Maternity care deserts in the United States

Maternity care deserts in the United States, also known as maternal care deserts, are counties that lack maternity care resources. The March of Dimes defines a maternity care desert as a county that has no hospitals or birth centers offering obstetric care and no obstetric providers.^[1][2] As of 2020 March of Dimes classified 1095 of 3139 of U.S. counties (34.9%) as maternity care deserts.^[3] Its 2022 report indicated an increase of nearly 2%, with 1119 of 3142 US counties (35.6%) considered maternity care deserts, affecting a population of over 5.6 million women.^[1][4] People living in maternity care deserts may have to travel longer distances to receive care, which is associated with higher costs and a greater risk of pregnancy complications.^[5]

The March of Dimes also classifies counties as having low access to maternal care if the county has one hospital or less offering obstetric care, fewer than 60 obstetric providers per 10,000 births and 10% (or greater) of women have no health insurance.^[1] Counties were classified as moderate access if they met the requirements of having low access to maternity care but the % of women with no insurance was less than 10%. A county with full access to maternity care had two or more hospitals with obstetric care facilities and 60 or more obstetric providers per 10,000 births.^[1]

Maternity care deserts are associated with high maternal mortality rates.^[1][6] Since 2018, there has been a 4% increase in maternity care deserts in the U.S.^[1] In the United States, up to 60,000 women a year experience severe maternal morbidity, life-threatening complications as a result of pregnancy, resulting in up to 700 pregnancy-related deaths annually.^[7][8] Maternal morbidity displays decades-long racial, geographical, and socioeconomic disparities. The United States is one of two countries worldwide that has reported significantly increased maternal mortality since 2000.^[7]

Race plays a role in maternal mortality. In 2021, the maternal mortality rate for Black women was 69.9 deaths per 100,000 live births.^[9] This is 2.6 times the rate for White women.^[1] Approximately 1 in 6 Black infants were born in maternity care deserts and 1 in 4 Native American babies were born in maternity care deserts.^[1] Women who identify as American Indian or Alaska Native (AIAN) form 2.2% of the population of women in the U.S.,^[10] and around 13% of them gave birth in maternity care deserts.^[11][2] They are more likely to experience negative outcomes including pre-term delivery, infant mortality, maternal morbidity, and maternal mortality.^[12][1]

Two in three maternity care deserts are in rural counties.^[11][1] Since 2004, rural communities in America have seen a decrease in obstetric services in hospitals.^[13] Between 2004 and 2016 obstetric services have decreased from 54% to 45%.^[14] Rural areas have a higher number of people on Medicaid and because Medicaid covers less than private insurance for childbirth, rural hospitals are unable to support obstetric care fiscally or through necessary staffing.^[13] When care units shut down, the healthcare workers who are able to provide maternity care might leave the area, potentially creating a new desert.^[13]

The overturning of Roe v. Wade and changing abortion policy has led to a decrease in access to abortion care across the United States.^[15] 3.7 million women (about 5.8% of all women of reproductive age) live in both a maternity care desert and somewhere that has no access to abortion services.^[16] States and counties with abortion restrictions have fewer maternity care providers, with a 32% lower ratio of obstetricians and a 59% lower ratio of certified nurse midwives compared to states with abortion access. This disparity has increased the prevalence of maternity care deserts in recent years.^[17]

Since 1991, the United States government has passed policies to reduce infant and maternal mortality through programs including Healthy Start. Healthy Start was first funded by President George H. W. Bush under Section 301 of the Public Health Services Act. It was further authorized by Congress under the Children's Health Act of 2000, signed by President Clinton, which funded prenatal care and support for children and mothers through early childhood).^[13][18]

In 2020, the Division of Reproductive Health of the Centers for Disease Control and Prevention (CDC) launched a national "Hear Her" campaign called to raise awareness of danger signs during and following pregnancy and to improve communication between pregnant or postpartum people, support systems, and health care providers.^[19][20]

Federally Qualified Health Centers (FQHC) receive federal money through the Department of Health Resources and Services and provide care for underserved populations or areas.^[21] FQHCs fill maternity care gaps by providing reimbursements through Medicaid, which helps providers receive reimbursement for their services.^[1] In Houston, one FQHC that provided maternity care increased the number of women who received prenatal care by 44%.^[22] The Affordable Care Act increased funding for FQHCs between 2011 and 2015.^[23] As of December 2021, 48% of rural counties did not have any FQHC. Urban counties had an average of 3.5 FQHCs per county while rural counties had an average of 1. Half of the counties with no FQHC were also classified as maternity care deserts.^[1] Increasing FQHCs can improve maternity care deserts.^[24]

