Maternity Care Deserts

Summary:

“Maternity Care Deserts” isn’t just a catchy phrase; it’s a distressing reality many across our nation face, revealing areas starved of vital obstetrical services. The lack of these services nearby means countless mothers-to-be struggle to access routine care during pregnancy, labor, delivery, and the postpartum period, which are all key to ensuring the health and well-being of both mother and child.

Regrettably, the U.S. is grappling with rising maternal mortality rates, with access to care being one of the contributing factors. The growing trend of labor and delivery ward closures across the country is cause for urgent concern. We need to address this issue to ensure the safety and health of mothers and babies, no matter where they call home.

Your home address or zip code should never dictate the fate of your pregnancy, but for some, it does.

Definition:

Maternity care deserts are geographic areas where access to maternity health services is limited or nonexistent. These deserts can be found in both urban and rural areas, though they are most prevalent in rural areas due to fewer healthcare facilities and providers.

The term is derived from the concept of a “food desert”, which is used to describe areas where access to fresh, healthy food is limited. Similarly, a maternity care desert is an area where access to necessary healthcare for pregnant women is scarce or non-existent, which can lead to serious health complications for both mother and baby.

Impact in one picture:

Maternity Care Desert was defined by March of Dimes as any county without a hospital or birth center offering obstetric care and without any obstetric providers.

Image credit March of Dimes, definitions in the legend.

• More than 2.2 million women of childbearing age live in maternity care deserts (1,119 counties) that have no hospital offering obstetric care, no birth center and no obstetric provider.
• Almost 150,000 babies were born in maternity care deserts.
• An additional 4.7 million women of childbearing age live in counties with limited access to maternity care.
  

Why it Matters:

The beauty of most pregnancies lies in their typical course, which generally unfolds without complications, leading to healthy outcomes for both mother and child. The smoothness of this journey hinges on the availability of quality prenatal care and access to providers and birthing centers that are capable of interventions when needed both in non-emergent and emergent situations.

👉🏽Who needs added stress? Living far from or without access to essential maternity care services can be incredibly stressful for expectant mothers and families. Imagine the constant worry, knowing that routine prenatal check-ups, emergency care, and even your delivery require long-distance travel, planning, and additional expenses. This stress can take a toll not just on the mother’s physical health, but also on her mental and emotional well-being, potentially impacting the course of her pregnancy and the health of the newborn. It’s a strain that no expectant family should have to bear.

👉🏽With the rise of chronic preventable diseases at their highest levels, our population’s health is deteriorating. Rather than seeing our healthcare facilities, especially maternity wards, shrinking in number, we should be working towards expanding and enhancing these critical services. It’s a stark contradiction that as our healthcare demands increase, the resources to meet them are dwindling.

👉🏽When expectant mothers are denied these essentials of obstetrical care, the risk of poor outcomes increases for both mother and baby. Complications may arise at any stage of the journey. As a obstetrician, I’ve watched everything go well until it doesn’t. Within minutes we can go from safe and normal to dangerous and life-threatening.

👉🏽It’s not only the mother who is impacted. The lack of proper maternity care exposes newborns to adverse outcomes, including higher rates of preterm delivery and low birth weight. High-risk infants, in particular, face a heightened risk of mortality if they are not delivered in a facility capable of providing the necessary level of care and they face long-term complications that can follow them for a lifetime.

👉🏽The escalation of maternity care deserts is not solely a rural problem, it’s a nationwide crisis. When rural hospitals close their maternity wards, these patients don’t simply disappear. They find care in the cities. This influx stresses urban healthcare systems, filling maternity wards to capacity, overburdening staff, and straining resources. Our city hospitals are at capacity.

Recent Closures Across the Nation:

What caught my attention was a Becker Hospital Review outlining closure of hospital services. Since 2011, around 200 maternity wards have shut their doors. However, the recent surge in closures is particularly concerning. Citing data from the Becker Hospital Review of June 30, 2023, an alarming 19 additional hospitals are poised to discontinue their maternity services. 19 closures since February, 2023. All citied various reasons but most common were financial constraints, provider shortages, and declining birth rates.

If you want to go deeper and see if your state has any closures, click on the link.

Recent Maternity Ward Closures

Why is this happening?

Provider Shortages: Obstetrician-gynecologists (OBGYNs) specialize in women’s health, pregnancy, and childbirth, while Family Practice physicians can provide a wide spectrum of care, including prenatal and delivery services, especially in rural areas or places with a shortage of OBGYNs. Midwives, too, play an essential role, providing personalized care during pregnancy, labor, birth, and the postpartum period. OBGYNs are the only ones who can perform cesarean sections. There is a new specialty forming called “FMOB” who are Family Practice doctors who train further to learn cesarean sections. I have also seen in rural areas where a surgeon and Family Practice doctor will work together during a cesarean section. There is a significant shortage of maternity care providers, particularly OBGYNs and midwives, especially in rural areas. The reasons vary including geography and compensation models.

