Filling the Gap

What are they and what can be done to address the staggering gaps in care.


With fewer than half of all rural counties having a practicing OB/GYN, the realities of the maternity care desert crisis are pressing. The thousands of women of women in these areas are at higher risk for complications during pregnancy and postpartum. Inadequate prenatal care is associated with poor obstetric outcomes such as preeclampsia, preterm delivery and gestational diabetes of which some can be life-threatening. Nationally the maternal mortality ratio is 16.9 percent per 100k live births but in rural communities with restricted access to care this jumps up to 29.4 percent per 100k births.


Series 2 - Post 2 – 4@2xDespite the challenges and risks posed by maternity deserts, there are many important steps and solutions finally receiving attention. To address the staggering gap in access to care, it is important to broaden the definition of crucial players and pieces in maternal care. We will cover five.


Birthing centers are health facilities separate from a traditional hospital where mothers can give birth and receive pre- and post-natal care in a midwifery model. Analysis in 2018 of nationwide birthing center data showed that women receiving prenatal care at such centers had lower rates of preterm birth, low birth weight and Cesarean delivery and overall reduced racial disparities for Black and Hispanic women. The general population's interest in such out-of-hospital births is also rising with the number of out-of-hospital births increasing by 72 percent from 2004 to 2014. Despite increased interest, across the US there are only 234 birthing centers. Only 2 percent of rural counties have at least 1 birthing center whereas it is 16 percent in urban counties. This limited number of centers matched with the closure of hospitals can quickly overwhelm the existing care systems in rural areas causing more challenges in managing care. This can be alleviated by increasing the number of birthing centers across the US and specifically in rural areas where access to care is already limited.


Midwifes, trained health professional who work alongside the physician to help women during labor, delivery, and after birth, are crucial to raising the quality of maternal care received specifically when in conjunction with traditional OB/GYN care. The American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives suggest that the highest quality of care for women occurs when physicians and midwives work together to provide maternal health care. A separate 2018 study shows a correlation between higher levels of collaboration among maternal care providers and significantly higher rates of positive birth outcomes- such as spontaneous vaginal delivery, significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. If utilized on a large scale, the proposal of joint midwife and OB/GYN care holds huge promise for increasing access to care.


Doula who are non-medical trained professionals provide continuous physical, emotional and informational support to a mother before, during and shortly after childbirth, can be crucial to addressing the care gap. Such continuous care is seen to decrease the likelihood of risky intervention during delivery and increases satisfaction with the birthing experience. A study by the Maternal and Child Health Journal found that mothers who used doulas were also more likely to practice healthy infant care post pregnancy, such as initiating breastfeeding and practicing safe sleep, both of which have positive outcomes for the child. Further, low income, socially disadvantaged and women experiencing cultural, or language barriers receive heightened positive outcomes of doula care. Finally, doulas often practice in the homes of their patients, a benefit of this care that can specifically aid mothers who may be living in maternity care deserts. Increasing access to doula care should be valued as a solution to not only increase access to care, but also improve birth outcomes and experiences.


The incorporation of remote monitoring and telehealth services into prenatal health plans promises access without distance restrictions. Healthcare has seen a drive in the number of remote care products that allow patients to receive care from the comfort of their home which COVID further accelerated. A 2020 Amwell Physician and Consumer Annual study found the usage of video visits jumped from 22% of providers utilizing the service in 2019 to 80% in 2020. Specifically with maternal care, a study in the Lancet found a 46 fold increase in virtual antenatal care during the pandemic. An AJOG study has shown that remote patient monitoring devices for mothers, such as at-home blood pressure cuffs, pulse oximeters, scales, and blood glucose monitors, result in fewer high-risk obstetric monitoring visits while maintaining maternal and fetal outcomes. These studies indicate that increasing access to telehealth and remote monitoring devices will bridge the gap of distance and time that inhibit mothers living in rural areas from reaching maternal care.

Series 1 Post 1.1 – 7@2xEXPANDING COVERAGE 

Expansion when it comes to Medicare can be effective in increasing maternal care access in one of two ways, extending the length and types of services covered. First, the American Rescue Plan Act plans to extend Medicaid coverage for pregnant people from 60 days to one year postpartum. With nearly 12% of pregnancy related deaths still occurring within days 43–365 postpartum, this is an extremely important step in improving access. Second the types of services covered changed pre and post the pandemic. Before 2020, only 19 state Medicaid programs paid for telehealth services delivered to patients in their homes. However, the need last year to continue providing services while minimizing risks for both patients and providers pushed the telehealth expansion ahead. Last year all 50 states and the District of Columbia expanded telehealth for their Medicaid populations. Increased coverage to telehealth services can be hugely beneficial to maternity care deserts. Take a look at our four-part series on Maximizing Your Impact & ROI in Perinatal Telehealth. These are just two examples of how expanded coverage can bring care to mothers most in need. March of Dimes also argues for doula care to be part of expanded coverage Overall, with expansion to more services and for a greater amount of time, the maternal care gap can be effectively addressed.


With multiple ways to address the maternity care desert crisis, we must act now. To read more on maternity care deserts, see Part 1: Thousands of Mothers Left Without Care.