2020-Maternity-Care-Report.pdf

NOWHERE TO GO:

MATERNITY CARE DESERTS

ACROSS THE U.S.

2020 REPORT

HEALTHY

MOMS.

STRONG

BABIES.

MARCH OF DIMES MATERNITY CARE DESERT REPORT 2

STACEY D.

STEWART

PRESIDENT & CEO

MARCH OF DIMES

oms and babies need us now more than ever. Today in the U.S.,

we face an urgent maternal and infant health crisis that has only

intensiied with the COVID-19 pandemic. Every 12 hours a woman

dies due to complications resulting from pregnancy. Additionally, 2 babies

die each day. These numbers are disproportionately higher for moms and

babies of color. Nothing sums up the state of the situation that we face in

America as well as this one fact: In 2020 the U.S. remains among the most

dangerous developed nations for a woman to give birth.

There are numerous health, societal and economic factors that collectively

contribute to this crisis. Unequal access to health care is one of these

factors. In our 2020 report: Nowhere to Go: Maternity Care Deserts

Across the U.S., we shine a light on the impact of no or limited access to

maternity care on the health of moms and babies. Today, 7 million women

of childbearing age live in counties without access or with limited access

to maternity care. These women are giving birth to more than 500,000

babies a year and this is putting them at risk of serious health complications.

Without access to routine, quality health care these moms and babies

have an increased chance of maternal and infant mortality and morbidity,

including low birth weight and preterm birth.

Communities and policymakers must take immediate action to better serve

the women and children in our country. While no single solution exists to

address limited access to care, in our report we speak to key policy actions

that can create positive change. These policy items include improving

access to quality and aordable preconception, prenatal and postpartum

care (e.g., expand Medicaid, provide coverage to telehealth services, expand

access to midwifery care), focusing on prevention and treatment (e.g., create

paid family leave systems and address social determinants of health) and

expanding research and collection of surveillance data on maternal mortality

and morbidity.

We imagine a nation where every mom and every baby is healthy, regardless

of wealth, race or geography. Providing women with access to quality health

care during the perinatal period is a critical part of this equation. We hope

you join us in this ight for maternal and infant health. Learn about the actions

you can take at BlanketChange.org.

MARCH OF DIMES MATERNITY CARE DESERT REPORT 3

n these diicult and unprecedented times, ensuring the health of moms

and babies remains essential. The year 2020 has brought hardship

across the nation and families are experiencing life in unfamiliar ways.

Where a mom lives and her ability to access health care during pregnancy

are important determining factors for the health of mom and baby. We

believe that where you live should not determine the level of care you

receive.

In our 2020 report on maternity care deserts, we build upon the 2018 report

and continue to identify counties where a woman’s access to maternity

health services may be limited or absent. March of Dimes continually

advocates for increases in health insurance coverage, quality and equity

of maternal health care; this report informs researchers, policymakers

and families alike so that we all move toward the best outcomes for moms

and babies. In addition to information on COVID-19 and pregnancy, this

report includes birth centers as a component of our analysis of maternity

care deserts, a section on the topic of telemedicine, information on

the role of doulas in maternity care and an extended section on policy

recommendations. Since our report in 2018, six percent of counties have

shifted in their maternity care designation; however, only three percent of

these counties moved towards a better designation indicating greater levels

of care.

We know that societal, economic and environmental determinants of health

inluence maternal health outcomes. In addition, structural and systemic

inequities exist in the health care system resulting in health disparities.

There are well known examples of disparities in birth outcomes, such as

racial dierences in the rates of maternal mortality, prematurity and infant

mortality, that have been present for decades. Throughout this report, we

highlight where some of these inequities exist in the context of maternity

care deserts.

As our nation continues to face COVID-19, the serious public health threat

could exacerbate the nations maternal and infant health crisis. Many health

systems and/or hospital-based maternity care centers located in both urban

and rural areas, are facing unprecedented inancial declines that could

necessitate the increased closure of maternity care centers as well as entire

hospitals.

