1. Simpson, Kathleen Rice PhD, RNC, CNS-BC, FAAN

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Many women have limited access to basic maternity services in areas of the United States where there are no nurse midwives, nurse practitioners, family medicine physicians, or obstetricians, and no hospital with a maternity unit. They have to travel long distances for care. In 2016, >5 million women lived in counties without a maternity care provider or hospital offering maternity services, and 10 million women lived in area with limited access (March of Dimes, 2018). According to the March of Dimes, a maternity care desert is a county in which access to maternity healthcare services is limited or absent, either through lack of services or barriers to a woman's ability to access that care. There is a higher poverty rate and lower household income in maternity care deserts compared with counties with access (March of Dimes). This is an ongoing crisis. About 100 rural hospitals have closed since 2010; it is estimated that 20% of rural hospitals are at risk of closing (Centers for Medicare and Medicaid Services [CMS], 2019). Less than half of rural counties have a hospital with a maternity unit (CMS , 2019; Hung, Henning-Smith, Casey, & Kozhimannil, 2017).


Lack of near access to maternity care is a significant patient safety issue. Imagine living 50 miles from the nearest hospital with maternity services, being pregnant, experiencing spontaneous rupture of membranes at 28 weeks, and preterm labor contractions. Likely, getting to the hospital is going to take at least an hour or more (under good weather conditions and accessible roads) and be extremely stressful with concern for the baby and an unknown outcome. This will be followed with long-distance travel for the mother and her family to visit the baby in the neonatal intensive care unit. There is disparity in outcomes for women in rural counties with no maternity services compared with women in areas where maternity care is available. Without maternity services, there are more out-of-hospital births, births at hospitals without maternity units, and preterm births (Kozhimannil, Hung, Henning-Smith, Casey, & Prasad, 2018). Teen births (Hamilton, Rossen, & Branum, 2016) and neonatal mortality are higher in rural counties than in large urban counties (Ely, Driscoll, & Matthews, 2017).


There are no easy solutions (CMS, 2019). The March of Dimes (2018) and CMS offer these suggestions. They will require much effort from many stakeholders, policy changes, legislation, and government financial support. Providers should be incentivized to work in underserved areas. Training for rural providers should be expanded. Access must be increased to affordable care for the entire continuum of childbirth. Logistical support and financial assistance must be offered to women to support travel to get care. Care must be regionalized. Telemedicine should be a routine aspect of maternity care (Pflugeisen, McCarren, Poore, Carlile, & Schroeder, 2016). Women in all parts of the United States should have access to high-quality safe maternity care.




Centers for Medicare and Medicaid Services. (2019). Improving access to maternal health care in rural communities (Issue Brief). Baltimore, MD: Author. [Context Link]


Ely D. M., Driscoll A. K., Matthews T. J. (2017). Infant mortality rates in rural and urban areas in the United States, 2014 (NCHS Data Brief No. 285). Hyattsville, MD: National Center for Health Statistics. [Context Link]


Hamilton B. E., Rossen L. M., Branum A. M. (2016). Teen birth rates for urban and rural areas in the United States, 2007-2015 (NCHS Data Brief No. 264) (pp. 1-8). Hyattsville, MD: National Center for Health Statistics. [Context Link]


Hung P., Henning-Smith C. E., Casey M. M., Kozhimannil K. B. (2017). Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14. Health Affairs (Millwood), 36(9), 1663-1671. doi:10.1377/hlthaff.2017.0338 [Context Link]


Kozhimannil K. B., Hung P., Henning-Smith C., Casey M. M., Prasad S. (2018). Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA, 319(12), 1239-1247. doi:10.1001/jama.2018.1830 [Context Link]


March of Dimes. (2018). Nowhere to go: Maternity care deserts across the U.S. White Plains, NY: Author. [Context Link]


Pflugeisen B. M., McCarren C., Poore S., Carlile M., Schroeder R. (2016). Virtual visits: Managing prenatal care with modern technology. MCN. The American Journal of Maternal Child Nursing, 41(1), 24-30. doi:10.1097/NMC.0000000000000199 [Context Link]