More US counties have become maternity care deserts since 2020, March of Dimes finds

There has been a 2% rise in maternity care deserts since 2020—meaning 1,119 additional counties, a new analysis suggests.

The latest 2022 report on maternity care deserts, put together by nonprofit March of Dimes (PDF), relied mostly on 2019-20 data for its analysis.

It classified more than a third of all U.S. counties as maternity care deserts in the report. These were defined as counties with no hospitals or birth centers offering obstetric care and no obstetric providers. 

Nationwide, 5% of counties have less maternity access than two years ago while 3% shifted to higher access. Florida had the most women impacted by improvements to maternity care access, while Ohio had the most women impacted by overall reductions in access to care. 

In maternity care deserts, there’s a higher risk for poor maternal and infant health outcomes. In the U.S., an average of two women die every day from complications of pregnancy or childbirth. Two babies die every hour. 

"A person's ability to have a healthy pregnancy and healthy birth should not be dictated by where they live and their ability to access consistent, quality care," Elizabeth Cherot, M.D., March of Dimes president and CEO, said in a press release. "Our research shows maternity care is simply not a priority in our healthcare system and steps must be taken to ensure all moms receive the care they need and deserve to have healthy pregnancies and strong babies. We hope the knowledge provided in these reports will serve as a catalyst for action to tackle this growing crisis."  

The proportion of women living in counties below the national median household income is twice as high for maternity care deserts as it is in full-access counties. They are more likely to have asthma, hypertension and smoke tobacco compared to women in counties with full access.

Two in 3 maternity care deserts are rural counties. Though more than half a million babies were born to women who reside in rural counties, only 7% of obstetric providers practice in these areas. 

Nearly half of the counties with full access to maternity care have a high proportion of women without health insurance (10% or more). Two-thirds of maternity care deserts have a high proportion of uninsured women.

Thirteen percent of Native American women who gave birth in 2020 lived in maternity care deserts. In 2020, 27% of Native American and 16% of Black babies were born in areas of limited or no access to maternity care services.

March of Dimes' report noted that most women living in maternity care deserts are white; however, it did not specify the percentage of white women who gave birth in 2020 that lived in maternity deserts. 

Per the report, 1 in 4 Native American women and 1 in 5 Black women did not receive adequate prenatal acare in 2020, as opposed to 1 in 10 white women. White women were also more likely to receive adequate prenatal care compared to Hispanic and Asian and Pacific Islander women.

Hospital closures, lacking alternatives 

Women in rural areas are at higher risk for childbirth complications. Rural hospitals report higher rates of hemorrhage and blood transfusions as compared to urban hospitals, the report noted. 

In 2020, the vast majority of all live births occurred in hospitals. While hospitals expanding obstetric services increased access to care in eight counties, those limiting the services decreased access to care in 37 counties. 

Nineteen rural hospitals closed in 2020, according to the report. Half of women in rural communities must travel more than 30 minutes to reach an obstetric hospital. This lack of access contributes to women having a 9% higher chance of maternal mortality or morbidity in rural areas. The closure of maternity wards happens most frequently in the most remote counties. 

Birth centers are health facilities independent from health systems dedicated to health during the perinatal period that can be free standing or co-located in a hospital. They must be located within the vicinity of a hospital in case a higher level of care is needed.

As of December 2021, there were 406 free-standing birth centers in the U.S. Seven states, however, have none.

Since 2020, there has been an increased presence of birth centers in rural counties and those with limited access to care. Though less than 1% of all births were delivered in birth centers in 2020, it was still a 13% increase since 2019, or 21,884 births. Most women who use birth centers are white and have private insurance. Fewer Medicaid-covered births take place in birth centers than in hospitals.

Federally qualified health centers (FQHCs) are another option, as more than 8,100 of which provided maternity care as of December 2021, per the report. Nearly half of rural counties did not have one. At least 2.6 million Medicaid eligible women live in counties without one. More than half of counties with no FQHC are maternity care deserts. 

In 2020, one-fifth of counties had low telehealth access, defined by at least 40% of consumer broadband providers advertising low speed. Counties with little access to telehealth were 30% more likely to be maternity care deserts. 

To help expand access to telehealth, the report suggested standardizing state Medicaid programs to include obstetric and pregnancy-related care in telehealth reimbursement laws and to ensure all payers provider coverage for such services. The report also called on an increase in equitable, affordable patient and provider telehealth technology, training and support, including access to high-speed broadband internet services.

About 12% of births occur in counties with limited or no access to maternity care. While there is no single solution to address the problem, several opportunities exist, per the report.

These include expanding Medicaid for individuals who fall at or below 138% of the federal poverty level and raising parental income eligibility levels under Medicaid.

The report also advocated for expanding access to the midwifery model and access to doula services in all states. Perinatal regionalization, which sets up a care referral system ahead of emergencies when higher levels of care are needed, is another important component of improving outcomes, the report stated. 

Other improvements included broader insurance coverage for telehealth maternal health services, improved maternal mortality and morbidity data collection and surveillance, further investments in perinatal quality collaboratives and other efforts addressing the social determinants of health.

“Although some temporary gains in access to health care were seen through the Public Health Emergency executive orders, we hope lessons are learned for long-term solutions,” the report concluded.