RAHUL

GUPTA,

MD, MPH,

MBA, FACP

SVP & CHIEF MEDICAL

AND HEALTH OFFICER

INTERIM CHIEF

SCIENTIFIC OFFICER,

RESEARCH & GLOBAL

PROGRAMS

ACKNOWLEDGEMENT

This report was supported by RB and their Enfa portfolio of brands, our partner in the Better Starts for All

pilot initiative, aimed at providing easier access to care for moms-to-be in maternity care deserts.

MARCH OF DIMES MATERNITY CARE DESERT REPORT 4

With approximately 10 percent of births nationwide

occurring in counties with limited access to maternity

care, action is needed now to help ensure that all

women receive the care and support they need

before, during and after pregnancy. Policymakers

must take swift action to better serve the women and

children in our country. No single solution will address

the problem of limited access to care; however, key

opportunities include:

SUPPORT ELIMINATING MATERNITY CARE

DESERTS

• Implement perinatal regionalization, a strategy

to improve both maternal and neonatal outcomes.

By coordinating a system of care within a

geographic area, pregnant women would receive

risk-appropriate care in a facility equipped with the

proper resources and health care providers.

• Expand Medicaid for individuals who fall at

or below 138 percent of the Federal Poverty

Level (FPL). New research shows that states that

expand Medicaid improve the health of women

of childbearing age by increasing access to

preventive care, reducing adverse health outcomes

before, during and after pregnancies, and further

reducing maternal mortality rates.

• Expand access to midwifery care and further

integrate midwives and their model of care into

maternity care in all states. This can help improve

access to maternity care in under-resourced

areas, reduce interventions that contribute to risk

of maternal mortality and morbidity in initial and

subsequent pregnancies, lower costs and improve

the health of moms and babies.

IMPROVE ACCESS TO QUALITY AND AFFORDABLE

PRECONCEPTION, PRENATAL AND POSTPARTUM

CARE

• Extend the Medicaid postpartum coverage

period to 12 months. The need for postpartum

services exists well beyond the current limit in

federal law of 60 days after the end of pregnancy.

• Reimbursement for doula care. Support increased

access to doula care as one tool to help improve

birth outcomes and reduce the higher rates of

maternal morbidity and mortality among women

of color in the U.S. In some states, coverage of

doula services is provided under the full range of

private and public insurance programs, including

Medicaid, the Children’s Health Insurance Program

(CHIP), TRICARE and others. Payment levels should

be suicient to support the care provided. Eorts

should be made to make the doula profession more

accessible to people of diverse socio-economic

and cultural backgrounds.

• Provide coverage for evidence-based telehealth

services for pregnant and postpartum

women and support alignment of telehealth

reimbursement approaches across payers.

PREVENTION AND TREATMENT

• Create paid family leave systems that make

beneits available to all workers while also

distributing the responsibility for funding this

system among employers.

• Address determinants of health caused by social,

environmental and economic factors to reduce

disparities to improve health equity.

• Expanding the scope of research on social

determinants of health as fundamental drivers

for population maternal and infant health.

• Engaging in health system reform, including

educating providers on implicit racial bias

to better serve the highest risk populations;

empowering communities through inclusion,

education, social activism and advocacy; and

advancing work to change social and economic

conditions (poverty, employment, low wages,

housing, education, etc.) as well as underlying

health inequities.

RESEARCH AND SURVEILLANCE

• Improve maternal mortality and morbidity data

collection and surveillance and prioritize policy

recommendations from Maternal Mortality Review

Committees.

POLICY SOLUTIONS

AND ACTIONS

MARCH OF DIMES MATERNITY CARE DESERT REPORT 5

Maternity care encompasses health care services

for women during pregnancy, delivery and

postpartum.

There are nearly four million births

in the United States, each year.

