Report: Over a Third of US Counties Are Maternity Care Deserts

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The US is experiencing a maternity healthcare crisis where pre-term labors and infant and maternal mortality rates are up due to a lack of access to prenatal and postpartum care. 

Many of these women live in areas designated as maternity care deserts. These are areas where pregnant individuals and mothers have limited or nonexistent access to vital prenatal and postpartum health care. 

Maternal care deserts exist in 35% of US counties — encompassing 2.3 million reproductive aged women, according to the March of Dimes’ annual report, Nowhere to Go: Maternity Care Deserts in the US. 

According to the report, living in these areas greatly increases their risk for infant and maternal mortality, pre-term labor, and untreated conditions that could harm the lives of the mother or child. 

Let’s dig into the report’s findings to find out what factors are driving maternity care deserts and explore ways to increase access to maternal healthcare. 

Maternal Health Care Access 

3,142 US counties experience from one or multiple factors – the ratio of obstetric clinicians to births, access to birth facilities, and health insurance – that designate the county as a maternity care desert.  

What’s more, 6 in 10 of these maternity care deserts are in rural areas, which are often home to a larger minority population, such as Latinos. 

Over 150,000 babies (4.1% of all babies) were born to pregnant individuals living in maternity care deserts in 2022, according to the report.  

The states with the most maternity care deserts in the US included, North Dakota (73.6%), South Dakota (57.6%), Oklahoma (51.9%), Missouri (51.6%), Nebraska (51.3%), and Arkansas (50.7%).  

Not only do pregnant individuals have low access to care living in these areas, but they also tend to receive inadequate prenatal care.  

From 2020 to 2022,15.8% (1 in 6) babies were born to individuals living in maternity care deserts and 17.6% (1 in 5) babies in low access counties did not receive adequate care. 

What’s more, 13.8% or 18,000 didn’t receive care at all.  

Pre-Term Birth Rates in Maternity Care Deserts 

Pregnant individuals living in maternity care deserts or in areas with low access to care tend to have a greater risk for preterm labor, which occurs before 37 weeks’ gestation. 

In fact, living in a maternity care desert or low access county can increase the risk for preterm birth by 13% and 11%, respectively.   

Of the pregnant individuals living in counties with no or low access to care between 2020 and 2022, 11% were preterm, compared to 10.2% in full access counties.  

A total of 51,000 preterm babies were born to individuals in maternity care deserts and 65,000 in low and moderate access counties between 2020 and 2022.  

Rates of preterm birth can differ by race. 

From 2020 to 2022, Black individuals experienced preterm birth at a rate of 14.6%.  

For Black individuals in maternity care deserts, there is a 12% higher preterm birth rate than those in full access counties.  

Latinos in maternity care deserts experience preterm births at a rate of 11%, compared to a 10% preterm birth rate for those in full access counties.  

Maternity Healthcare Worker Care Shortage 

Many maternity care deserts are also designated as health professional shortage areas (HPSAs).  

There are 780 US counties considered as HPSAs. 

48.2% of those counties are also maternity care deserts while 23.7% are low access counties and 17.6% are moderate access counties.  

There is a higher concentration of HPSAs in the southern parts of the US in states like Mississippi, Arkansas, Louisiana, Oklahoma, West Virginia, and Kentucky.  

Meanwhile northern states had better marks when it came to behavioral/mental health provider access, fertility, driving distance to a hospital, and availability of obstetric clinicians.   

One of the biggest driving factors fueling the care shortage in the US is the closure of obstetric units. 

“In 2021 and 2022, approximately 1 in 25 (over 100) obstetric units closed nationwide,” according to March of Dimes.  

Closing these obstetric units has had disastrous consequences on the availability of care in the US, compounding the maternity care desert issue.  

Without access to prenatal care from these units, pregnant individuals have suffered delays in emergency treatment and added to hospital overcrowding. 

This was particularly difficult for rural residents who solely rely on hospitals for care and was the reality for 72% of rural hospitals that closed.  

Reasons for closure included “low birth volume, insufficient reimbursement rates from insurance providers, and a shortage of staff such as obstetricians, family physicians, and nurses.” 

In fact, insurance is a huge component for hospital closures. 

In 2022, 41% of births were paid by Medicaid reimbursement, which have much lower rates than private insurance.  

Low reimbursement rates can make it difficult to make money for obstetric services rendered, thus making it hard to retain obstetric units altogether.   

The March of Dimes report suggests that alternative payments models and changes to reimbursement rates could help solve the issue.  

When it comes to obstetric clinician shortages, 47% of US counties lack an OB-GYN and 61.8% don’t have a certified nurse-midwife or certified midwife.  

Rural counties lack obstetric clinicians more than urban counties.  

