The maternity care crisis in the US

Overall, the March of Dimes report found that 1,104 U.S. counties, or 35.1% of all counties, were designated as maternity care deserts, which do not have a single obstetric provider. In addition, over half of U.S. counties do not have a hospital that provides obstetric care outside of emergency situations.

Currently, over 2.3 million reproductive aged women live in maternity care deserts, and over 150,000 babies were born to women living in these areas. An additional 3 million women live in counties that have limited access to maternity care.

According to the report, the average percentage of uninsured women in maternity care deserts was two times higher than those living in areas with full access. Maternity care deserts were also more likely to be in rural areas, and people living in maternity care deserts had lower median household incomes than those living in areas with more access. 

The states with the highest percentage of maternity care deserts were North Dakota (73.6%), South Dakota (57.6%), Oklahoma (51.9%), Missouri (51.6%), Nebraska (51.3%), and Arkansas (50.7%). People living in maternity care deserts have to drive an average of 38 minutes to reach the nearest birthing hospital, compared to the overall U.S. average of 16 minutes.

Individuals living in maternity care deserts also face greater health risks, having a 13% increased risk of preterm birth. They are also more likely to receive inadequate prenatal care, which could increase the risk of pregnancy complications and poor health outcomes.

The report also recognized racial disparities in maternal care. For example, Black patients were more likely to receive inadequate prenatal care (21.9%) compared to white patients (11.1%) between 2020 and 2022. Black people were also 1.5 times more likely to experience preterm births compared to other racial/ethnic groups.

In addition, a separate report from the National Bureau of Economic Research found that obstetricians were more likely to perform unnecessary cesarean sections (C-sections) on Black patients, putting them at a higher risk of serious complications such as ruptured surgical wounds.

In the report, researchers analyzed almost 1 million births at 68 hospitals in New Jersey and found that Black patients were around 20% more likely to give birth via C-section compared to white patients. These additional surgeries on Black patients were also more likely to happen when hospitals had no scheduled C-sections.

According to the researchers, the findings suggest that racial bias, along with financial incentives, may impact doctors' decision-making when it comes to C-sections for Black patients.

How abortion laws are affecting ob/gyns and patients

According to the March of Dimes report, the U.S. Supreme Court's Dobbs decision, which overturned Roe v. Wade in 2022, has impacted how and where ob/gyns train and deliver care to patients.

"In states with the most restrictive abortion laws, physicians face severe consequences, including the potential risks of losing their medical licenses and imprisonment for providing abortions, including ones that are medically necessary," the report said.

Currently, the American College of Obstetricians and Gynecologists predicts that the United States will face a shortage of 12,000 to 15,000 ob/gyns by 2050.

"[T]here's been a significant uptick in, say, the last five years in terms of hospitals closing their obstetric units, with staff shortages, poor reimbursements, low birth volumes, all of those are influencing the hospital's decision to close obstetric units and leaving patients with very limited choices about where they can have their delivery," said Amanda Williams, March of Dimes' interim CMO.

Meanwhile, research suggests that the overturning of Roe has also pushed more people to seek out tubal sterilization to prevent pregnancy.

In a new study published in the Journal of the American Medical Association, researchers analyzed insurance claims for 4.8 million women ages 18 to 49 between January 2021 and December 2022. In states that effectively banned abortions, the sterilization rate increased from an average of 3.6 per 10,000 women in the 18 months before the Dobbs decision to 5 in 10,000 women by December 2022 — a 39% increase.

Jacqueline Ellison, an assistant professor at the University of Pittsburgh's School of Public Health, said the study's findings pose important questions about how the general population was responding to the Dobbs decision.

"To me it suggests that people are experiencing fear and anxiety around the ruling, either for their ability to get an abortion or even to access contraception in the future," Ellison said.

Advisory Board's maternal health and health equity resources

For more insights on maternal health and health equity, check out these Advisory Board resources:

Read our take on how to address the root causes of maternal health inequity. Similarly, this research outlines five steps to take to improve women's health and well-being.

Health plans are also making efforts to improve maternal health and reduce disparities. This research outlines health plans' top three maternal health priorities, including expanding reimbursement for midwives and doulas, increasing postpartum coverage, and implementing new technological tools.

Organizations interested in launching their own midwifery programs can also use this white paper, which outlines key tactics and explains how to overcome common implementation challenges. We also offer a cheat sheet on postpartum depression care.

For a broader look at maternal health in America, this Radio Advisory episode discusses key drivers of poor maternal health outcomes and explains why there needs to be a massive shift in how the healthcare industry thinks about maternal health going forward. (AHA News, 9/13; March of Dimes report, accessed 10/8; Howard, CNN, 9/10; Kliff, New York Times, 9/10; Schmall, New York Times, 9/12)