Access to quality

maternity care is a critical component of maternal

health and positive birth outcomes, especially in

light of the high rates of maternal mortality and

severe maternal morbidity in the U.S. In our 2018

report, Nowhere to Go: Maternity Care Deserts

Across the U.S., maternity care deserts are

deined as counties in which access to maternity

health care services is limited or absent, either

through lack of services or barriers to a woman’s

ability to access that care. This report builds

upon the 2018 report by updating the maternity

care desert status of all counties based on the

most recent data on availability of hospitals,

birth centers, health care providers and health

insurance.

BACKGROUND

Every year in this country, approximately 700

women die of complications related to pregnancy

and childbirth

and more than 50,000 women

experience severe maternal morbidity, a life-

threatening complication as a result of labor and

delivery.

Maternal Mortality Review Committees

around the country have estimated that 60

percent of maternal deaths are preventable

5,6

and despite many countries around the world

successfully reducing their maternal mortality

rates since the 1990s, the U.S. rate remains

higher than most other high income countries.

In fact, the U.S. maternal mortality rate has been

increasing for the past three decades (Figure 1)

and signiicant racial and ethnic disparities exist

in maternal health care in the U.S. Non-Hispanic

Black women and American Indian/Alaskan Native

women have higher rates of maternal mortality

(3 and 2.5 times, respectively) as compared

with non-Hispanic White women.

Some of this

disparity can be addressed through equal access

to quality health care as a way towards achieving

health equity.

The data indicate women in the

U.S. do not have equal access to maternity care.

This report examines some key factors related

to maternity care access such as access to

hospitals, maternal health care providers and

health insurance. Along with eorts to reduce

preventable maternal mortality and morbidity,

ensuring access to maternity care for all women

has the potential to reduce disparities across the

U.S. and improve birth outcomes for all.

KEY FINDINGS

More than 2.2 million women of childbearing age live in

maternity care deserts (1,095 counties) that have no hospital

oering obstetric care, no birth center and no obstetric

provider.

• In this 2020 report, birth centers were included as an

additional factor used to identify maternity care deserts.

In 2017, almost 150,000 babies were born to women living in

maternity care deserts.

• Among women of childbearing age living in maternity

care deserts, 1 in 3 live in a large metropolitan area or

urban setting.

• Maternity care deserts have a higher poverty rate and

lower median household income than counties with

access to maternity care.

An additional 4.8 million women of childbearing age live in

counties with limited access to maternity care.

• This report combines three factors (access to obstetric

care, obstetric providers and insurance) to identify limited

access counties.

In 2017, approximately 514,000 babies were born to women

living in rural areas.

• Only 8 percent of obstetric providers report practicing in

rural areas.

Due to the addition of birth centers in this 2020 report, 13

counties shifted to a higher level of access to care between

2018 and 2020.

Overall, between 2018 and 2020, 6 percent of counties shifted

in their level of access to care.

• 3 counties moved from a maternity care desert to a higher

level of access to care

• 3 percent of counties shifted to a higher access of care

» Of these counties,

» 14 shifted due to an increase in hospitals

» 44 shifted due to an increase in obstetric

providers

» 5 shifted due to a combination of increases in

obstetric providers, birth centers or hospitals

• 3 percent of counties shifted to a lower access of care

» Of these counties,

» 24 shifted due to a decrease in hospitals

» 52 shifted due to a decrease in obstetric

providers

» 5 shifted due to a combination of decreases

in obstetric providers and hospitals

INTRODUCTION

MARCH OF DIMES MATERNITY CARE DESERT REPORT 6

*Pregnancy-related mortality ratio is the number of pregnancy-related deaths per 100,000 live births.

