The Rise of Rural 'Maternity Deserts'

What strikes me almost immediately when reading Whitney Brown’s story is how much energy and care was put into saving her life, just hours after she gave birth. A team of 70 health professionals desperately worked to stabilize the young woman after she suffered a seizure during labor, and then cardiac arrest in the ambulance that shuttled her from the rural Tennessee hospital in which she gave birth to the maternal-fetal medicine practice in Chattanooga, 77 miles away. Once she arrived, the massive hemorrhaging started.

Although doctors were able to almost immediately diagnose her condition and control the bleeding, less than a day after giving birth to her daughter Phoenix, Brown died from an extremely rare condition called amniotic fluid embolism (AFE). The trip from the rural hospital in which she gave birth to the facility with specialized services took hours. There were no helicopters available and few ambulances. If we as a country decided to devote as much time and energy to ensuring that Brown, and the millions of women like her who live in rural U.S. counties, had access to quality care during pregnancy, labor, and birth, Brown’s death may never have happened.

Since 2000, it’s become increasingly dangerous for women to give birth in rural settings across the United States, according to an article in the Wall Street Journal, “Rural America’s Childbirth Crisis”:

The rate at which women died of pregnancy-related complications was 64% higher in rural areas than in large U.S. cities in 2015. That is a switch from 2000, when the rate in the cities was higher, according to Centers for Disease Control and Prevention data analyzed by The Wall Street Journal.

The article calls these rural areas “maternity deserts” and notes that they are growing. According to the American College of Obstetricians and Gynecologists (ACOG), in 2008 only 6.4% of obstetricians and gynecologists practiced in rural settings; and by 2010 almost half of all U.S. counties (most of which are rural) lacked an ob-gyn. Forty-five percent of rural counties no longer have hospitals with maternity wards.

What’s going on?

In Whitney Brown’s case, although her initial obstetrician recognized her symptoms as potentially those of AFE, the small hospital simply did not have the capacity to help her. The problem snowballed when there was no easy access to specialized care.

The WSJ article explains,

Pregnancy-related complications are rising across the U.S., and many require specialized care. For some women, the time and distance from hospitals with the resources and specialists to handle an obstetric emergency can be fatal.

As Reuters reported earlier this year on the growing number of hospital closures and the impact on women’s health:

When local doctors and midwives leave town, rural women lose access to essential services. Many skip or delay prenatal care that could prevent complications, premature birth or even death.

Rural women are also more likely to have their births induced or via scheduled cesarean section, even though unnecessary interventions during childbirth pose their own health risks. However, for ob-gyns who practice in rural areas, the benefit of a scheduled c-section may outweigh the risks of an unforeseen complication for which specialized care isn’t available in a timely way.

There’s more. The United States is the most expensive country in the entire world in which to give birth. Nearly fifty percent of all births in the U.S. are paid for through Medicaid, the state and federal insurance program for people who are poor. Obamacare aimed to support rural hospitals, in part by expanding Medicaid. Although Medicaid reimburses hospitals for childbirth care at a lower cost than private insurance companies do, hospitals still receive a reimbursement. However, 19 states chose not to expand Medicaid under Obamacare, leaving hospitals in these states with rising numbers of families who cannot pay their hospital bills for maternity care (in 2013, a vaginal delivery cost on average $10,000; $15,000 on average for a cesarean section).

The two states with the highest number of hospital closures since 2010 are two of those that did not expand Medicaid: Texas and Tennessee (the state in which Whitney lived and died). Texas also has the distressing distinction of being the state with the highest rate of maternal deaths in the country–and in the developed world. (Tennessee ranks as 32nd in the country for maternal deaths.)

To be clear, even states with high numbers of Medicaid births have high costs that are overwhelming many hospitals. But one thing is certain: repealing the Affordable Care Act and/or replacing it with one of the Republican plans would make the situation for rural hospitals, and thus pregnant and birthing women, worse.

The choice comes down whether or not we’re willing to continue to let women die from largely preventable pregnancy and childbirth related complications. If we cannot prioritize funding for rural hospitals to remain open and to provide quality, affordable maternity care for the millions of women who need it, then we’re allowing where a woman lives to determine whether she lives or dies.