Boosting Maternity Care in Rural America

By Mairin Rivett, Erik Skinner and Kate Bradford | Vol . 27, No. 39 | November 2019

Did You Know?

  • The Centers for Medicare and Medicaid Services estimates the U.S. will experience a shortage of 6,000 to 8,000 obstetricians and gynecologists by 2020.
  • In the United States, births in birth centers increased by 56% between 2007 and 2015, with 16,000 births in 2015.
  • According to the March of Dimes, more than 5 million women live in “maternity care deserts” with a lack of maternity care providers and no hospital offering obstetric care.

Hospital closures, shrinking budgets, a diminishing workforce and poorer health outcomes in rural areas are prompting policymakers to look for ways to boost maternal health care in the nation’s less-populated communities.

Over the last decade, increasing hospital closures and shrinking budgets have led to declining access to hospital obstetric (OB) care in rural areas across the country. These closures increase the burden on women and families living in rural communities, who often must drive long distances for prenatal visits and delivery. The likelihood of a rural hospital closing its OB unit is higher in low-income areas, which can disproportionately affect women and families who may have difficulty covering the cost of traveling farther for care.

In addition, almost 700 women in the United States die of pregnancy-related complications every year, and the mortality rate in rural areas tends to be higher than in urban areas. Between 2006 and 2015, severe complications at delivery increased by 45%. Rural residents are more likely to experience these complications because they are less likely to be healthy before, during and after pregnancy than their urban counterparts. Furthermore, some rural hospitals are not as likely to be equipped with specialists.

Workforce shortages and decreasing access to OB care can compound the comparatively poorer health of rural residents. As of 2016, approximately 45% of rural counties had OB services, a decrease of 9% from 2004. According to the March of Dimes, more than 5 million women live in “maternity care deserts,” areas in which there is a lack of maternity care providers and no hospital offering OB care. 

Each year, 98% of the nearly 4 million U.S. births occur in hospitals. Doctors primarily perform the deliveries, although there has been an uptick in birth centers run by midwives, especially in rural communities. Partially due to rural hospital closures, the number of births in birth centers jumped 56% between 2007 and 2015 for a total of about 16,000 births. Cost is another factor contributing to this increase. The cost of a normal delivery in a birth center averages about half the cost of delivering in a hospital. Birth centers are typically intended for women with low-risk pregnancies who want to give birth with a midwife or without medical pain relievers. They are generally not intended for complex pregnancies that may require complicated services or close proximity to a hospital.

State Action

Policymakers, providers and researchers are working together to improve access to quality care and generate better birth outcomes for women and babies in rural areas across the country.

Medicaid paid for 43% of all births and about 50% to 60% of births in rural areas in 2017. Because Medicaid is the nation’s largest payer of perinatal care and finances roughly half of all births in the United States, some states identify opportunities to bolster the workforce through Medicaid reimbursement. In February 2019, Wyoming passed HB 43, the Midwife Services Medicaid Act, which requires services provided by midwives licensed by the board of midwifery to be covered under Medicaid. This followed legislation that requires services provided by certified nurse midwives licensed by the board of nursing to be covered under Medicaid. In April 2019, Indiana passed SB 416, which allows Medicaid reimbursement for doula services. There is some evidence that doula support during labor can lead to better outcomes for women.

Some states established maternal mortality review committees or similar entities to identify larger issues in the health care system and develop policy considerations. At least 47 states and Washington, D.C., have a maternal mortality review committee or are implementing a review, according to the American College of Obstetricians and Gynecologists. For example, in 2019, Arkansas passed HB 1440, establishing a maternal mortality review committee and New York passed AB 3276, establishing a maternal mortality review board to investigate maternal mortality and morbidity.

States, medical associations and universities also are exploring new ways to train providers. For example, the University of Wisconsin-Madison Department of Obstetrics and Gynecology is offering the first rural residency training track in the nation that focuses training specifically on rural women’s health.

Federal Action

All state Medicaid programs are required to cover prenatal, labor and delivery care for most pregnant women with incomes below 133% of the federal poverty level through 60 days postpartum, but states have the option to extend those services. The Affordable Care Act also requires Medicaid programs to pay birth centers a facility fee, in addition to paying midwives. This payment requirement may contribute to the growth in birth center births by making deliveries at these centers more financially accessible.

Several federal laws passed in recent years aim to increase quality maternal health care for women. They include HR 1318, the Preventing Maternal Deaths Act of 2018, which reauthorizes the Centers for Disease Control and Prevention’s maternal health programs through fiscal year 2023. In addition, S 3029, the PREEMIE Reauthorization Act of 2018, renews the federal government’s commitment to invest in research relating to preterm labor and delivery. The law also supports evidence-based strategies to prevent preterm births and directly addresses a need for increased awareness of the risks that elective deliveries can pose.

In addition to research, the Health Resources and Services Administration (HRSA) addresses health care issues affecting rural communities. HRSA offers information, resources and grants to improve access to quality health care and health professionals. HRSA also provides support to rural hospitals, community health centers and state departments of health.

The Federal Office of Rural Health Policy (FORHP) advises the secretary of the U.S. Department of Health and Human Services on health care issues affecting rural communities. FORHP funds research to document trends in rural health care, including access to OB services at rural hospitals. FORHP and the Maternal and Child Health Bureau (MCHB) partnered to develop and fund the Rural Maternity and Obstetrics Management Strategies program, a pilot to explore improving access to and continuity of maternal and OB care in rural communities.

MCHB supports patient-centered, evidence-based programs that improve health care access and quality for families, including a number of programs working to address rural health priorities.  MCHB supports the State Maternal and Child Health Services Title V Block Grant Program, which served 86% of pregnant women, 99% of infants and more than 55% of children in the United States in 2017.