57.7% of rural counties lack an obstetric clinician, compared to 23.8% of urban counties. Over 36% have no obstetric clinician at all.  

Arkansas (98.1), Oklahoma (101.2), Alabama (102), Mississippi (106.1), and Texas (107.5) were among the states with the lowest number of obstetric clinicians per 10,000 births. 

By 2050, there will be 12,000 to 15,000 fewer OB-GYNs, according to the American College of Obstetricians and Gynecologists (ACOG).  

This is why family physicians are also used for obstetric care, especially in rural counties where 17% of family physicians reported delivering a baby, compared to 6% in urban counties. 

Lastly, nurse-midwives and certified midwives can help close the gap on maternity care in the US.  

The use of midwives has been known to have a positive impact on birth, including higher likelihood of spontaneous vaginal delivery and lower rates of birth interventions like cesarean sections.  

However, some states have prevented certified midwives from being able to lawfully practice and limited practice for certified nurse-midwives, deepening the gap in care in maternity care deserts. 

Maternal Insurance Coverage 

Health insurance for expecting mothers can be a huge barrier to care. 

According to the report, 11.5% of women who are of reproductive age are uninsured.  

The number of uninsured reproductive-aged women was higher in maternity care deserts and low access counties, 15% and 19% respectively, compared to those living in full access counties (11.9%). 

Lack of insurance can cause women seeking obstetric care to delay or forgo care altogether because of healthcare costs, resulting in worse health outcomes for the mother and baby.  

Many expectant mothers take advantage of government-funded healthcare through Medicaid, which helps cover prenatal care and has been recently extended out to provide benefits up to a year postpartum. 

The expansion helps reduce the risk for maternal and infant morbidity and mortality, including postpartum depression — a pervasive problem in the US.    

However, there are many barriers to seeking health insurance through Medicaid. 

While some barriers may be undone with the expansion of Medicaid, there are 10 states, including Texas, Georgia, and Florida, that have yet to expand their offerings.  

What’s more, six of the 10 states that have not expanded Medicaid also have some of the highest rates of uninsured reproductive-aged women in the US.  

The proportion of uninsured reproductive-aged women in states with expanded Medicaid coverage was 9%, compared to 17% in states with no expansion.  

Texas is among the states with the highest uninsured rates among reproductive-aged women with approximately 1 in 4 (23.8%) uninsured.  

Barriers to Maternal Healthcare  

Distance continues to be one of the biggest barriers to maternal healthcare in the US.  

Without access to care nearby, pregnant women are forced to travel longer distances for care. 

This can increase their risk of maternal morbidity, stillbirth, and neonatal intensive care unit (NICU) admission. 

“Over two thirds (64%) of birthing people living in maternity care deserts live more than 30 minutes from a birthing hospital, compared to only 9% of all birthing people in the US,” according to the report. 

The average travel time in the US to get to the nearest birthing hospital is 15.9 minutes by car.  

In urban areas that amount of time drops to 15.3 minutes and increases to 26.2 minutes in rural areas. 

In maternity care deserts the average time is more than double the average at 38 minutes.  

Alaska (39.2 minutes), West Virginia (26.6 minutes), Wyoming (23.3 minutes), Hawaii (22.9 minutes), and Montana (22.6 minutes) are among the states with the longest travel times. 

This is the reality for many expectant mothers receiving care.  

Without access to care nearby, some women could be forced to give birth in a car like Claudia, who lives in Ward County, Texas — a maternity care desert.  

“My second baby was born in the car,” Claudia told March of Dimes. “The third one was almost the same, I barely made it to the hospital.” 

Claudia lives at least 30 minutes away from the nearest hospital with obstetric services.  

Natalia, who lives in Odessa, Texas, was also faced with a long drive to get to the nearest birthing hospital and had a similar fear of giving birth in a car.  

“During an emergency, 30 minutes is a lot of time, especially when you’re pregnant,” Natalia told March of Dimes. 

Long drives can also have other dire consequences. 

Vania, who lives in Colstrip, Montana, lives two hours away from the nearest birthing hospital in Billings.  

When Vania was 29 weeks along, her water unexpectedly broke and she had to be put on bed rest at the hospital for the remainder of her pregnancy. This effectively separated her from her husband and two sons.  

“For the majority of my pregnancies I went to Crow for all of my care. Closer to the birth we were transferred to Billings because there was no other place closer with those services and resources. We had to travel two hours,” she told March of Dimes. 

Maternal Health Conditions 

Where you live may not only determine what kind of healthcare you can receive, but it also may put you at a higher risk for developing adverse health conditions. 

For instance, expectant mothers may have preexisting health conditions, such as diabetes, kidney disease, and hypertension, which could put them at a higher risk for complications and may require more individualized care. 

