The United States is facing an ongoing maternity health crisis in which 1 in every 3 counties does not have a single obstetric clinician, affecting women’s access to care, according to a new report.
The report, released Tuesday by the infant and maternal health nonprofit March of Dimes, says that in many parts of the country, obstetrician/gynecologists and family physicians who deliver babies are leaving the workforce, which worsens access to care.
Ob/gyns nationwide delivered more than 85% of babies born in 2022, according to the report, but the American College of Obstetricians and Gynecologists (ACOG) now projects that the nation will face a shortage of 12,000 to 15,000 ob/gyns by 2050.
Additionally, “there’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 Dr. Amanda Williams, interim chief medical officer for March of Dimes.
“We know that, especially following the pandemic, there are many staffing shortages, particularly in nursing,” she said. “And then we have shortages of ob/gyns and family practice doctors and midwives who could be taking on more of the burden.”
Family physicians provide maternity care in some areas where access to ob/gyns is limited or nonexistent, according to the new report. Family physicians account for 1 in 4 obstetric clinicians in rural counties, compared with just 1 in 20 in urban counties, the new report says, and family physicians practicing in rural counties are more likely to report delivering babies than those in urban counties.
The new report also says that the US Supreme Court’s Dobbs decision, which overturned Roe v. Wade in 2022, continues to affect how and where ob/gyns train and deliver care.
“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,” according to the report.
The report added that data from 2021 showed that states where abortion is now prohibited had fewer ob/gyns for every 10,000 births compared with states where abortion rights were upheld.
“In those states that have the strictest abortion bans, there are an increased number of providers who say that it is changing the way that they’re able to take care of their patients,” Williams said.
Where most maternity care deserts are
Overall, more than 35% of US counties are considered “maternity care deserts,” which means there is limited or no access to maternity care there, according to March of Dimes.
In about 1,104 counties, there is no birthing facility or obstetric clinician available to provide care – and these counties are home to more than 2.3 million women of reproductive age.
Women in those counties gave birth to more than 150,000 babies in 2022. But living in a maternity care desert is associated with a 13% higher risk of preterm birth, according to the new report. And about 6 in 10 maternity care deserts are in rural areas.
As more hospitals eliminate obstetric services due to financial challenges related to the Covid-19 pandemic and other factors, the number of maternity care deserts in the United States will “steadily become a more dire situation,” ACOG President Dr. Stella Dantas said in an email.
“This is why ACOG, in addition to advocating for improved reimbursement and decreased administrative burdens, has made it a priority to advance policies that support training and education for nonobstetric health care professionals in a variety of settings. Emergency medical services practitioners need to be able to stabilize pregnant and postpartum patients, especially in rural areas with long transport to a facility with obstetric services,” Dantas said.
She added that ACOG is working with the US Centers for Disease Control and Prevention and the federal Health Resources and Services Administration to provide resources for medical facilities and practitioners in rural areas to help improve their readiness to identify and manage pregnancy-related emergencies.
Because the Dobbs decision is “likely playing a major role” in the shrinking ob/gyn workforce in many rural areas, Dantas said, “we must also vigorously combat legislative interference in the practice of medicine so that clinicians are free to practice without fear of criminalization and patients are able to get the care they need and deserve in the communities they live and raise their families in.”
‘We can now see the impact’
The states with the highest percentage of maternity care deserts include North Dakota, where 73.6% of counties are maternity care deserts; South Dakota, where 57.6% of counties are maternity deserts; Oklahoma with 51.9%; Missouri with 51.6%; Nebraska with 51.3%; and Arkansas with 50.7%.
The new report says that on average, women giving birth in the United States travel about 16 minutes by car to their nearest birthing hospital without traffic, but that driving time climbs to about 38 minutes for residents in maternity care deserts and about 26 minutes for those living in rural areas.
“What’s different about this report is that we can now see the impact of the maternity care deserts,” Williams said.
“We can see that families who live in maternity care deserts are traveling 2.6 times longer to reach a birthing hospital. They are having a 13% increased risk of preterm birth. If you live in a maternity care desert, you are far less likely to have adequate prenatal care,” she said. “We’re now actually able to see what is the impact, so that whether it’s with policy or programming, we can be even more targeted in knowing that we can make a difference in these areas.”
The March of Dimes report also says that more than half – about 52% – of all US counties do not have a hospital that provides obstetric care. Between 2021 and 2022, about 1 in 25 obstetric units closed nationwide.
In 2022, even though 97.7% of births in the United States happened in hospitals, nearly 6 million women of reproductive age – and 1 in 10 babies born – lived in counties without hospital obstetric services, according to the report.
But the United States has seen an increase in the use of birth centers, which provide maternity care services. A freestanding birth center is a health care facility specifically for childbirth, an option for mothers who want to give birth outside of a hospital setting but not at home. Often, a midwife will lead the patient’s care.
From 2017 to 2022, the number of births that happened within birth centers rose 20%, from 19,878 to 23,945, according to the new report.
However, there are just 416 licensed birth centers spread across 270 counties nationwide, and less than 5% are in rural areas. About 70% of all birth centers are within 10 states: Arizona, California, Florida, Idaho, Oregon, Texas, Utah, Virginia, Washington and Wisconsin.
“Birth centers are a way of expanding care for low-risk patients who don’t need a lot of intervention, and those could be leveraged, for example, in communities where there may not be the funding to create an entire hospital or the ability to support a hospital unit, but it could create a birth center that works in conjunction with nearby hospitals,” Williams said.
What’s needed to improve access to care
To improve access to maternity care in the United States, March of Dimes has called for expanded training opportunities to encourage more midwives to join the health care workforce and for investments in telehealth to reach more patients, among other actions.
“We need to expand our ability to take care of patients and low-risk patients really are best taken care of by the experts in physiologic birth, and that is midwifery care,” Williams said.
“Unfortunately, only about 10% of births in the United States are attended by midwives, which is astronomically different from what’s going on in most European countries, where the vast majority of births are attended to by midwives and, of note, there are much lower maternal mortality rates,” she said. In the United States, “we have decreased rates of C-section, decreased rates of preterm birth, if the patients are being taken care of by nurse midwives.”
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The findings in the new report are “quite frightening” and reflect what can result from the underfunding of the public health infrastructure in the country, said Dr. Georges Benjamin, executive director of the American Public Health Association.
“This brings into great clarity the failure of the lack of more concrete health system planning,” Benjamin said.
“And when you look at where these holes in maternity care are in our system, it’s in the same part of our nation that also has inadequate access to health care for health insurance, highest morbidity and mortality for chronic diseases, which is primarily in the South and parts of the midwestern part of the nation,” he said. “We have an enormous lack of health system planning and policies to ensure that people have access to care.”