Doulas:A doula is a trained maternal support professional who offers emotional, informational and/or psycho-social care during pregnancy, childbirth and/or the postpartum periods. Doulas do not replace but complement the role of clinicians (physicians, midwives and nurses).^[25] They provide culturally competent care and have been shown in multiple studies to decrease cesarean sections. Doula care has also been show to reduce the rate of postpartum depression and postpartum anxiety. Continuous support during labor may reduce rate of low 5 minute Apgar scores. Doulas may be a useful tool in decreasing disparities^[26] As of August 2022, six states were reimbursing doula services on Medicaid plans^[27] and 32 states had proposed legislative efforts to provide doula services or Medicaid reimbursements.^[28] There is evidence that this reduction in cesarean rates and improved outcomes may be a cost savings for state Medicaid programs.^[29] In order to increase the number of midwives, policy makers have invested in midwifery training programs to make the field more accessible.^[30]

Telehealth has been shown to improve obstetric care and early abortion care.^[31] Telehealth can be a partial solution to providing care for women in rural areas with a lack of access to care nearby.^[32] Telehealth access also overlaps with broadband access as the biggest barrier to telehealth care is internet access.^[33]

Medicaid expansion is associated with lower maternal mortality, with 6-7 out of 100,000 fewer maternal deaths than states with no Medicaid expansion.^[34] The evidence suggests that long-term coverage before and after pregnancy can reduce rates of maternal mortality.^[35] As of 2023, 41 states have passed amendments that extend Medicaid coverage for 12 months, with 5 states planning on expanding access and two states providing limited expansion. This was originally introduced through an improvision through the American Rescue Plan. The option was made permanent by the Consolidated Appropriations Act 2023.^[36]

Maternal health care has received more legislative attention since the end of Roe v. Wade. The Biden Harris administration has included the phrase "Maternity care deserts" in their blueprint to tackle maternal health in America.^[37] In September 2023 the U.S. Department of Health and Human Services announced 90 million dollars in funding to support the plan for tackling maternal care in America.^[38]

46.5% of counties in Texas are maternity care deserts and 4.6% of women in Texas do not have birthing centers within 30 minutes from themselves. 66% of counties in Texas report high rates of chronic health conditions and preterm births, which can worsen maternal health outcomes.^[43]

20.4% of women in Texas have inadequate prenatal care compared to 14.8% for the US as a whole.^[43] Socioeconomics also impacts prenatal care in Texas. BIPOC women who live in areas with high socioeconomic vulnerability have a 44% increased likelihood of inadequate socioeconomic vulnerability compared to areas with low socioeconomic vulnerability.^[43]

Based on the CDC initiative, the Texas Department of State Health Services (DSHS) started its own Hear Her campaign of education and resources to help people recognize urgent maternal warning signs and know when they need to seek help. The campaign also encourages doctors and medical providers to listen to women.^[44][45][46]

The United States Health Resources and Services Administration funds the Rural Maternity and Obstetrics Management Strategies (RMOMS) Program In September 2019. RMOMS provides funds to programs that build networks to coordinate continuum of care and use telehealth and specialty care in areas that need it the most. From 2019 to 2020 the Texas RMOMS Comprehensive Maternal Care Network (TX-RMOMS) served 1,644 women and delivered 1,230 babies.^[47]

The Texas Presumptive eligibility program allows hospitals to determine if individuals need short term Medicaid. Pregnant women can qualify for both prenatal care and care during pregnancy depending on the hospital's approval.^[48] In 2024 there will be a new March of Dimes "Mom & Baby Mobile Health Center" in Houston due to funding from Blue Cross and Blue Shield of Texas.^[49]

In Massachusetts, 100% of counties are full access. 4.6% of people had no birthing hospital within 30 minutes. There is an overall low vulnerability to adverse outcomes due to the availability of reproductive health services.^{[citation needed]}

9.7% of people received no or inadequate prenatal care.^[50]

As of December 8, 2023 Masshealth (Medicaid) announced a new benefit of allowing coverage of doula services for pregnant, birthing and post partum members.^[51]