Mitigating maternal care deserts

Prepare the nursery. Install the car seat. Make freezer meals. Stock up on diapers. And, for some: research the nearest place to deliver a baby. This may involve traveling for hours, crossing state lines, or even creating a home-birth backup plan in case they simply can’t make it to the hospital in time.

The need to make such dire calculations affects 6.9 million American women, all of whom live either in maternal care deserts — counties in which access to prenatal care, obstetricians or hospitals with birth-giving facilities are absent — or areas with very limited maternal care options.¹

This sobering reality makes it clear that the time is now for payers to do all they can to bridge the gap between the care these members need and the limited options currently available to them. Here, we delve into 5 key factors for payers to keep in mind as they craft their strategy.

According to a report published by March of Dimes, 1,119 American counties — more than a third of the country’s total — fit the description of a maternal care desert, affecting roughly 146,000 births per year. Another 4.7 million women live in areas with limited maternal care options, affecting an additional 300,000 births.² Even worse, the problem appears to be growing, with the number of maternal care deserts increasing by 2% between 2020 and 2022.³

What’s behind this trend? Budget constraints that so often hamstring underfunded hospitals — particularly in poorer communities — are playing a large part. In addition, COVID-19 is estimated to have cost American hospitals billions in revenue.⁴ When cashflow runs dry, the OB unit is often among the first to get the axe.

That’s because maintaining an OB unit is a pricey proposition, requiring an on-call anesthesiologist and a high concentration of staff. It’s also logistically challenging, since any hospital that offers OB services is required to be within 30 miles of a facility that can perform an emergency caesarean section — a significant difficulty for many hospitals, especially those in sparsely populated areas.⁵ Further, many patients in rural regions with high poverty rates rely on Medicaid. (Half the women who give birth in rural areas are covered by Medicaid, compared to about 42% in urban areas.)⁶ And because Medicaid reimburses hospitals at a lower rate than private health insurance, OB units in these communities are particularly unprofitable and thus more likely to close.

The result is a vicious cycle: the women most likely to suffer dire maternal health outcomes — since lower socioeconomic status is a strong predictor of adverse health effects for expecting mothers⁷ — are the same women most at risk of losing their access to maternal care.

When an underfunded hospital is in an area that sees relatively few births, such as a rural region, keeping its obstetric unit up and running becomes difficult to justify. It’s a longstanding issue, according to Brock Slabach, senior vice president of member services for the National Rural Health Association, who noted in a 2017 report that OB services in rural areas have been closing for decades.⁸

That slow disintegration is due to a number of issues, including demographic shifts that have turned rural providers’ attention to aging populations, as well as growing workforce challenges: Currently, fewer than 7% of the nation’s obstetricians practice in rural areas.⁹

Yet a lack of adequate maternal care doesn’t solely affect rural communities. While more than 60% of U.S. maternal care deserts qualify as rural, that still leaves hundreds of deserts in metropolitan areas.¹⁰ Maternal deserts encompass many urban environments — including areas of Washington D.C.¹¹ — and exist in densely populated states such as Texas and Florida.¹² What’s more, these shortages are worsening: some 200 urban counties lost one or more obstetric units between 2019 and 2020.¹³

The United States has the highest maternal mortality rate among comparable high-income countries — and it continues to increase year over year.¹⁴ Decreasing access to medical care plays a major role in this maternal mortality crisis.

Even when mothers’ and babies’ lives are not directly at risk, a lack of obstetric resources creates other adverse effects. Women forced to travel more than 50 miles for prenatal care are at greater risk for high blood pressure,¹⁵ which can in turn increase the likelihood of poor birth outcomes such as preterm birth and low birthweight. Likewise, lack of access to prenatal and postnatal care is associated with a higher risk of preterm birth as well as extended time spent in the hospital post-birth.¹⁶

Compounding the issue? Each of these issues are all but certain to result in greater acute care utilization and higher healthcare spend. For example, the average cost of a preterm birth is $76,153, while the average cost of a low-birthweight birth is $114,437 — a whopping 50% more.¹⁷ Again, a vicious cycle emerges: When hospitals or obstetric units shutter due to financial pressures, vulnerable patients are more likely to incur complicated and expensive births, heaping additional financial stress on individuals and the healthcare system alike.

What’s more, maternal deaths disproportionately impact communities of color and low-income rural communities. The maternal mortality rate is 2.9 times higher for Black women, who experience 55 deaths per 100,000 live births.¹⁸ Rural residents, meanwhile, are 9% more likely to suffer maternal morbidity/mortality than their urban counterparts.¹⁹ Another layer of the crisis is clear: maternal deserts contribute significantly to the unacceptable health disparities that plague U.S. communities.

What can payers do to address this complex issue? Take a comprehensive approach, deploying risk-minimizing strategies and meeting patients where they are each step of the way.

Information sent to newly pregnant or soon-to-be-pregnant members can cover a range of prenatal care topics — everything from the basics of self-care during early pregnancy to answers to frequently asked first trimester questions. Payers can also make this information available on a website or a stand-alone pregnancy-focused app, allowing members to access this targeted content at their leisure.

Telehealth offers a promising solution for filling the maternal care gap. A report from the Kaiser Family Foundation makes clear that numerous forms of prenatal and postnatal care can be effectively conducted via virtual appointments and at-home patient monitoring. These include prenatal care visits, during which the patient can measure her own vital signs and fetal heart rate with a blood pressure cuff and wireless fetal monitor sent to her home; consults with any needed specialists, such as genetic counselors or obstetricians who specialize in high-risk pregnancies; mental health care; general communication between the patient and their OB; virtual postnatal check-ups; and lactation consultations.²⁰ In fact, virtual doula programs are gaining traction around the country, and the potential benefits apply to rural Americans in particular.

Payers may also consider taking the show on the road. Some health plans are chartering their own fleet of mobile prenatal care clinics, or medically outfitted vans or buses that bring prenatal services to areas in need. They can also offer support to similar efforts already in place by partnering with community-based organizations (CBOs). Many such organizations work to provide better access to doulas and midwives for members living in care deserts, as these practitioners have been shown to reduce the rate of caesarean section and other aggressive interventions in low-risk pregnancies.²¹

As America reckons with its severe maternal health shortcomings, it’s increasingly clear that bold action is required. By gaining an understanding of the stark hurdles facing millions of mothers and then working to dismantle these barriers, payers can not only save lives, but also reduce their pregnancy-related spend and dramatically improve a corner of medicine long threatened by constant cuts.

That’s good news for payers, certainly, but it’s even better news for millions of parents-to-be — the ones driving hours each way to receive a simple sonogram, wondering if they will make it to the hospital in time, and living in a system that has let them down for too long. It’s time to invest in them — and in our collective future.