Expectant mothers in rural areas, especially women of color, that have some of these conditions have a higher likelihood for severe maternal morbidities or medical interventions such as cesarean birth and postpartum hospital readmission.  

“Infants born to women with chronic conditions can also experience adverse birth outcomes, including preterm birth, fetal growth restriction, macrosomia, birth defects, and even death,” the report stated.  

According to the report, one third of all expectant mothers had one or more chronic health conditions prior to pregnancy between 2020 and 2022.  

There are other factors that could impact maternal health based on the non-medical drivers of health , such as housing, access to healthy food, and access to safe active places. 

In fact, “exposure to tobacco, poor nutrition, lack of physical activity, and excessive alcohol use contribute to obesity, a significant risk factor for the development of chronic disease, according to the report. 

Between 2015 and 2022, two pre-pregnancy health conditions, hypertension and diabetes, increased by 81.3% and 50%, respectively. Over 140,000 babies were born to women with these pre-pregnancy conditions.  

There was a prevalence of 2.9% and 1.2% chronic hypertension and diabetes in women who gave birth in 2022.  

The prevalence of those conditions remained higher among people of color, including Black individuals who had a 5.4% and 1.6% prevalence for chronic hypertension and diabetes, and American Indian and Alaskan Native with a prevalence of 3.8% and 2.9%, respectively. 

Obesity is another prevalent problem that affects many expectant mothers. 

In 2022, 31.6% of babies were born to pregnant women who were considered obese. 

To address some of these health conditions, the ACOG and the American Society for Reproductive Medicine (ASRM) recommend pre-pregnancy counseling and care to discuss modifiable risk factors and educate women on what can be done to maintain a healthy pregnancy.  

How Do We Improve Access to Maternal Healthcare? 

One way to improve access to maternal healthcare is to change the way hospitals receive payment for services rendered.  

A big reason many birthing units are closing is due to insufficient funds.  

By changing the payment model from one where they receive payment for every covered service and adopting one that allows “providers to deliver cost-efficient, high-quality, and coordinated care,” fewer units will have to close their doors.  

Another way to address the maternal healthcare crisis in the US is by tackling access to health insurance by extending and expanding Medicaid offerings in all states.  

“Recent data indicates that 53% of pregnancy-related deaths occur between 1 week and 1 year after delivery,” according to the report. 

By extending Medicaid coverage up to a year after birth, mothers can have the coverage they need to seek life-saving medical care and cut down on lives lost postpartum.  

While Medicaid is made available to those in need, several people may fall through the cracks due to strict financial requirements.  

Expanding Medicaid to include individuals up to 138% of the federal poverty level can improve health outcomes for pregnant and all individuals.  

There are several states that have limited or created barriers to healthcare via birth centers, which is a vital aspect of prenatal care.  

To remedy this, the report suggests that state certification requirements be exempt, make special regulations for freestanding birth centers, and adopt a unique accreditation system that helps keep everything together. 

To help close the transportation and distance divide, providers and other stakeholders can invest in telehealth and other technologies to see patients. 

“In maternity care, telehealth has enabled virtual consultations with specialists, remote ultrasound monitoring by maternal-fetal medicine experts, postpartum blood pressure monitoring using Wi-Fi connected devices, and fertility tracking through patient-generated data,” the report stated.  

Lastly, there are fewer providers than ever before, and midwives could be the key to filling the care gap. 

However, some states limit or prohibit the use of either certified nurse-midwives and midwives.  

To increase the use of certified nurse-midwives and midwives, states and hospitals could grant midwives full medical privileges, change licensure policies, and eliminate certain state statutes and licensing requirements that keep them from practicing.  

Become Aware of Implicit Bias 

The maternal health care crisis extends to more than just a care shortage. 

Many women, especially women of color, can face mistreatment during maternity care, which can contribute to lower quality of care and worse health outcomes.  

A recent survey found that 1 in 5 women experienced mistreatment by healthcare workers during pregnancy and delivery.  

Black individuals experienced mistreatment at a level of 30%, Latinas at 29%, and multiracial women at 27%, compared to 19% of White women.  

While the survey looked at more direct forms of mistreatment, mistreatment isn’t always obvious and can be done subconsciously. 

Implicit biases are stereotypes that can influence our understanding of someone and impact decisions or draw harmful conclusions about a person.  

In healthcare, implicit bias, which can be made beyond our conscious control, can affect negatively inform the type of care or treatment a person receives.  

The best way to fight implicit bias is by being aware of it.  

Download the free Salud America! Action Pack “Health Care Workers and Researchers: Find If You Have Implicit Bias and What to Do Next.” 

This Action Pack allows you to take a test to help you identify what biases you may have so you can address it head on.  

After receiving your results, encourage a colleague or co-worker to take the test and determine their implicit bias.