Report: One-third of US counties are “maternity care deserts”

Nearly 7 million women of childbearing age and 500,000 babies live in areas that have no obstetric hospitals or birth centers, and no obstetric providers. That is the sobering news from the 2022 March of Dimes report “Nowhere to go: Maternity care deserts across the US.”

A pregnant woman waits in line for groceries with hundreds during a food pantry, sponsored by Healthy Waltham for those in need due to the COVID-19 virus outbreak, at St. Mary's Church in Waltham, Mass. [AP Photo/Charles Krupa]

The report by the maternal and infant health nonprofit found that over 2.8 million women of childbearing age and nearly 160,000 babies were impacted by reduced access to maternity care.

Five percent of US counties shifted to lower access in maternity care, while 3 percent of counties moved to higher access. Shifts in the number of obstetric providers was the primary driver for decreases in access, with 56 counties shifting to a lower level of access to maternity care due to a loss of obstetric providers.

March of Dimes describes quality maternal care as “providing safe, effective, timely, efficient, equitable and person-centered care.”

The report found that one in four Native American women (24.2 percent) and one in five black women (20.1 percent) did not receive adequate prenatal care in 2020, while the rate for white women was one in ten (9.9 percent).

Hispanic and Asian/Pacific Islander women were less likely to receive adequate prenatal care when compared to white women (17.3 and 11.3 percent less likely, respectively). In 2020, the maternal mortality rate for non-Hispanic black women was 55.3 deaths per 100,000 live births, nearly three times the rate for non-Hispanic white women.

Severe maternal morbidity (SMM), or unexpected outcomes of labor and delivery that result in significant short- or long-term health consequences affects approximately 50,000 women in the US each year.

A JAMA Network Open research letter published in June found a staggering 18.4 percent increase in US maternal mortality between 2019 and 2020. These figures include deaths during pregnancy or within 42 days of pregnancy.

The leading causes of death in pregnancy, the day of delivery and a year postpartum are hypertensive disorders of pregnancy, cardiovascular conditions, hemorrhage, amniotic fluid embolism, infection and cardiomyopathy. 

The March of Dimes report paints a slightly grimmer picture than the organization’s last report in 2020. It finds that 36 percent of counties nationwide, largely in the Midwest and South, are “maternity care deserts.” The latest report finds that nearly 16,000 women of childbearing age in more than 1,000 counties have no access to maternity hospitals, centers and providers.

In maternity care deserts, the proportion of women living in counties below the national median household income is twice as high as it is in full access counties (90.1 percent versus 45.2 percent). Women with no access to maternity care are more likely to have asthma, hypertension and smoke tobacco. 

The bleak maternity care outlook for the nearly 7 million women in areas without birth centers, obstetric hospitals and providers is largely attributable to the diminishing profitability of hospitals and providers in mostly rural areas, along with the financial fallout from the COVID-19 pandemic and burnout of hospital staff.

Since 2005, 181 hospitals in rural areas have closed across the US, with 138 closing in the last 12 years and 19 closing in 2020. “With hospital closures, inflation and COVID-19 limiting access to care, the compounding issues of our time are bearing down on families, forcing them to extend themselves in new ways to find the care they need and ways to afford it,” Stewart said.

Maternal care in the pandemic has seen significant deterioration during the pandemic. The report notes: “Staff shortages, restructuring of where and how care was delivered, shortage of personal protective equipment, caring for COVID-positive pregnant people and restriction of support during childbirth were all reported as challenges during pandemic care.”

In 2019, 48 percent of US counties did not have a single obstetrician (OB) and 55 percent did not have a certified nurse-midwife (CNM). OBs are far more likely to work in metropolitan areas, with fewer than 10 percent of obstetric providers practicing in rural areas. One in eight US babies is born in a county that has zero obstetric hospitals, centers or providers.

Infant mortality is defined as the death of an infant before his or her first birthday. CDC figures show the infant mortality rate in the US was 5.4 deaths per 1,000 live births in 2020. 

According to worldpopulationreview.com, the 10 countries with the lowest infant mortality rates are 29 to 40 percent of that in the US. These are Iceland (1.54 per 100,000), San Marino (1.56), Estonia (1.65), Slovenia (1.76), Norway (1.79), Japan (1.82), Singapore (1.85), Finland (1.88), Montenegro (1.95) and Sweden (2.150).

Eight US states—South Dakota, Kansas, Arkansas, Louisiana, Mississippi, Alabama, West Virginia, and North Carolina—had infant mortality rates ranging from 6.62 to more than 8 deaths per 100,000 babies born. In Mississippi, 288 infants born in 2020 died before their first birthday, for an infant mortality rate of 8.12 per 100,000—the worst of any US state.

In a country that spends more per capita on health care than any other industrialized nation, about 900 women died of pregnancy related causes in the US in 2020. The deaths of nearly two-thirds of these women were preventable and would not have taken place if they had access to quality maternity care.

With the delivery of health care subordinated to profit in the US, over 55 percent of all US counties had a greater than 10 percent proportion of women without health insurance. The March of Dimes notes: “Uninsured women often do not have adequate access, receive a lower quality of care and use fewer preventative services.” In the 12 states that have not adopted Medicaid expansion under the Affordable Care Act, many women lose coverage 60 days after childbirth.

The period studied predates the US Supreme Court’s overturning of the right to abortion established by Roe v. Wade. Anti-abortion legislation in mostly Southern and Midwestern states will exacerbate a deplorable situation in which access to maternity care is already virtually nonexistent, as clinics that provide abortion services as well as prenatal and other women’s health care shutter. One-third of US women now live in areas that lack access to abortion services.

The March of Dimes report follows an analysis of maternal death data released last month by the Centers for Disease Control and Prevention (CDC) showing that four out of five maternal deaths in the US are preventable.

“With an average of two women dying every day from complications of pregnancy and childbirth and two babies dying every hour, our country is facing a unique and critical moment as the infant and maternal health crisis continues intensifying,” March of Dimes President and CEO Stacey D. Stewart said in a statement announcing the report.