When Vania Biglefthand, a 38-year-old mother of three, was pregnant with her third child in 2017, her water broke two months before she was due. That day, Biglefthand, who is Native American and lives near a reservation in rural Montana, decided to go to her nearest clinic, which was 25 minutes away. There, the doctor who examined her said she was just “producing excess pee,” Biglefthand remembers. “And I was like, ‘Well, can I get an ultrasound?’ [And he answered], ‘Oh, ultrasound’s not in today. You’ll be fine.’” A week later she started bleeding, so she drove two hours to the nearest hospital, where after several blood tests, ultrasounds, and urine tests, she was hospitalized and placed on a month-long bed rest because her water had actually broken, she was in active labor, and she didn’t have a lot of amniotic fluid left. “Every time I got up, my amniotic fluid would leak. And the fear was if I tried to travel home, I would definitely lose the baby because between [those] two hours there is nowhere to give birth.”
According to a recent March of Dimes report, 2.2 million women of childbearing age in the United States, like Biglefthand, live in a maternity care desert—a county with no hospitals or birth centers offering obstetric care and no obstetric providers. The widespread closure of maternity wards has been an issue for almost two decades, and access to maternity care in the U.S. has only become more limited. Abortion bans following the overturning of Roe v. Wade are expected to make the situation worse as more people give birth, placing greater demand on available health care providers. While policy change will be necessary to improve access to care, there are some resources available for pregnant people living in maternity care deserts.
What it’s like to live in a maternity care desert
Women living in maternity care deserts, like Biglefthand, often have to drive long distances to give birth or to get specialized obstetric care for complications. Biglefthand traveled 25 minutes to a small clinic for regular checkups, but when her water broke, she had to head to her nearest ER with obstetric services, which was two hours away. According to the March of Dimes report, 50 percent of women who live in rural communities have to travel more than 30 minutes to reach an obstetric hospital, compared to 7 percent of women living in urban areas.
During her second pregnancy, which was considered high-risk, Nakeenya Wilson, a maternal health advocate in Texas and co-founder of the Maternal Health Equity Collaborative, had to drive 40 minutes each way to see a maternal-fetal medicine specialist. At 36 weeks, she was having what’s known as prodromal labor (when contractions start in the third trimester but stop before active labor begins). “I was in a lot of pain,” Wilson remembers. “So in the matter of a week, I went to the hospital three times, and each time they sent me home; and I was bawling and crying. I’m making this 40-minute drive back and forth. I’m two centimeters dilated. I’m getting induced within the week, and they’re like, ‘There’s nothing we can do. We can give you some fluids.’”
Care is often hardest to access for those who already face the greatest inequities in maternal health outcomes in the U.S. Research has shown that Black and American Indian and Alaska Native women have higher rates of pregnancy-related death compared to white women; they also are more likely to experience preterm or low birthweight births. “We know that we’re losing obstetric services in this country, and the places where we’re losing services tend to be places where racially marginalized people live,” Maggie Thorsen, associate professor of sociology at Montana State University and co-author of a recent paper on access to obstetric care for American Indian women, tells PGN. “And it’s not just obstetric services, it’s also prenatal care.”
In Nebraska, for instance, where 71 percent of counties are considered maternity care deserts, the majority of obstetric care is provided by family physicians because OB-GYNs are concentrated in larger cities, according to Dr. Carl V. Smith, an OB-GYN and maternal-fetal medicine specialist at the University of Nebraska Medical Center. That’s why specialized physicians like Dr. Smith often travel to provide their services. “We’ll travel as far as almost 200 miles to see patients [and] perform ultrasounds on high-risk pregnancies,” he says. “What is sometimes lacking in the smaller critical access hospitals are our skilled providers and equipment to care for more critically ill premature infants. And in that situation, we try and transfer the mother to a larger center.”
How did the U.S. end up with so many maternity care deserts?
