For 6 million US women, finding a safe place to have a baby is difficult, report finds

The report estimates that nearly 6 million women in the United States live in counties with no or limited access to maternity care services.

The report, which looked at birthing-related services offered in all 50 states, Washington, D.C., and Puerto Rico, highlights the dangers faced by pregnant women in the U.S., which already has the dubious distinction of having one of the highest maternal mortality rates in the developed world.

“Where You Live Matters: Maternity Care Deserts and the Crisis of Access and Equity,” is an update of a report issued by the March of Dimes in 2018, which found that states with large rural populations — including North Dakota, South Dakota, Alaska, Oklahoma and Nebraska — had the highest number of counties that could be classified as “maternity care deserts,” counties without a hospital or birthing center offering obstetric care and without any obstetric providers.

In the newest study, 632 counties, or about 60 percent of the total “desert” counties, would be considered rural. Another 392 counties, or about 40 percent of the total, would be considered urban, according to the organization that is working to address the nation’s maternal and infant health crisis.

Separately, the Centers for Disease Control and Prevention earlier this year reported that the overall U.S. maternal mortality rate — the number of deaths per 100,000 live births — doubled between 2018 and 2021, leaping from 17.4 in 2018 to 32.9 in 2021. And the 2021 rate of nearly 70 for Black women was more than double the 26.6 rate for non-Hispanic white women.

CDC data that combined deaths from 2018 to 2021 showed that the states with the highest death rates were Arkansas, Mississippi, Tennessee, Alabama and Louisiana. (The CDC did not list mortality rates for North Dakota, South Dakota and Alaska because of the low number of deaths. The rates for Oklahoma and Nebraska were not among the 10 highest rates.)

For the five states with the highest maternal mortality rates, there was no overlap with the states with the most “desert” counties. 

Still, the report, and a March of Dimes executive, noted the dangers facing pregnant women who find themselves miles from care.

“Women who do not get prenatal care are three to four times more likely to die than women who do get prenatal care,” Elizabeth Cherot, March of Dimes president and chief executive said in an interview.

Distance from care also can cause women with underlying medical conditions — from hypertension to cardiac issues — to forgo appointments, which can have a host of negative outcomes. The report also tracks average distances from care for residents of each county.

What if “I've got blood pressure, how do I get monitoring?” she asked. “How do I get access to care or get into care when I have a higher-risk pregnancy, diabetes, hypertension, those chronic conditions? And we see that when you have one chronic condition, we're seeing an increase in preterm birth.”

Some care solutions being looked at in “desert” counties, such as increased use of telehealth services, can be useful in counties with high mortality rates, said Rachel Bervell, who works in maternal health care for the Baltimore City Health Department

 “Maternal mortality is influenced by a multitude of factors, right? And access is just one of those many factors. There's a really complex interplay of, let's say, having access to quality health care, socioeconomic status, having good education, overall health status. … It overlays with race, a lot of this overlays with class, and things like that,” said Bervell, who has written about the Black maternal health crisis.

A program that uses digital technology is a "tool (that) can very easily be used and implemented in a community that is considered quote unquote, more urban, that can be (used in) the South where you're seeing these higher rates and maternal deaths and more maternal morbidity,” she said.

Cherot also noted that mobile care units that bring care to the patient can be used in care deserts and in areas with high mortality rates. 

The March of Dimes report found that the closure of obstetric units in hospitals was responsible for reduced maternity care access in 369 counties since the 2018 report. That’s nearly 10 percent of the counties in the nation.

An additional 70 counties — in 26 states — dropped into the “maternity care desert” classification because of the loss of obstetric providers and obstetric units in hospitals, since the 2018 report, according to the new report.

Texas, the U.S. state with the most counties, led the flight from care with eight counties, largely in the Panhandle and western portion of the state, falling from low or in some cases “full” care access to desert status since 2018, the report showed.

A spokesperson with Texas’ Health and Human Services department could not immediately be reached for comment.

The report did not state reasons behind the drop in available care other than to observe that “maternity care is simply not a priority in our health care system today.”

Both Bervell and Cherot mentioned lower medical reimbursement rates for childbirth, compared with heart surgery, for instance, as being part of the motivation moving some providers out of birthing business.  

Asked about the impact of the Supreme Court’s nullification of Roe v. Wade and the wave of restrictive pregnancy-related laws imposed in more than a dozen states since the high court’s ruling, the organization said in the email: “The impact of the ruling continues to have ripple effects across the nation, and we will continue to monitor how access is impacted in states with abortion bans and restrictions.”

Cherot said she hopes the report will elevate the amount of attention paid to health care access for pregnant women, adding “This is one area that we're pointing out that is a problem area.”

The report’s information on the availability of services is drawn from the 2021-2022 Area Health Resource File from the U.S. Health Resources & Services Administration (which contains data reporting from 2019-2021). 

To calculate the distance to birthing facilities and hospitals, the organization used data from the 2021 American Hospital Survey, HealthCare Cost and Utilization Project, and 2017-2021 U.S. Census Bureau Fertility data. 

Data  on chronic health conditions is a five-year aggregate (2017-2021) from the National Center for Health Statistics (NCHS). The data for prenatal care is a three-year aggregate (2019-2021) and is also from NCHS. Some prenatal care information is from Surgo Venture’s Maternal Vulnerability Index or 2021 Census Bureau Poverty data (depending on the state).

Karen Robinson-Jacobs is a member of the Lee Enterprises Public Service Journalism team.