Politico
‘It’s a crisis’: Maternal health care disappears for millions
Alice Miranda Ollstein and Megan Messerly – August 1, 2023
Access to maternal health care is evaporating in much of the country, as hospitals close and obstetricians become harder to find for millions of pregnant people.
New data from the nonpartisan health advocacy group March of Dimes shows that the U.S. — which already has the worst maternal mortality rate among developed nations — saw a 4 percent decline in hospitals with labor and delivery services between 2019 and 2020.
But the raw figure masks the inequities playing out across the country, according to the report. Alabama and Wyoming lost nearly one-quarter of their birthing hospitals in that time period, while Idaho, Indiana and West Virginia lost roughly 10 percent.
“It’s a crisis,” said Stacey Brayboy, the senior vice president of public policy and government affairs at March of Dimes. “Women are struggling to access care, and that’s before and during and after their pregnancies, and we’ve seen an increase in terms of maternal and infant deaths.”
Access to care is also likely to worsen in the coming years, according to several public health experts, as obstetrics units struggle to stay financially afloat, more people become uninsured and new anti-abortion laws limit the number of physicians willing to practice in several states.
Nationally, about 5.6 million women live in counties with no access to maternity care, according to March of Dimes. Far more, 32 million, are at risk of poor health outcomes because of a lack of care options nearby. March of Dimes considers more than a third of all U.S. counties maternal care deserts, with no access to reproductive health services. States with large rural populations — Alaska, Nebraska, North Dakota, Oklahoma and South Dakota — are especially prone to shortages.
The scarcity of maternal health care is particularly acute in areas with higher instances of underlying health problems that are risk factors for maternal mortality — such as hypertension and diabetes — and where states have not expanded Medicaid, leaving hundreds of thousands uninsured.
The declining access to maternal care is one reason maternal mortality rates in the U.S are so high and rising, Brayboy said.
In 2021, roughly 33 people died for every 100,000 live births in the U.S., according to the CDC, up 40 percent from 2020. That’s roughly 10 times the mortality rate of other industrialized nations such as Spain, Germany, Australia or Japan. The maternal mortality rate for non-Hispanic Black people was 69.9, two-and-a-half times the rate of non-Hispanic whites, according to the CDC.
The report relies on data from 2020 and 2021 — before the Supreme Court overturned Roe v. Wade — and the full impact of state abortion bans on maternal care has yet to be documented. But Tuesday’s report reveals most states that have restricted abortion access since then, or where the procedure remains in limbo pending a court ruling, have seen access to obstetric care decline in recent years.
“Abortion providers, OB-GYNs, nurse practitioners are being pushed out of certain parts of the country that do have these restrictive abortion laws. That’s having a spillover effect for those that want to continue their pregnancies,” said Jamila Taylor, president and CEO of the National WIC Association.
There isn’t, however, a clean red state-blue state divide in the data. A few states with near-total abortion bans saw an improvement in access to birthing hospitals in recent years — including Arkansas, North Dakota and Mississippi — and a few states where abortion remains legal saw access worsen, including California, Maryland, and Washington state.
The situation is particularly dire in Alabama, where the number of hospitals with labor and delivery services decreased by 24 percent between 2019 and 2020, and where many more could soon go out of business. The Alabama Hospital Association warned earlier this year that half of the state’s remaining hospitals are “operating in the red,” and are “likely on a collision course with disaster.”
“Many of them are just teetering on the edge, almost not able to cover payroll,” Farrell Turner, the president of the Alabama Rural Health Association, said in an interview. “There are at least seven more, according to my calculations, that are at very high risk of closing before the year is out.”
One factor fueling the obstetric unit closures across the country is the financial mismatch facing hospitals — maternal care is expensive to provide and reimbursements are low, particularly from Medicaid, which pays for more than 40 percent of births. That’s a particular challenge for rural hospitals, which have a higher proportion of patients on government-run health insurance than their urban counterparts.