Source: CDC, Pregnancy Mortality Surveillance System, 1987-2016 (http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html)

Figure 1. Pregnancy-related mortality ratio*, United States, 1987-2016

MARCH OF DIMES MATERNITY CARE DESERT REPORT 7

In this report, March of Dimes (MOD) deines a

maternity care desert as any county without a hospital

or birth center oering obstetric care and without any

obstetric providers. Women may have low access to

appropriate preventive, prenatal and postpartum care if

they live in counties with few hospitals or birth centers

(one or fewer) providing obstetric care, few obstetric

providers (fewer than 60 per 10,000 births) or a high

proportion of women without health insurance (10

percent or more). Moderate access to care is deined

as living in a county with access to few hospitals/

birth centers or OB providers and adequate health

insurance coverage (less than 10 percent of women of

reproductive age uninsured). Full access to maternity

care can be deined by availability of hospitals or birth

centers providing obstetric care and availability of

providers oering obstetric care (Table 1). To further

understand counties with full access to maternity

care, we examined those counties’ levels of uninsured

women. We found that some counties that are classiied

as having full access to maternity care, also have high

rates of uninsured women.

MATERNITY CARE DESERTS

Notes: CNM/CM = certiied nurse midwives/certiied midwife

*U.S. average is approximately 11%. Source: Kaiser Family Foundation

https://www.k.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/

Table 1: Deinitions of maternity care deserts and access to maternity care

Deinitions

Maternity care deserts

Low access to

maternity care

Moderate access to

maternity care

Full access to

maternity care

Hospitals and birth centers oering

obstetric care

zero <2 <2 >2

Obstetric Providers

(obstetrician, CNM/CM)

per 10,000 Births

zero <60 <60 ≥60

Proportion of women 18-64 without

health insurance*

any ≥10% <10% any

MARCH OF DIMES MATERNITY CARE DESERT REPORT 8

Figure 2: Change in county maternity care classiication between 2018 and 2020 Nowhere to Go:

Maternity Care Deserts Across the U.S Report

The inclusion of birth centers into our methodology

improved access in 13 counties in the 2020 report

(Figure 2). Birth centers were included because they

provide an alternative option for women to receive

prenatal care and delivery services outside of the

hospital setting. These centers operate independently

of hospital systems and have autonomy in choosing

patient populations as well as manner of care delivery.

There were three counties that shifted from being

classiied as maternity care deserts to a level of greater

access due to the inclusion of birth centers.

Between 2018 and 2020, 6 percent of counties across

the U.S. shifted between classiications of access to

care. These shifts occurred for varying reasons such

as changes in the number of providers or in health

insurance. Of these counties, 3 percent were classiied

at a higher level of access than they were in 2018.

44 of these counties shifted due to an increase in

obstetric providers. 14 of these counties shifted due to

an increase in hospitals, and 5 counties shifted due to

a combination of increases in obstetric providers, birth

centers or hospitals. 3 percent of counties shifted to a

lower level of access. Of these counties, 52 counties

shifted due a decrease in hospitals. 24 counties shifted

to a lower level of access due a decrease in obstetric

providers.

OBSTETRIC PROVIDERS

AND BIRTH CENTERS

OBSTETRIC PROVIDERS

AND HOSPITALS

BIRTH CENTERS

HOSPITALS

OBSTETRIC PROVIDERS

0 202040

NUMBER OF COUNTIES CHANGED BETWEEN 2018 AND 2020

Better Worse

1424

5

4452

MARCH OF DIMES MATERNITY CARE DESERT REPORT 9

Maternity care deserts [1095]

Low access to maternity care [ 359]

Moderate access to maternity care [251]

Full access to maternity care [1434]

Table 2: Distribution of counties, women and births by access to maternity care

Figure 3: Maternity care deserts, United States, 2018

Source: U.S. Health Resources and Services Administration (HRSA), Area Health Resources Files, 2019

Maternity care deserts

Low access to

maternity care

Moderate access to

maternity care

Full access to

maternity care

Total

Count Percent Count Percent Count Percent Count Percent Count

Counties 1095 34.9 359 11.4 251 8.0 1,434 45.7 3139

Women 15–44yr* 2,232,000 3.5 2,852,000 4.5 1,919,000 3.0 57,133,000 89.1 64,136,000

Births 146,451 3.8 187,964 4.9 123,722 3.2 3,397,363 88.1 3,855,500

MARCH OF DIMES MATERNITY CARE DESERT REPORT 10

One way that quality of health care can be aected

is through the availability of access to care. Since

2010 there has been an increase in the percentage

of rural obstetric units that have closed their doors.

