In his 40 years as an obstetrician-gynecologist, Carl Smith has delivered thousands of babies in the Midwest. Smith works at the University of Nebraska Medical Center and says many childbearing women in the state have to travel dozens of miles just to see their provider.
“We have a large number of areas that don't provide maternity care any longer, because of the size of the hospitals and the low volume of patients that deliver in some of our rural areas,” Smith told Yahoo News.
Since maternal care is limited, he said, most women rely on family physicians for obstetric care. “And many of those patients end up having to travel several miles in order to see their local provider and several miles in order to deliver in a hospital that continues to do obstetrics.”
“We go as far as 200 miles to the west of us to provide on-site consultative care for obstetrician-gynecologists who are caring for patients locally,” he added.
Over 36% of counties across the United States are in the same predicament and fully lack access or have very limited access to maternal care, according to a 2022 study from March of Dimes, a nonprofit organization that advocates for the health of women and babies.
The study found that nearly 7 million women nationwide live in areas where there is minimal or no access to maternal care. “We have coined this term 'maternity care desert' as a way of describing a county that has no hospital that offers obstetric services, no other obstetric provider, like an ob-gyn or midwife, and no birthing center,” Stacey Stewart, president of March of Dimes, told Yahoo News.
In this year's report, the nonprofit found a 2% increase in the number of counties that are considered maternity care deserts, compared with a study completed in 2020. “That’s [an additional] 1,119 counties and an additional 15,933 women with no maternity care,” the 2022 study stated.
The lack of access puts the health of childbearing women and their children at risk, Stewart said. “Women are having to travel in a rural area 50, 60, 70 miles just to get to the nearest obstetric provider to deliver a baby or go to a pregnant prenatal visit.”
“The lack of access is a huge contributing factor to why so many women die or come close to death as a result of pregnancy, or why so many babies don't make it to their first birthday in this country,” she added.
Of all highly industrialized countries worldwide, the United States is considered to be the one where it is the most dangerous to give birth. “In every other highly industrialized country, what we find is that those countries do a much better job of attending to women's health overall,” Stewart said.
Two women die every day from complications of pregnancy and childbirth, yet over 80% of those pregnancy-related deaths are preventable, according to the Centers for Disease Control and Prevention. The CDC found that the leading causes of pregnancy-related deaths are mental health conditions, excessive bleeding, cardiac conditions, infection, blood clots and high blood pressure.
But the gaps in access to care are a major concern too. “It is very harmful, because anytime you introduce distance as a variable for receiving care, it tends to decrease the number of encounters and visits that patients will have,” Brock Slabach, chief operations officer of the National Rural Health Association, told Yahoo News.
Rural areas make up the most maternity care deserts in the country. In 2019, 47 hospitals closed across the country, double the number that closed in 2018. “We know that hospital closures and just many providers not choosing to locate in many rural areas — or moving out of rural areas — has been a big challenge,” Stewart said.
But that's not the only problem. Rural hospitals also can’t keep up with the financial burdens. “Rural hospitals have lower volumes by definition because they are small,” Slabach said. “These low-volume obstetrical units have higher per-unit costs. And so when you start to look at these unit costs being extremely high, reimbursements just aren't enough to cover it.”
Peiyin Hung, the deputy director of the South Carolina Rural and Minority Health Research Center, found that most rural hospitals rely on Medicaid insurance and reimbursements. Hung said Medicaid pays, on average, half of what private insurance pays.
“We know that a lot of women of color, they rely on Medicaid when they seek pregnancy care,” Hung said. He said rural hospitals located in communities with a higher proportion of African American women of reproductive age are more likely to close their labor units.
Hung added, “A lot of rural hospitals are still at risk of OB [obstetrics] closures, because they are operating in the red, and they are facing a lot of difficulties to recruit new OB providers. And a lot of those existing OB providers in those communities are about to retire. So we see a lot of red flags here.”
Medicaid, which covers about 40% of all births, Slabach said, is “the single largest purchaser of obstetric services in the United States. But unfortunately, Medicaid is a federal-state partnership. So all of the policies related to payment and delivery of services through Medicaid are state-organized and state-controlled.”
As the number of maternity care deserts increases nationwide, advocates are calling for change to protect the maternal care of women. March of Dimes is pushing for action on the national level.
“We're heading into the midterm elections,” Stewart said. “This is an important time for people, if they care about these issues, to actually elect policymakers, both Republican and Democrat, who will take action around these issues.”