March of Dimes found that nearly a third of women in Alabama already have no birthing hospital within a 30-minute drive and for some residents, the nearest hospital is more than 70 minutes away — factors the group said raised the risk for “maternal morbidity and adverse infant outcomes, such as stillbirth and NICU admission.” More than a third of the state is considered a maternal care desert, and more than 18 percent of people giving birth received inadequate prenatal care or none at all.
“People have to drive quite some distance in order to deliver, and to obtain prenatal care leading up to that time,” Turner said. “And many folks either lack transportation or can’t afford the gas to get to the care they need. There are some telehealth options out there, but a lot of people lack access to broadband, so the uptake and implementation has been slow.”
The problem is similar in Wyoming, where five of the state’s 23 counties are maternity care deserts and more than 15 percent of residents have no hospital with labor and delivery services within 30 minutes. The state’s vastness poses particular challenges to accessing care, with people living in counties with the highest travel times spending nearly 90 minutes on average to reach the nearest hospital with obstetric care.
Abortion remains legal in Wyoming because a judge temporarily blocked the state’s new pill ban in June, and the state’s trigger ban remains enjoined. But Dr. Giovannina Anthony, an OB-GYN in Jackson, Wyo., said those laws are already affecting access to maternal health care.
“Abortion bans just create one more deterrent to anyone who might want to practice obstetrics and gynecology in Wyoming,” Anthony said.
Even in North Carolina, which has fewer maternity care deserts than the national average, access to obstetric care is headed in the wrong direction. The number of hospitals with labor and delivery services in the state decreased by 1.9 percent between 2019 and 2020, and the March of Dimes report found that 13.4 percent of people in North Carolina had no birthing hospital within 30 minutes.
“These rural communities where the maternity care deserts are, these individuals tend to be sicker. They can have chronic hypertension. They can have diabetes,” said Karen Sheffield-Abdullah, a certified nurse-midwife who has a doctorate in nursing from the University of North Carolina at Chapel Hill. “These are individuals who are coming in with what we call these comorbidities, and yet there aren’t providers for an hour away? Absolutely maternal morbidity and mortality goes up.”
Sheffield-Abdullah said access to maternity care in the state is likely to worsen because of a new law banning abortion after the first trimester.
“If we look at the most recent ban, getting more restrictive in the types of care that we provide to perinatal individuals is not going to improve our outcomes,” she said. “It only makes it more difficult for minoritized populations to get the care that they need.”
Hospitals are also struggling to recruit and retain OB-GYNs and other maternal health providers. Two Idaho hospitals, for example, shut down their labor and delivery services earlier this year, citing staffing woes exacerbated by the state’s near-total abortion ban, which went into effect last summer.
Dr. Stacy Seyb, a maternal fetal medicine specialist who has practiced for 23 years in Idaho, told POLITICO that two of his colleagues have left the state in the last few months, with several more also considering a move, and applications for medical residencies have plummeted.
“It’s hurting our ability to find doctors for a state that’s already severely underserved,” he said of the state’s abortion ban, which threatens medical providers with felony charges if they perform an abortion or help someone obtain one. “It’s hard to take care of patients while looking over your shoulder. So residents and young doctors are saying: ‘Why would I go there and deal with that?’”
Idaho saw a 12.5 percent decrease in the number of birthing hospitals in the state between 2019 and 2020, and nearly 30 percent of the state is considered a maternal health desert, according to March of Dimes. More than 27 percent of counties have both a high rate of chronic health conditions and high rate of preterm births.
Idaho providers fear the situation will further deteriorate now that abortion is banned in the state, but warn the public might remain in the dark because officials dissolved the state’s maternal mortality review committee in July.
“It’s scary for sure,” said Dr. Kylie Cooper, a former leader of the state’s chapter of the American College of Obstetricians and Gynecologists who left Idaho after the abortion ban went into effect. “Most states have the ability to track data and trends for why people are dying in pregnancy and post-partum, but now I don’t know how that will be tracked at all in Idaho.”
