Barriers to Improving Rural Maternal Health

Rural communities face barriers to improving rural maternal health.

Social determinants of health. There are strong links between the social determinants of health — including structural discrimination and social inequities — and obstetric outcomes. Factors that influence maternal health status before and during pregnancy include racial disparities, insurance status, educational attainment, and median income level. Rural residents are more likely to be affected by social determinants of health that contribute to late-onset prenatal care. These include lower household incomes, lower educational attainment, higher rates of uninsurance, and higher rates of public insurance.

Rural women face significant socioeconomic barriers to maternal healthcare. Social and environmental risk factors include poverty and housing instability, housing quality and housing affordability. Evidence suggests that pregnancy increases a woman's risk of homelessness, and housing insecurity poses health risks to pregnant women, including low birthweight and preterm birth. Rural women also face challenges with food insecurity, transportation challenges, and a lack of educational and employment opportunities. Finally, structural racism also drives disparities in maternal and infant health and undermines maternal health and wellness. Structural racism refers to social systems in which governmental and institutional polices and practices reinforce racial inequity and perpetuate racial disparities.

Closure of rural hospitals and obstetric units. The closure of rural hospitals and obstetric units contributes to challenges accessing maternal healthcare in rural communities. The number of rural counties with available hospital obstetric services has declined over time. Reasons for rural hospital obstetric unit closures include staffing issues (provider recruitment and retention), low reimbursement, low birth volume, and financial challenges. Rural hospital closures can limit access to obstetric services, particularly if communities also lack freestanding birth centers and other obstetric providers. These are maternity care deserts, defined by the March of Dimes as "any county without a hospital or birth center offering obstetric care and without any obstetric providers." The March of Dimes Maternity Care Desert Dashboard is an interactive map depicting access to maternity care at the county level.

Workforce shortages. In the U.S., there is a shortage of maternal healthcare providers including obstetricians and gynecologists and family physicians. There are many factors that affect rural workforce shortages. Family physicians commonly attend births in rural hospitals, making the trend of declining family physicians particularly concerning for rural maternal healthcare. There is also a shortage of other healthcare providers who deliver services to women during their pregnancies, including behavioral health providers and dentists.

Lack of care coordination. Rural women lack access to coordinated care, and specifically, coordinated maternal health services, from prenatal through postpartum care. With the closure of rural hospitals and obstetric units, rural women may experience challenges receiving coordinated care. Maternal healthcare in rural communities is provided by specialty providers, family physicians, advanced practice nurses, nurses, certified nurse midwives, community health workers, and doulas.

Limited scope of practice for midwives. Midwifery care improves maternal and newborn health. Certified nurse midwives attend one third of deliveries in rural hospitals. Large volume rural hospitals were more likely to have certified nurse midwives attending births. Regulations on their scope of practice limit their ability to practice.

Insurance coverage. Medicaid is an important payer for perinatal care in rural communities. Many women with Medicaid lose their coverage 60 days postpartum, which creates challenges for getting services after this time. Also, many private insurers do not cover services provided by midwives or offer limited coverage.

Transportation barriers. Rural women face significant transportation barriers to maternal care, which may result in delayed prenatal care. Rural women may face long travel distances to appointments, or lack of transportation options. As a result of rural hospital closures, over half of rural women need to drive more than 30 miles to receive obstetric services, with some needing to drive 100 miles or more.

Lack of access to social and human services. Access to social and human services in rural communities is important to population health. However, access in rural communities is often limited due to an insufficient number of social and human services programs or staff for existing programs. As a result, women in rural communities may not be able to get needed social and human services to support rural health, such as those to address domestic violence/intimate partner violence, income supports, job training, and child care assistance, among others.

Poor physical and mental health. Rural women experience worse health outcomes in comparison to their non-rural counterparts. They have higher rates of chronic disease, smoking, substance use, and unintentional injuries. They are also less likely to receive preventive healthcare such as screenings. Rural women also experience a higher risk for perinatal depression. Exposure to intimate partner violence is one of the main risk factors for common mental disorders that rural women face.

Lack of broadband internet. Access to consistent, affordable, high-speed internet is critical for delivering and receiving healthcare, particularly in light of the shortage of healthcare workforce. Telehealth, remote monitoring, and video chat follow-up services can improve access to maternal healthcare for rural women, reducing the need to travel to receive services. Telehealth care also facilitate access to maternal–fetal medicine services located in other communities. However, a lack of access to broadband internet in rural communities limits access to these services.

Lack of data on maternal health. Rural-specific data are needed to better understand and prevent maternal mortality, including data to better understand racial and ethnic disparities.

Resources to Learn More

Child and Maternal Health in Rural Areas Lags the Nation, Highlighting Barriers to Access
Document
Summarizes key factors that have contributed to negative health outcomes for women and children, including maternal mortality.
Organization(s): The Pew Charitable Trusts
Date: 2/2020

Health Disparities in Rural Women
Document
Describes health disparities for rural women, obstetric and reproductive health outcomes, health services access, availability of specialty women's health services, and workforce in rural areas.
Organization: The American College of Obstetricians and Gynecologists
Date: February 2014

Improving Access to Maternal Care in Rural Communities
Document
Provides information on barriers to accessing maternal care in rural communities, including hospital closures, access to care, insurance coverage, workforce, quality, health disparities, and social determinants of health.
Organization(s): Centers for Medicare & Medicaid Services
Date: 9/2019

Maternal and Obstetric Care Challenges in Rural America: Policy Brief and Recommendations to the Secretary
Document
Describes maternal circumstances and social factors affecting maternal health, including structural and systemic issues; programs available to support women; and policy recommendations.
Organization(s): National Advisory Committee on Rural Health and Human Services
Date: 5/2020