Maternity care deserts in the United States

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US map of maternal mortality US map of maternal mortality rates by state.jpg
US map of maternal mortality

Maternity care deserts in the United States, also known as maternal care deserts, are counties that lack maternity care resources. The March of Dimes defines a maternity care desert as a county that has no hospitals or birth centers offering obstetric care and no obstetric providers. [1] [2] As of 2020 March of Dimes classified 1095 of 3139 of U.S. counties (34.9%) as maternity care deserts. [3] Its 2022 report indicated an increase of nearly 2%, with 1119 of 3142 US counties (35.6%) considered maternity care deserts, affecting a population of over 5.6 million women. [1] [4] People living in maternity care deserts may have to travel longer distances to receive care, which is associated with higher costs and a greater risk of pregnancy complications. [5]

Contents

The March of Dimes also classifies counties as having low access to maternal care if the county has one hospital or less offering obstetric care, fewer than 60 obstetric providers per 10,000 births and 10% (or greater) of women have no health insurance. [1] Counties were classified as moderate access if they met the requirements of having low access to maternity care but the % of women with no insurance was less than 10%. A county with full access to maternity care had two or more hospitals with obstetric care facilities and 60 or more obstetric providers per 10,000 births. [1]

Maternity care deserts are associated with high maternal mortality rates. [1] [6] Since 2018, there has been a 4% increase in maternity care deserts in the U.S. [1] In the United States, up to 60,000 women a year experience severe maternal morbidity, life-threatening complications as a result of pregnancy, resulting in up to 700 pregnancy-related deaths annually. [7] [8] Maternal morbidity displays decades-long racial, geographical, and socioeconomic disparities. The United States is one of two countries worldwide that has reported significantly increased maternal mortality since 2000. [7]

Contributing factors

Race

Race plays a role in maternal mortality. In 2021, the maternal mortality rate for Black women was 69.9 deaths per 100,000 live births. [9] This is 2.6 times the rate for White women. [1] Approximately 1 in 6 Black infants were born in maternity care deserts and 1 in 4 Native American babies were born in maternity care deserts. [1] Women who identify as American Indian or Alaska Native (AIAN) form 2.2% of the population of women in the U.S., [10] and around 13% of them gave birth in maternity care deserts. [11] [2] They are more likely to experience negative outcomes including pre-term delivery, infant mortality, maternal morbidity, and maternal mortality. [12] [1]

Rural communities

Two in three maternity care deserts are in rural counties. [11] [1] Since 2004, rural communities in America have seen a decrease in obstetric services in hospitals. [13] Between 2004 and 2016 obstetric services have decreased from 54% to 45%. [14] Rural areas have a higher number of people on Medicaid and because Medicaid covers less than private insurance for childbirth, rural hospitals are unable to support obstetric care fiscally or through necessary staffing. [13] When care units shut down, the healthcare workers who are able to provide maternity care might leave the area, potentially creating a new desert. [13]

Restrictions on abortion services

The overturning of Roe v. Wade and changing abortion policy has led to a decrease in access to abortion care across the United States. [15] 3.7 million women (about 5.8% of all women of reproductive age) live in both a maternity care desert and somewhere that has no access to abortion services. [16] States and counties with abortion restrictions have fewer maternity care providers, with a 32% lower ratio of obstetricians and a 59% lower ratio of certified nurse midwives compared to states with abortion access. This disparity has increased the prevalence of maternity care deserts in recent years. [17]

Policies

Since 1991, the United States government has passed policies to reduce infant and maternal mortality through programs including Healthy Start. Healthy Start was first funded by President George H. W. Bush under Section 301 of the Public Health Services Act. It was further authorized by Congress under the Children's Health Act of 2000, signed by President Clinton, which funded prenatal care and support for children and mothers through early childhood). [13] [18]

In 2020, the Division of Reproductive Health of the Centers for Disease Control and Prevention (CDC) launched a national "Hear Her" campaign called to raise awareness of danger signs during and following pregnancy and to improve communication between pregnant or postpartum people, support systems, and health care providers. [19] [20]

Federally Qualified Health Centers (FQHC) receive federal money through the Department of Health Resources and Services and provide care for underserved populations or areas. [21] FQHCs fill maternity care gaps by providing reimbursements through Medicaid, which helps providers receive reimbursement for their services. [1] In Houston, one FQHC that provided maternity care increased the number of women who received prenatal care by 44%. [22] The Affordable Care Act increased funding for FQHCs between 2011 and 2015. [23] As of December 2021, 48% of rural counties did not have any FQHC. Urban counties had an average of 3.5 FQHCs per county while rural counties had an average of 1. Half of the counties with no FQHC were also classified as maternity care deserts. [1] Increasing FQHCs can improve maternity care deserts. [24]

