The Rural Maternity Care Crisis
Americans living in rural areas often face barriers getting needed health care because of where they live. These barriers range from difficulty getting transportation to finding a provider that takes their insurance and has appointments available. As rural hospitals continue to close and the shortage of health professionals grows, it’s becoming harder for rural Americans to get the care they need.
These issues are particularly acute for an often-overlooked group: pregnant women.
What are the risks pregnant women in rural areas face?
Pregnant women living in rural America face unprecedented barriers to maternity care. First, hospitals are closing at an alarming rate; nearly 100 rural hospitals have closed their doors since 2010. Of those that remain, 20 percent are at risk of closing. Rural hospitals also are shutting down their obstetric (OB) units, leaving fewer than half of rural counties with such units.
These hospital and OB unit closures mean rural women in labor increasingly face lengthy journeys to the hospital, sometimes even hours long. They also have contributed to increases in births outside hospitals, births in hospitals without OB care, and in preterm births — all of which carry greater risks for mom and baby.
Experts believe these closures also contribute to early elective deliveries using induction and cesarean section — procedures that increase the risk of complications — because women do not want to risk going into labor when they are hours from the nearest hospital.
There is also a growing shortage of prenatal care in rural areas. Fewer than half of all rural counties have a practicing obstetrician or gynecologist (OB/GYN). This lack of prenatal care increases the likelihood by three to four times that women will die a pregnancy-related death, and contributes to higher rates of infant mortality. The scarcity of rural OB/GYNs also means rural women have poor access to postpartum care. This is alarming since one-third of maternal deaths happen one week to a year after giving birth.
Why is maternity care disappearing across rural America?
There are several possible explanations for why maternal health care is disappearing across rural America. Although more than 28 million women of reproductive age live in rural areas, the majority of the rural population is aging and the fertility rate among rural women is decreasing, perhaps leading hospitals to cut infrequently used maternity services. In addition, as with all kinds of providers, it is difficult to recruit the dwindling supply of OB/GYNs to rural areas and to keep them there.
In addition, the cost of providing labor and delivery services is increasing — following the overall trend of U.S. health care costs — but reimbursement from insurers has not caught up. This is particularly problematic for rural hospitals since Medicaid, which pays for half of all rural births, often has lower reimbursement rates for labor and delivery than other insurance providers. Given that rural hospitals are already financially strained, they may have to cut OB services just to stay afloat.
What can be done to reverse these patterns?
To reverse this crisis, we’ll need to grow the maternity care workforce, using OB/GYNs, family practitioners, and midwives. Federal policymakers could expand programs like the National Health Service Corps, which incentivizes these providers to practice in rural areas by offering tuition reimbursement and training opportunities.
In the shorter term, states also could expand the scope of practice for nurses and midwives, giving them the authority to provide more and different services without the requirement of physician supervision. Pregnant women in states that have expanded scope of practice for nurses and midwives have seen better outcomes including fewer preterm births and fewer neonatal deaths.
Payers, particularly Medicaid, could offer coverage for doulas, who assist women during childbirth and help before labor by creating a birthing plan. They also could expand reimbursement for telehealth or other digital support services to ensure providers can connect with rural pregnant women for prenatal care.
Health care systems, colleges, and universities also have an important role. They could offer training to a range of health professionals, specifically on maternity and pediatric care, and create programs designed to promote rural health care. For example, the University of Wisconsin School of Medicine and Public Health created an academy for rural medicine, which has the goal of recruiting and retaining rural providers. Health systems also might consider creating a tiered system, where low-risk births are conducted by nurses and midwives and higher-risk births are referred to specialists.
Finally, it may be helpful to prevent the rapid hospital and OB unit closures in rural areas. Higher reimbursement for rural hospitals in general — and labor and delivery services, specifically — could reduce these closures. Medicaid policy, even if it is not directly related to reimbursement, could have an effect. Evidence suggests that Medicaid expansion helps to improve rural hospitals’ finances. Conversely, policies that reduce Medicaid coverage for low-income adults, such as Medicaid work requirements, could intensify rural hospital closures by worsening their financial constraints.
While these solutions will not make the crisis disappear overnight, they could be helpful in providing needed assistance for pregnant women — as well as their children and families — who live in rural America.