s cosponsor, Katherine D. Clark (D-MA-5), the bill was meant to expand access to birth centers and midwives for Medicaid.⁸ More of the same transpired during the 118^th Congress (2023 to 2024) in the course of which reference was made to maternity care deserts in 3 bills which remain unenacted at this time. Midwives for MOMs Act of 2023 [S1851/H.R.3768], intent on increasing the “number of trained midwives in the United States,” was referred to the Senate Committee on Health, Education, Labor, and Pensions and to the House Subcommittee on Health, Energy, and Commerce. A similar path was followed by the Perinatal Workforce Act [S.1710/H.R.3523] which seeks to fund programs that will see to the growth and diversity of the maternal health clinical and nonclinical workforce. Improving Access to Maternal Health for Military and Dependent Moms Act of 2024 [S.3722/H.R.7214] would require the Secretary of Defense to report to Congress on access to maternal health care within the military health system for covered individuals, including identifying DOD medical facilities located in a maternity care desert. The bill has been referred to the respective Armed Services Committees in the House and Senate.

Redress of the challenges presented by the maternity care deserts is bound to be multifactorial. Absent relevant federal legislation, most of the requisite corrective measures would have to be state- based. Significant relief could be derived from the liberalization of current state Medicaid policies inclusive of the extension of the Medicaid postpartum coverage period from 2 to 12 months.² Further relief could be derived from the establishment of birthing centers and from enhanced access to certified nurse midwives and doulas.² Concurrently, every effort should be made to advance telehealth maternal health services and perinatal regionalization.² Substantial relief could also be derived from the establishment of new Federally Qualified Health Centers (FQHCs) since over half (50.7%) of the counties that constitute maternity care deserts lack a FQHC at this time.²

There also is an opportunity for family physicians to help fill the gap in providing much needed care in maternity care deserts. “While nearly 40% of counties in the US do not have an obstetrician or CNM [Certified Nurse Midwife], only 6.5% of counties (204) do not have a family physician.”² “In rural areas the likelihood of a delivery by a family physician is increased and often these may be supported virtually by specialists in urban areas. Although 23% of newly graduated family physicians report an interest in providing maternity care, only 8% are currently providing these services.”²

Assuming successful implementation, the aforementioned interventional options stand to curtail the adverse impact of maternity care deserts and thereby the national maternal mortality rate.

• Received for publication May 19, 2024.
• Revision received August 1, 2024.
• Accepted for publication August 5, 2024.