The focus of maternity care deserts is often in rural

areas, but this problem also occurs in urban areas and

areas adjacent to urban centers.

Closing of hospital

maternity care units in cities disrupts continuity of

care and can create barriers to access needed for

prenatal and obstetric services due to issues such as

transportation, inding/coordinating new services and

health insurance. This is concerning if hospital closings

are concentrated in low income areas or contribute

to the exacerbation of racial/ethnic disparities in that

community. Hospital closings in urban areas means

that the remaining birthing care facilities experience a

surge in patient volume and can introduce a new mix

of patient populations into an already stressed health

care setting.

Hospital quality, deined through structural,

organizational and clinical process measures, diers

between facilities that mainly serve Black, Hispanic

or American Indian women compared to a mostly

White-patient population.

In one study, hospitals that

serve Black women were lower-quality as compared

to hospitals that have a higher proportion of White

women receiving care.

These dierences between

hospitals lead to higher rates of morbidity and

mortality for the minority women, especially Black

women.

Black women have died at a rate 2.4 to 3.3

times higher from pregnancy complications than White

women

and it’s been estimated that that up to 50

percent of maternal deaths could be prevented with

focused improvements at the provider, system and

patient levels with the provider level being the most

impactful.

Quality improvement initiatives in hospitals,

such as standardization of care through safety bundles

utilizing protocols/checklists, and sta training on

implicit bias can improve care at all hospitals.

To create a culture of equity, it’s important to address

providers’ implicit bias

—especially when research has

demonstrated providers have the same varying degree

of implicit bias as the public,

and nearly 50 percent of

all providers practicing in obstetrics and gynecology

admit to having some bias.

ACCESS TO AND QUALITY OF CARE

*Source: U.S. HRSA, Area Health Resource File, 2019, Data from 2017 **Source U.S. HRSA, Area Health Resource File, 2019, Data from 2013-2017

Table 3: Access to maternity care and economic characteristics

CHARACTERISTICS OF MATERNITY CARE DESERTS

Characteristic

Maternity care deserts

(n=1095 counties)

___________________________

Mean

Counties with full access to maternity care

(n=1434 counties)

___________________________

Mean

Median household income+ $45,804 $55,761

Women without health insurance (18-64 yrs)* 13.6% 10.7%

Population in poverty** 16.9% 15.1%

Urban Counties 18.1% 49.4%

Characteristic

Urban Counties

(n=206 counties)

___________________________

Mean

Rural Counties

(n=889 counties)

___________________________

Mean

Median household income+ $50,018 $44,827

Population in poverty** 16.1% 17.1%

Women without health insurance (18-64 yrs)* 12.7% 13.8%

Table 4: Urban and rural county maternity care desert characteristics

*Source: U.S. HRSA, Area Health Resource Files, 2019. Data from 2017 **Source U.S. HRSA, Area Health Resource Files, 2019. Data is from 2013-2017

MARCH OF DIMES MATERNITY CARE DESERT REPORT 11

One measure of lack of maternity care access is

the proximity of hospital obstetric services. Women

who live in rural areas have excess risk for childbirth

complications due to both clinical factors and social

determinants of health.

Analysis of trends in hospital

obstetric service closures found a 7.2 percent decline

in the percentage of rural counties with hospital-based

obstetric services in the U.S. between 2004 and

2014.

