May 1, 2023

Maternity Deserts an Alarming Trend in the U.S.


More than 2.2 million women of childbearing age live in maternity care deserts. Employers have a critical role to play in addressing this problem.
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Living in a maternity care desert contributes significantly to a woman’s risk of maternal mortality, and the risk is even higher for women in rural areas.
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Maternity units across the country continue to close at increasing rates, leaving women at a heightened risk of maternal mortality. In fact, 47% of rural community hospitals report having no obstetric services in 2020. According to a report by the March of Dimes, more than 2.2 million women of childbearing age live in maternity care deserts, affecting nearly 150,000 babies.

Maternity care deserts are counties in which access to maternity health care services is limited or absent, either through lack of services or barriers to a woman’s ability to access that care. Living in a maternity care desert contributes significantly to a woman’s risk of maternal mortality. Studies show that this risk is even higher for women in rural areas, who have fewer options for prenatal care and fewer health care providers available to deliver their babies. This creates longer wait times and longer travel times to seek care.

The reasons behind these closures are complex, but many hospitals with obstetrics units are closing due to financial pressures, such as low reimbursement rates and high malpractice insurance costs. Additionally, the aging population of health care providers, particularly among obstetricians and midwives, creates additional challenges for rural communities. This results in fewer obstetricians and midwives available to provide prenatal care and deliver babies.

What’s the Solution?

Intervention from policymakers, including legislation, may be necessary to address the underlying causes of maternity deserts. Policy efforts should focus on ensuring all women have access to quality prenatal care and a safe environment for delivering their babies. Federal and state governments can invest in programs to recruit and retain physicians and midwives in rural areas, and the root causes of these closures can be addressed by offering financial incentives, such as loan forgiveness and tax incentives, to hospitals that offer obstetric services.

Several state Medicaid programs and major health systems in New Mexico, Missouri and Utah are leveraging telemedicine and remote monitoring and developing hub and spoke models of care in which obstetricians or maternal fetal medicine specialists in urban areas provide education and support to rural providers, who are more likely to be family medicine physicians and nurse practitioners than obstetricians.

Since obstetric unit closures in rural hospitals are often due to inadequate payments from private insurers, it’s time to rethink the way we pay for maternity care in these settings. The Center for Healthcare Quality and Payment Reform has proposed a new strategy which could create sweeping change – paying rural hospitals a monthly fee for each insured woman of childbearing age in the community, in addition to paying service-based fees directly related to pregnancy, delivery and postpartum.

Employers also have a critical role to play and know that improving maternal health outcomes in the U.S. and reducing disparities will require changes to the existing system of care to make it more patient-centered.

Here’s what employers can do to mitigate the trend of increased maternity deserts:

  • Benefit design: Ensure employees have access to and coverage for community models of perinatal care, including midwives and birth centers. Evidence shows freestanding birth centers in rural communities offer a safe and local alternative for high-quality maternity care, rather than pregnant women having to drive long distances for labor and birth. For example, employers can cover out-of-network midwives and birth centers at in-network rates to improve access to community providers.
  • Payment models: Paying for maternity care in one bundled payment encourages high-value maternity care by utilizing midwives, reducing unnecessary interventions such as C-sections and increasing maternal mental health screening in the prenatal period. When all providers, including the facility, are operating under a single budget, they are incentivized to coordinate care, increase efficiency and choose care delivery options that offer the best outcome for the patient’s health and experience.  Purchasers can also consider paying rural hospitals a standby capacity payment in addition to service-based fees.
  • Contracting standards and accountability: Employers can work in coordination to develop common standards, measures and purchasing principles. This set of tools could be used in contracting with health plans and providers to ensure high-quality, affordable and equitable maternity care. The PBGH Comprehensive Maternity Care Workgroup has begun this work. Employers and public purchasers interested in joining this effort can reach out to Blair Dudley.


Read more about employer strategies to promote high-value maternity care.

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