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America’s increasingly atrocious access to maternity care, explained in 3 charts

Nearly 7 million women of childbearing age live somewhere with limited or zero access to maternity care.

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

America is already littered with maternity care deserts — places without a hospital that contains a labor department and practicing OB/GYNs — and these deserts are expanding.

According to a new report from the March of Dimes, the number of counties in the United States that meet their definition of a care desert had grown in 2022 compared to 2018, the last time the group surveyed the maternity care landscape.

Nearly 7 million American women of childbearing age now live in a county with either no maternity care services or with limited services, the report’s authors found. One-third of US counties are a maternity care desert, more than half of them classified as rural. And in 2020, more than 146,000 babies were born in these counties.

A color-coded map of the United States showing which counties have maternity care and which don’t. March of Dimes

While they make up only about 9 percent of births, these are mothers who already have less access to medical care and who are more likely to struggle with chronic health conditions like heart disease or diabetes. They are more likely to live in rural areas, where these care deserts are concentrated. They live in areas with more tobacco and drug use. They are more likely to deal with hypertension during their pregnancy.

Black women and American Indian women are especially at risk of either serious complications or death in pregnancy. One in four births of American Indian babies occurs in a county with no or limited maternity services, as do one in six Black babies’ births. They were found to be more likely to have received inadequate prenatal care and experienced higher mortality rates than their white and Hispanic peers.

A bar chart titled “Maternal mortality rate per 100,000 live births, by race and ethnicity, 2018-2020.” Peterson-KFF Health System Tracker

All told, about 900 Americans died in 2020 from complications related to childbirth. Another 50,000 or more women experienced severe pregnancy-related complications. Four of five of those deaths were from preventable causes. In terms of scale and rate, America’s maternal mortality dwarfs the issues of other wealthy countries, and these gaps in maternity care shoulder much of the blame.

A chart titled “Maternal mortality rate (deaths per 100,000 live births), 2020 or latest year.” It shows the United States as well above the average for developed nations. Peterson-KFF Health System Tracker

It is yet another way in which US health care is an outlier among its international peers. And the increase in the number of maternity care deserts has been driven at least in part by the profit-centric nature of the American health system, unique among wealthy nations.

Two trends drove the decrease in access to maternity care: A reduction in the number of obstetric providers and hospitals either eliminating these services or closing entirely. The losses are directly the result of the financial incentives — or rather, disincentives — that the US health system has set up for pregnancy-related care, as I wrote earlier this year.

Some hospitals try to argue that closing a maternity ward is not financially motivated, but labor and delivery services don’t make money for them. More than 40 percent of births in the US are covered by Medicaid, and the program’s low reimbursement rates are frequently cited to explain a hospital’s decision to close its OB department.

There has also been a general trend toward consolidation and specialization among hospitals. It’s usually cheaper to deliver babies at maternity departments with a high volume of births than those in communities with declining birthrates. The less active labor units will sometimes enter a downward spiral before they close: Birthrates drop, making it harder to staff the unit and more expensive to maintain these services. The staff’s skills atrophy with infrequent deliveries, and hospitals cite that risk when justifying their decision to close a maternity ward.

As a consequence of these closures, people in labor sometimes have to travel half an hour or even much more to reach another hospital where they can have their baby. If they have any complications, this inconvenient access to emergency care can make the situation life-threatening for both, as the March of Dimes report highlighted.

According to the group, nearly 300,000 women with high-risk pregnancies lived in counties without high-level obstetric beds in 2020. And almost 80,000 infants admitted to neonatal intensive care units were born to families that lived in counties without NICU beds. At a state level, Wyoming does not have any NICU beds at all.

The March of Dimes proposed a variety of policy ideas to address America’s inadequate access to maternity care: making more people eligible for Medicaid, making midwife care more widely available and authorized, and improving insurance benefits. This report and other data showing that the maternal mortality rate increased during the pandemic make the case for urgent action to protect the country’s mothers and their babies.

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