Rural hospitals have been closing all over the country since the early 2000s. Over 400 maternity wards have closed across the country between 2006 and 2020, and the pandemic might have accelerated it. These closures were concentrated in rural areas as well as Black and Hispanic communities. There are many reasons for these widespread closures, including staffing shortages and a lack of local obstetric physicians. A low volume of births each year makes it financially tough for hospitals to remain staffed and maintain spaces and equipment. “In these rural areas, there aren’t many births. … And so how do you have the training and the ability to perform these services in these rural spaces? That’s a real challenge,” Thorsen says.
OB-GYNs also face significant liability, with some of the highest levels of malpractice lawsuits and insurance costs compared to other specialties, which, some argue, has fueled the shortage of obstetricians in the country. “There’s a lot of liability that comes with that, so we have actually seen a reduction in the number of people willing to do obstetric services,” Thorsen adds. And in states with abortion bans post-Roe, obstetricians are already turning down positions because of potential legal challenges. The national OB-GYN shortage could become worse as more people could be forced to give birth in these areas, leading to greater demand even as fewer physicians are available.
Dr. Jennifer Liedtke, a family physician in Sweetwater, Texas, a rural area, is one of only three doctors in her area who delivers babies. She says there hasn’t been an OB-GYN there for around four years. They have been trying to recruit one but haven’t been able to so far. “I think part of it is probably the call schedule—if we’re in town, we’re on call 24/7 for our patients,” Liedtke explains. “If we’re out of town, or for patients that don’t have a doctor here, we’re on call one out of every three weeks.” Few physicians have been willing to consider the location. “Unless we find somebody who wants to move here; it’s a very small town. It’s pretty isolated. Not everybody wants to live in a town like that.”
What can be done to improve access to care?
One of the main solutions that both advocates and physicians have proposed is expanding Medicaid coverage so more low-income pregnant people have access to care. This is especially important because, as Thorsen notes, “about 40 percent of births to people who live in maternity care deserts are births to people who are using Medicaid, so Medicaid is the thing that connects people to care, especially in these maternity care deserts.” Another important Medicaid-related solution is to extend postpartum coverage from 60 days to 12 months to continue supporting parents after childbirth.
Additionally, making it easier for people to become licensed nurse midwives and loosening some state restrictions on midwifery practices could improve the care that women receive in rural areas and their outcomes. Research cited in the March of Dimes report shows that midwifery care is associated with an increased chance of having a low-intervention birth (delivering a baby with little or no pain medication) and a possible reduction of preterm birth. Making the services of doulas more accessible (through Medicaid coverage, for instance) has also been cited as a potential solution. Doulas don’t offer medical services but do offer emotional and physical support to pregnant people—and their services have been associated with a decrease in the use of medical interventions during birth.
Setting up mobile health clinics (like March of Dimes has done), increasing access to telehealth services, and incentivizing doctors to work in rural areas are other possible solutions. Thorsen adds, “The health of infants and the health of mothers [are] the backbone of the health of our communities, and they impact health across the life course, so we should be invested in this.”
Resources for pregnant people living in maternity care deserts:
What should pregnant people living in a maternity care desert know?
First, it’s important for pregnant people to have advocates and to become comfortable making decisions about their care. “You should advocate for the kind of care that you deserve, and if you don’t feel empowered to do that, that’s where a doula or a patient advocate comes in to help you with that,” Wilson says, “Understand that you are part of the team: the medical team and the decision-making team for your care.”
“I know a lot of women, especially minorities, are scared to speak up because I feel like we get bashed or we’re [told we’re] hypersensitive or we’re overreacting,” Biglefthand adds. “Always let your voice be heard.”
Second, have a plan in place, “where people know how far along you are, your birthing plan, [and] make sure that you have a friend that knows what’s gonna go on,” Biglefthand notes, “someone that’s going to be willing to help you out if you need to rush somewhere.”
And finally, lean on your local primary care or family physician to ask questions, get support, and access resources. “The person who best knows what care can be provided safely in the community hospitals are the family doctors, and that’s really the first place to turn,” Dr. Smith says. “And those are the ideal folks to be able to identify where is a reasonable place to go to provide prenatal care and delivery if they don’t do it themselves. And they’re the experts in what’s available in smaller communities.”