Maternity care deserts: politics, policy, and (Un)Wellness

In this week’s Politics of Childbirth series, I want to talk about Maternity Care Deserts. In preparation for the academic writing I probably should be doing, as opposed to the fiction writing I will be doing, next week, we’re going to start walking through the political and institutional barriers to maternal/perinatal health and wellness.

A word on language: while I often use the word maternity to describe maternal health/mortality/care because that is what is typically used in the sources I cite, I do try to also use the term perinatal in order to include those who give birth who do not identify with the words maternity/maternal. I apologize in advance if there is awkwardness as I try to balance current health and policy discourse with inclusive language.

Maternity  Care Deserts and  Workforce Problems

According to the March of Dimes report Nowhere to Go: Maternity Care Deserts Across the US maternity care deserts are “areas where there is low or no access [to reproductive care and] affect up to 6.9 million women and almost 500,000 births across the U.S.” These can occur in inner-city areas that are under resourced but are often in rural areas. The March of Dimes also found that since 2020, there has been a five percent increase in maternity care deserts or areas with limited access to perinatal care. If you’re a visual aids kind of person, check out their 36-page report on this for some fabulous maps by US county.

States around the country can do little to stop hospitals from closing more maternity wards creating pockets of danger for perinatal health. These pockets come about due to hospital closures or the closing of maternity/perinatal wards in hospitals as well as the slashing of the perinatal care workforce.

Even without hospital closure problems there is a workforce issue: we have an OBGYN shortage with retirements outpacing new hiring. That shortage is expected to get worse in the next decade.  Add this to the number of doctors and medical residents leaving states with abortion bans, and people of childbearing age wind up living in risky medical climates.

Ways to Help

There are a handful of ways to soften the edges of this public health problem. The March of Dimes suggests encouraging family physicians to focus on birth (history lesson: When obstetricians attempted to monopolize the field of childbirth, family physicians (who were all men) were able to  argue their way back into being able to catch babies while midwives (who were all women) were denied this ability for decades and in some states homebirth midwives are still illegal).  The March of Dimes report suggests telehealth, satellite hospitals, and more family physicians to help increase health care access throughout the reproductive journey.

Midwives are also a helpful option. Homebirth midwives can be the best choice for  those who live in population sparse areas. Outcomes with trained homebirth midwives are roughly equivalent to hospital outcomes in low-risk birth and many religious communities in the US view homebirth as the only choice for them..

Hospital-based midwives provide a useful intervention.  Certified  Nurse Midwives (CNM) are nurses with extra training and education in midwifery. They have better health outcomes (mostly lower rates of intervention) than birth with OBGYNs, they are cheaper for patients (and insurance companies), but they are more expensive for hospitals for two reasons: lower intervention means less reimbursement from insurance and they are currently required to practice under the supervision of an OBGYN. To maintain their insurance reimbursement, some hospitals have turned to forbidding CNMs to catch babies. Revising their scope of practice and allowing these medical professionals to practice to their full potential could be a cost saving measure (it could be a lifesaving one too: there are many health outcomes and benefits to birth givers, but since we’re focusing on structure here, I’m not going to mention the dozens of studies that show better outcomes for parents and their babies with midwives). It’s important to note that births are as likely or more likely to be attended by midwives throughout other industrialized democracies which all have lower rates of maternal mortality than the US; their professionalism and skill is not up for dispute either in practice or in academic studies.

Health Politics and Profit

Maternity and Perinatal Care Deserts don’t come out of nowhere.  At the end of the day, we must acknowledge that living in a for-profit health care system—even if specific hospitals are not-for-profit—means that people are going to suffer if there is no regulation. Hospitals in rural areas are often not economically well, especially in poorer areas where they can’t rely on private insurance (which reimburses at higher rates) to supplement Medicaid reimbursements. This makes it hard for them to stay open. The ability of hospitals to prioritize profits over community health, safer staffing ratios, and other health factors is a fundamental flaw in the US healthcare system.  

As long as both federal  and state governments refuse or are unable to  regulate the health care industry, this will continue to happen.

Look, we can’t force  people to become OBGYNs or practice where they don’t want to. But ACOG and the American Medical Association could work to undo the toxic culture in medical school and in the medical profession which sends doctors into burnout in the first place and provide outreach to underrepresented communities. They could work to integrate midwifery into the profession both to help stop the hemorrhaging of care workers and to provide a better staff-to-patient ratio that is better for everyone. They could also stop donating money to politicians who play politics with people’s lives.

Short of miracle solutions like profit caps in industries that should not be profit driven (typical “life, liberty, property” stuff such as hospitals, pharmaceuticals, prisons, and housing (especially private equity firms buying up single-family homes)), we’re just going to be running around stopping the bleeding.

What you can do

 I’m suspiciously optimistic today, though, because there are some things we can all do to help.  You can check on your state’s use of telehealth, contact politicians about hospital closures, and advocate for the legalization of midwifery in your state. You can encourage lawmakers to increase access to telehealth and insurance for postpartum parents and support organizations working towards health equity.

This is a structural problem and we need to stop pretending individuals with passion and drive can solve structural problems without institutional and systemic change, but working together we can mitigate some of this problem as we work to change the structure itself.