The home birth had been going well, with the baby having been delivered safely, when midwife Lauren Genter noticed that the mother was losing more blood than normal. The family was Amish and didn’t have a phone in the house, so Genter took her cellphone to the one window where she had spotty service to call for an ambulance. She was able to keep the mother stable while they waited.
The nearest hospital was a 45-minute drive away, but “you have to make judgment calls in rural areas before it’s an issue,” Genter said.
The family had never been to the facility, and had no records there. When the clinician requested a follow-up appointment, Genter knew this family would not come back. They didn’t have insurance to pay for another visit, or a car to drive the distance.
Genter facilitates home births for low-risk pregnant people in southeast, rural Ohio and Appalachia, where it’s normal for the nearest hospital to be a long drive away, and where many communities struggle with poverty.
Some of the counties that Genter serves, like Vinton and Meigs, have been designated as maternity care deserts by the March of Dimes, a non-profit organization focused on improving the health of babies and mothers.
A maternity care desert is defined by the organization as any county without a hospital or birth center offering obstetric care and without any obstetric providers. The latest report, which March of Dimes will publish on Wednesday, shows that the number of American counties categorized as deserts increased by 2% since the organization’s 2020 report. Over a third of all counties are designated by the report as maternity care deserts, most of which are in rural areas. Seven million women across the country live in areas of limited or no access to maternity health care services.
“Every time a new report comes out, we seem to be going in the wrong direction,” said Stacey Stewart, president and CEO of March of Dimes. “You’re taking an already severe situation and it’s just getting worse.”
The U.S. is in a maternal care crisis, with the highest maternal mortality rate among comparable wealthy countries — one that continues to increase year over year. Black women, in particular, are three times more likely to die as a result of pregnancy than white women. In light of other stressors on the health care system including the pandemic, staff shortages, and increased abortion restrictions across the country, experts worry that access to comprehensive reproductive care will continue to decrease, putting pregnant people and their babies even more at risk.
The parameters for what qualifies as a maternity care desert are strict, according to Denise Jamieson, department chair for gynecology and obstetrics at Emory University, who follows March of Dimes’ work. For her, this means that the new data represent the tip of the iceberg when it comes to access.
“The report is certainly discouraging,” Jamieson said.
For pregnant people, living in a maternity care desert is one of many compounding issues that may affect their experience and jeopardize their lives. Those who live in maternity care deserts are more likely to be poor, but they’re also more likely to have asthma or hypertension, or have been diagnosed with a substance use disorder, or have low access to telehealth, according to the new report. On top of that, maternity care deserts also appear to be found disproportionately in states that restrict abortion. Analysis from NPR using the 2020 March of Dimes report showed that states with strict abortion bans have a higher percentage of residents living in maternity care deserts.
“It seems ironic that you would both create a system where people were sometimes forced to remain pregnant and forced to give birth, and that in those very same places, there would be a disinvestment in the health care facilities to care for people having babies,” said Cindy Colen, a professor and vice-chair of sociology at Ohio State University.
But Colen and other experts say that the continued abortion restrictions go hand-in-hand with decreased access to obstetric care.
“Anything that reduces a person’s ability to plan pregnancies adversely affects maternal health,” Jamieson said.
One of the driving factors for decreased access is a simple one that residents of rural areas have noticed for years: hospital closures. In 2020, 19 rural hospitals closed. It’s the continuation of a long-running trend — since 2005, over 180 rural hospitals across the country have closed.
The report cites physician shortages, low volumes of patients, and low-income communities as potential explanations for the closures. But Colen and her research collaborator Alison Norris, a co-founder of the Ohio Policy Evaluation Network, believe that closures are the result of health care being treated like a business. Large hospital systems may not be willing to spend money on the high administrative costs of providing medical care in rural areas, and many “mom and pop” type providers just aren’t able to.
Ohio has the most women who have been impacted by reductions in access to care — over 97,000 — per the new report.
“None of the patients or the providers are the ones who are making these choices. It’s at a systemic level that they have no voice in,” said Norris.
The report proposes a number of policy solutions to improve access to care. It recommends expanding access to Medicaid based on income as well as expanding the postpartum coverage period to a full year, as opposed to 60 days; better integration of and access to midwifery and doula services, which can supplement physician care; and providing insurance coverage for teleheath maternity services, though the report recognized that poor broadband access limits how one may be able to access virtual appointments. The authors of the report urge lawmakers to pass the Black Maternal Health Momnibus Act.
For Genter, improving the integration of midwifery services is a major priority. She is a certified professional midwife, which in Ohio means she isn’t legally considered a provider in the same way that certified nurse midwives are. As a result, she struggles to connect with hospitals and physicians when she meets with a client who may be at higher risk for complications.
“There are a lot of adverse outcomes that are preventable with good prenatal care, with good postpartum care and follow-up. And midwives can go a long way to help fill that gap,” she said.
Experts agree that it will take action from myriad leaders of the health care industry, government, and beyond to address the maternal care crisis.
“There’s no one reason why we are in the place that we’re in, and there’s no really one silver bullet solution to the change,” Stewart said.