Doulas:A doula is a trained maternal support professional who offers emotional, informational and/or psycho-social care during pregnancy, childbirth and/or the postpartum periods. Doulas do not replace but complement the role of clinicians (physicians, midwives and nurses). [25] They provide culturally competent care and have been shown in multiple studies to decrease cesarean sections. Doula care has also been show to reduce the rate of postpartum depression and postpartum anxiety. Continuous support during labor may reduce rate of low 5 minute Apgar scores. Doulas may be a useful tool in decreasing disparities [26] As of August 2022, six states were reimbursing doula services on Medicaid plans [27] and 32 states had proposed legislative efforts to provide doula services or Medicaid reimbursements. [28] There is evidence that this reduction in cesarean rates and improved outcomes may be a cost savings for state Medicaid programs. [29] In order to increase the number of midwives, policy makers have invested in midwifery training programs to make the field more accessible. [30]

Telehealth has been shown to improve obstetric care and early abortion care. [31] Telehealth can be a partial solution to providing care for women in rural areas with a lack of access to care nearby. [32] Telehealth access also overlaps with broadband access as the biggest barrier to telehealth care is internet access. [33]

Medicaid expansion is associated with lower maternal mortality, with 6-7 out of 100,000 fewer maternal deaths than states with no Medicaid expansion. [34] The evidence suggests that long-term coverage before and after pregnancy can reduce rates of maternal mortality. [35] As of 2023, 41 states have passed amendments that extend Medicaid coverage for 12 months, with 5 states planning on expanding access and two states providing limited expansion. This was originally introduced through an improvision through the American Rescue Plan. The option was made permanent by the Consolidated Appropriations Act 2023. [36]

Current response

Maternal health care has received more legislative attention since the end of Roe v. Wade. The Biden Harris administration has included the phrase "Maternity care deserts" in their blueprint to tackle maternal health in America. [37] In September 2023 the U.S. Department of Health and Human Services announced 90 million dollars in funding to support the plan for tackling maternal care in America. [38]

Bills in Relation Passed by 117th Congress [39]
BillsWhat it Does
Data Mapping to Save Moms' Lives ActIt calls on the Federal Communications Commission to include maternal mortality and severe maternal morbidity in its data on its broadband health mapping tool. [39] [40]
Maternal Health Quality Improvement Act of 2021This bill provides authority to the Department of Health and Human Services to provide grants to support care networks for maternal health in rural areas. [39] [41]
Protecting Moms Who ServedThis bill directs the Department of Veterans Affairs to implement the maternity care coordination program. [39] [42]

At the state level: Texas

46.5% of counties in Texas are maternity care deserts and 4.6% of women in Texas do not have birthing centers within 30 minutes from themselves. 66% of counties in Texas report high rates of chronic health conditions and preterm births, which can worsen maternal health outcomes. [43]

Map of Texas counties Texas counties map.gif
Map of Texas counties

20.4% of women in Texas have inadequate prenatal care compared to 14.8% for the US as a whole. [43] Socioeconomics also impacts prenatal care in Texas. BIPOC women who live in areas with high socioeconomic vulnerability have a 44% increased likelihood of inadequate socioeconomic vulnerability compared to areas with low socioeconomic vulnerability. [43]

Based on the CDC initiative, the Texas Department of State Health Services (DSHS) started its own Hear Her campaign of education and resources to help people recognize urgent maternal warning signs and know when they need to seek help. The campaign also encourages doctors and medical providers to listen to women. [44] [45] [46]

The United States Health Resources and Services Administration funds the Rural Maternity and Obstetrics Management Strategies (RMOMS) Program In September 2019. RMOMS provides funds to programs that build networks to coordinate continuum of care and use telehealth and specialty care in areas that need it the most. From 2019 to 2020 the Texas RMOMS Comprehensive Maternal Care Network (TX-RMOMS) served 1,644 women and delivered 1,230 babies. [47]

The Texas Presumptive eligibility program allows hospitals to determine if individuals need short term Medicaid. Pregnant women can qualify for both prenatal care and care during pregnancy depending on the hospital's approval. [48] In 2024 there will be a new March of Dimes "Mom & Baby Mobile Health Center" in Houston due to funding from Blue Cross and Blue Shield of Texas. [49]