Money Shortages: Maintaining a labor and delivery ward is expensive. Delivery in most circumstances is straightforward and without complications. However, when complications arise, they can escalate within minutes. You need someone immediately when an emergency happens. And I’m not just talking about a cesarean section. Postpartum hemorrhage (PPH) is the number one cause of death in women aged 15-44 worldwide. Bleeding after delivery is an emergency. Pregnancy care and childbirth services can be expensive to maintain, especially in smaller, rural hospitals that see fewer patients. Financially, these smaller hospitals can’t afford an OBGYN, nurses, anesthesiologist, baby nurses and team, and the list goes on. It makes financial sense to close their doors.

Insurance Coverage Shortages: Many people, unfortunately, are either uninsured or underinsured, leaving them with little to no access to necessary prenatal care. This issue is further compounded by the varying insurance regulations in each state, which can create inconsistencies in coverage.

In rural America, where maternity care deserts are more prevalent, this problem is especially acute. Approximately 40% of women rely on government insurance, which typically reimburses hospitals and clinics at lower rates. This financial dynamic can deter healthcare providers from accepting such insurance, thereby limiting access to essential prenatal and maternity services for a significant portion of the population. It’s a cycle that continues to exacerbate health disparities and the maternity care crisis. This is especially true in states that have not expanded Medicaid coverage.

Pregnant Lady Shortages: There are fewer people having babies. The gradual decrease in the number of births, marked by a 1% annual decline from 2014 to 2019 and an even steeper 2% per year from 2007 to 2013, underscores a continuing trend. The significant drop of 4% between 2019 and 2020 was then followed by a modest increase of 1% from 2020 to 2021. However, even with this slight uptick, the overall trend continues to point downwards.

Taken from CDC 2023 report

Now what?

Stop closing maternity wards! I wish it were that simple. Here are some real-life solutions.

1. Preconception care. Raising public awareness about the importance of preconception health, and ensuring access to preconception care, can help women enter pregnancy in the best possible health, thereby increasing the chances of healthy pregnancy outcomes. Public health campaigns, community outreach programs, and integrating preconception care into routine healthcare can all play significant roles in achieving this goal. This can be done with general practitioners including nutritionists and coaches. If I had all the power in the world, I tell women to take 6 months to get as healthy as possible before getting pregnant. This would help decrease the number of women getting diabetes and high blood pressure of pregnancy, both issues that are on a steep upward climb.
2. Leverage technology. Technology allows instant access to providers and healthcare professionals. Telemedicine can be a viable option for routine check-ups and monitoring, reducing the need for long travel distances. We just need to shift our mind-set; not all appointments need to be in person. All pregnant women should be given a blood pressure cuff. This one intervention will save so much time, travel, and money.
3. Improve Health Insurance Coverage: Wider and more comprehensive coverage for prenatal and maternity care, especially for those who are underinsured or uninsured need to be addressed. I don’t pretend to understand how the government works, but it would seem to me that providing prenatal care is in everyone’s interest.
4. Encourage Practice in Rural Areas: Incentives can be given to medical professionals to practice in rural or underserved areas. These incentives could include loan forgiveness, scholarships, or higher payment rates for treating patients in rural areas.
5. Strengthen Midwifery and Doula Services: Midwives and doulas can play a vital role in prenatal and postnatal care, particularly in rural or underserved communities. Policies can be created to better integrate these services into the healthcare system. Insurance companies should help pay for these services.
   

The Final Word 🔄

When I was in medical school, there was a huge push to get doctors to practice in rural areas. There was loan forgiveness, better paychecks, and a feeling of a higher purpose. The Rural Physician Associate Program (RPAP) is a nine-month, community-based educational experience for University of Minnesota third-year medical students who live and train in rural communities across Minnesota and western Wisconsin. I was too young and dumb to understand why this was being asked of us and the importance of care in rural America. I understand now.

This is not a problem confined to small-town America; it’s a problem knocking on the door of every city. Every person, regardless of their location, should be concerned about this issue. Your proximity to a hospital does not guarantee your access to care if that hospital is overwhelmed with patients. Your home address or zip code should never dictate the fate of your pregnancy.

Solutions won’t come easily, but they are essential. Greater investment in rural healthcare, innovative use of telehealth, and reform of insurance practices are just a few of the possible paths forward. It will take concerted effort from healthcare providers, government agencies, communities, and individuals alike to turn the tide.

Do you have any thoughts, experiences, or comments?