Continuous care impacts positively on maternal health outcomes. According to the World Health Organization, 60 percent of maternal deaths are preventable with timely management by a supportive, skilled health professional. Unfortunately, the growth of maternity care deserts means that more birthing people in our nation’s rural regions will lose access to this care, a reality which has the worst implications for low-income Indigenous and Black birthing people.
A maternity care desert is a county in which access to maternal health services is limited or absent. Maternity care deserts do not have hospitals or birthing centers with obstetric providers, and there are no freestanding units dedicated to providing obstetrical care. More than 2.2 million birthing people of childbearing age live in maternity care deserts, and this number continues to grow as rural hospitals shut down their maternity units. According to the American Hospital Association, about half of rural community hospitals did not provide obstetrical care in 2020. Unfortunately, this is not a budding issue—the conditions of 2020 are an extension of long-standing conditions. Between 2015 and 2019, there were at least 89 obstetric unit closures in rural hospitals.
The United States is already in the throes of a maternal health crisis, with the highest maternal mortality rates among comparably wealthy nations, and the issue is only worsening with time. As of last year, the gap in maternal mortality between white birthing people and Black birthing people increased. Among the viable strategies to improve bleak statistics is ensuring that all birthing people have access to free or affordable primary care and comprehensive reproductive health care at all points of the reproductive journey—a reality that cannot be actualized as rural regions abandon their maternity wards.
It is crucial to note that this abandonment only exacerbates pre-existing conditions in the United States. According to March of Dimes, a non-profit that centers maternal and infant health, birthing people and infants in maternal care deserts face a higher risk of mortality and morbidity. It is no surprise that low-income Indigenous and Black birthing people carry the greatest burden—two of three maternity care deserts are in rural counties, most of which house communities of color.
In addition to societal contributions and problems with policymaking, the decisions of obstetric providers and the hospitals that should be supporting them largely contribute to current circumstances. Many obstetricians choose to work in urban environments, and part of the aversion to rural environments is the inability to conceive of working in them. Very few of the United States’ OB-GYN residency programs offer opportunities for rural training, which diminishes the perceived scope of their work.
And the issue is certainly not about interest, as shown by the outcomes of our nation’s first rural obstetrics and gynecology residency. According to Ryan Spencer, M.D, the University of Wisconsin at Madison’s obstetrics and gynecology (OB/GYN) residency program director, there were 200 applications for one rural residency position. Many of our nation’s obstetricians have great interest in working on the front lines, but our current establishment does not always provide the pathways. This creates the staffing shortages that often lead directors to shut down their maternity care units altogether.
Unlike other closings, the abandonment of these units are not tied to outcomes. In fact, the clinical settings that our most vulnerable communities are losing underscore the importance of expansion—especially for Black and Indigenous women. According to a New York Times report, Astria Toppenish Hospital (based in Washington State) is credited with saving the lives of many birthing people in the region. It served a low-income population of mostly Indigenous people and many providers kept their backgrounds in mind, which only heightened the quality of care. Rural hospitals are significant not only because of their proximity to those in need, but also because of their specific, individualized approaches to promoting wellness.
It is quite evident that maternity care deserts threaten reproductive health. Reversing adverse outcomes requires large scale, intensive solutions. In the meantime, a few of our nation’s rural communities are currently working to bridge gaps in care through programs like the Hopi Breast and Cervical Cancer Early Detection Program, which provides transportation for patients to and from cervical or breast cancer screenings, and the employment of services of midwives and doulas.