At the state level: Massachusetts

In Massachusetts, 100% of counties are full access. 4.6% of people had no birthing hospital within 30 minutes. There is an overall low vulnerability to adverse outcomes due to the availability of reproductive health services.[ citation needed ]

9.7% of people received no or inadequate prenatal care. [50]

As of December 8, 2023 Masshealth (Medicaid) announced a new benefit of allowing coverage of doula services for pregnant, birthing and post partum members. [51]  

Related Research Articles

<span class="mw-page-title-main">Prenatal care</span> Medical check-ups during pregnancy

Prenatal care, also known as antenatal care, is a type of preventive healthcare. It is provided in the form of medical checkups, consisting of recommendations on managing a healthy lifestyle and the provision of medical information such as maternal physiological changes in pregnancy, biological changes, and prenatal nutrition including prenatal vitamins, which prevents potential health problems throughout the course of the pregnancy and promotes the mother and child's health alike. The availability of routine prenatal care, including prenatal screening and diagnosis, has played a part in reducing the frequency of maternal death, miscarriages, birth defects, low birth weight, neonatal infections and other preventable health problems.

A doula is a non-medical professional who provides guidance for the service of others and who supports another person through a significant health-related experience, such as childbirth, miscarriage, induced abortion or stillbirth, as well as non-reproductive experiences such as dying. A doula might also provide support to the client's partner, family, and friends.

<span class="mw-page-title-main">Maternal death</span> Aspect of human reproduction and medicine

Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while she is pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.

In obstetrics, gestational age is a measure of the age of a pregnancy taken from the beginning of the woman's last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method, if available. Such methods include adding 14 days to a known duration since fertilization, or by obstetric ultrasonography. The popularity of using this measure of pregnancy is largely due to convenience: menstruation is usually noticed, while there is generally no convenient way to discern when fertilization or implantation occurred.

<span class="mw-page-title-main">Traditional birth attendant</span> Person who provides maternity care informally

A traditional birth attendant (TBA), also known as a traditional midwife, community midwife or lay midwife, is a pregnancy and childbirth care provider. Traditional birth attendants provide the majority of primary maternity care in many developing countries, and may function within specific communities in developed countries.

Pregnancy options counseling is a form of counseling that provides information and support regarding pregnancy. Women seeking pregnancy options counseling are typically doing so in the case of an unplanned or unintended pregnancy. Limited access to birth control and family planning resources, as well as misuse of birth control are some of the major contributing factors to unintended pregnancies around the world. In 2012, the global rate of unintended pregnancies was estimated to be 40 percent, or eighty-five million pregnancies.

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. In most cases, maternal health encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of pregnant women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children. Maternal morbidity and mortality particularly affects women of color and women living in low and lower-middle income countries.

<span class="mw-page-title-main">Maternal–fetal medicine</span> Branch of medicine

Maternal–fetal medicine (MFM), also known as perinatology, is a branch of medicine that focuses on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy.

Unintended pregnancies are pregnancies that are mistimed or unwanted at the time of conception, also known as unplanned pregnancies.

The following outline is provided as an overview of and topical guide to obstetrics:

Prenatal care in the United States is a health care preventive care protocol recommended to women with the goal to provide regular check-ups that allow obstetricians-gynecologists, family medicine physicians, or midwives to detect, treat and prevent potential health problems throughout the course of pregnancy while promoting healthy lifestyles that benefit both mother and child. Patients are encouraged to attend monthly checkups during the first two trimesters and in the third trimester gradually increasing to weekly visits. Women who suspect they are pregnant can schedule pregnancy tests prior to 9 weeks gestation. Once pregnancy is confirmed an initial appointment is scheduled after 8 weeks gestation. Subsequent appointments consist of various tests ranging from blood pressure to glucose levels to check on the health of the mother and fetus. If not, appropriate treatment will then be provided to hinder any further complications.

<span class="mw-page-title-main">Maternal health in Uganda</span>

Uganda, like many developing countries, has high maternal mortality ratio at 153 per 100,000 live births. According to the World Health Organization (WHO), a maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. In situations where attribution of the cause of death is inadequate, another definition, pregnancy-related death was coined by the US Centers for Disease Control (CDC), defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant humans. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

A medical abortion, also known as medication abortion or non-surgical abortion, occurs when drugs (medication) are used to bring about an abortion. Medical abortions are an alternative to surgical abortions such as vacuum aspiration or dilation and curettage. Medical abortions are more common than surgical abortions in most places around the world.

This article summarizes healthcare in Texas. In 2022, the United Healthcare Foundation ranked Texas as the 38th healthiest state in the United States. Obesity, excessive drinking, maternal mortality, infant mortality, vaccinations, mental health, and limited access to healthcare are among the major public health issues facing Texas.

The maternal mortality rate is 224 deaths per 100,000 births, which is the 23rd highest in the world. The mean age of mothers at birth is 19.3 years old, and the fertility rate is 5.72 children born per woman, which is the 7th highest in the world. The contraceptive rate is only 40.8%, and the birth rate is the 4th highest in the world at 42.13 births/1,000 population. Infectious disease is a key contributor to the poor health of the nation, and the risk is very high for diseases such as protozoal and bacterial diarrhea, hepatitis A, typhoid fever, malaria, dengue fever, schistosomiasis, and rabies. The adult prevalence rate of HIV/AIDS is 12.37%, which is the 7th highest in the world.

<span class="mw-page-title-main">Maternal healthcare in Texas</span>

Maternal healthcare in Texas refers to the provision of family planning services, abortion options, pregnancy-related services, and physical and mental well-being care for women during the prenatal and postpartum periods. The provision of maternal health services in each state can prevent and reduce the incidence of maternal morbidity and mortality and fetal death.

<span class="mw-page-title-main">Maternal mortality in the United States</span> Overview of maternal mortality in the United States

Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this metric only includes causes related to the pregnancy, and does not include accidental causes. Some sources will define maternal mortality as the death of a woman up to 42 days after the pregnancy has ended, instead of one year. In 1986, the CDC began tracking pregnancy-related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System. According to a 2010-2011 report although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world.

<span class="mw-page-title-main">Medical deserts in the United States</span> Areas with limited access to healthcare in the United States

The United States has many regions which have been described as medical deserts, with those locations featuring inadequate access to one or more kinds of medical services. An estimated thirty million Americans, many in rural regions of the country, live at least a sixty-minute drive from a hospital with trauma care services. Regions with higher rates of Medicaid and Medicare patients, as well those who lack any health insurance coverage, are less likely to live within an hour of a hospital emergency room. Although concentrated in rural regions, health care deserts also exist in urban and suburban areas, particularly in predominantly Black communities in Chicago, Los Angeles and New York City. Racial demographic disparities in healthcare access are also present in rural areas, particularly in Native American communities which experience worse health outcomes and barriers to accessing quality medical care. Limited access to emergency room services, as well as medical specialists, leads to increases in mortality rates and long-term health problems, such as heart disease and diabetes.

Black maternal mortality in the United States refers to the death of women, specifically those who identify as Black or African American, during or after child delivery. In general, maternal death can be due to a myriad of factors, such as the nature of the pregnancy or the delivery itself, but is not associated with unintentional or secondary causes. In the United States, around 700 women die from pregnancy-related illnesses or complications per year. This number does not include the approximately 50,000 women who experience life-threatening complications during childbirth, resulting in lifelong disabilities and complications. However, there are stark differences in maternal mortality rates for Black American women versus Indigenous American, Alaska Native, and White American women.

References

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  39. 1 2 3 4 "Recent federal action advances key maternal health policies | National Association of Counties". www.naco.org. Retrieved 2023-12-14.
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  41. ↑ "H.R.4387 - Maternal Health Quality Improvement Act of 2021 117th Congress (2021-2022)". Congress.gov.
  42. ↑ "S.796 - Protecting Moms Who Served Act of 2021 117th Congress (2021-2022)". Congress.gov.
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  46. ↑ "Hear Her Texas | Texas DSHS". www.dshs.texas.gov. Retrieved 2023-12-14.
  47. ↑ "Texas Rural Maternity and Obstetrics Management Strategies (TX-RMOMS) Program" (PDF). Health Resources & Services Administration. 2021. Retrieved 11 February 2024.
  48. ↑ "Texas Administrative Code". texreg.sos.state.tx.us. Retrieved 2023-12-14.
  49. ↑ "Blue Cross and Blue Shield of Texas Grants $1.2 million to Fund March of Dimes' First Texas 'Mom and Baby Mobile Health Center'". www.bcbstx.com. Retrieved 2023-12-14.
  50. ↑ "Where you live matters: Maternity care in Massachusetts" (PDF). march of dimes.org. 2023.
  51. ↑ "MassHealth Announces Coverage of Doula Services". www.mass.gov. Retrieved 2024-05-08.
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