A total of 179 rural counties (about one in ten)

lost hospital-based obstetric services during those

ten years.

Of these counties, 150 were areas with

less than 10,000 residents, indicating that closures

disproportionately aected more remote areas.

of January 1, 2020, 120 rural health care facilities have

closed.

States in the Southeastern U.S. and lower

Great Plains and those states that have not expanded

Medicaid have the greatest risk of rural health

closures.

The areas where rural facilities are most

likely to close are also those areas of greater need,

experiencing higher levels of negative maternal health

outcomes.

Factors that contribute to hospital closures

include having higher rates of uninsured patients, large

amounts of uncompensated care, inancial distress,

hospital size and community poverty rates.

According to data from the 2018 American Hospital

Association Annual Survey,

there are 5,198 hospitals

in the U.S. and 45 percent (1,418 hospitals) oer

obstetric care services.

While more than two-thirds

of counties in the U.S. have at least 1 hospital (65.1

percent, n=2,043), not all of these hospitals provide

obstetric care. Almost half (45.2 percent, n=1,418) of

counties have at least one hospital providing obstetric

care (Figure 4), which is almost a 2 percent decrease

since the 2018 report. Urban counties are more likely

to have a hospital providing obstetric care than rural

counties (58.0 percent and 37.6 percent, respectively)

but urban counties have fewer hospitals providing that

care per 10,000 births than rural counties (6 hospitals

per 10,000 births in urban counties compared to 17

in rural counties).

In counties with at least 1 hospital

had a higher median income ($54,824 compared

to $48,030) and lower percent of the population in

poverty (15.3 percent compared to 16.5 percent) than

counties with no hospitals.

HOSPITALS

Source: U.S. Health Resources and Services Administration (HRSA), Area Health Resources Files, 2019; American Association of Birth Centers, 2020

Figure 4: Access to hospitals or birth center oering obstetric care by county, United States

MARCH OF DIMES MATERNITY CARE DESERT REPORT 12

Birth centers are another option for women with low-

risk pregnancies to receive delivery services, prenatal

and postpartum care. In general, birth centers are

deined as health facilities that are independent from

hospital systems or physicians and are dedicated to

health care for the perinatal period.

Birth centers

also provide a home-like environment and practice

the midwifery model of care, which emphasizes

a little to no intervention approach to birthing.

Midwives employed at birthing centers often have

relationships with hospital systems in the event that

medical intervention is needed.

Of the 234 birthing centers in the U.S., 98 percent

are located in counties that already have access to

maternity care,

with 16 percent of urban counties

having 1 or more birthing centers and only 2 percent

of rural counties having at least 1 birth center.

Over

the past few decades, less than

1 percent of births in the U.S. have been in a birth

center or at home, however, interest in out-of-hospital

births has been rising.

Midwifery-led models of care

have proven to improve outcomes for socially at-risk

communities.

Analysis in 2018 of nationwide birth

center data shows that women receiving prenatal

care at a birth center had lower rates of preterm

birth, low birth weight and Cesarean delivery and

reduced racial disparities for Black and Hispanic

women.

With midwifery care as the foundation of

birth centers, there’s opportunity to achieve similar

outcomes on a larger scale.

State regulatory

environments for births outside of hospitals are

varied across the U.S. and this may be a factor in

the availability of other options for women.

map showing the density of both birth centers and

hospitals across the U.S. can be seen in Figure 3 on

page 9.

BIRTH CENTERS

MARCH OF DIMES MATERNITY CARE DESERT REPORT 13

Maternity care providers include obstetricians, certiied

nurse-midwives/certiied midwives (CNM/CM), and

family physicians. These providers are distributed

unevenly across the U.S. and approximately half of

all counties lack a single obstetrician,

leading to

access inequities in certain communities such as rural

counties. It’s estimated that fewer than 10 percent of

obstetric providers practice in rural areas.

Shortages

of maternity care providers can result in long waiting

times for appointments and/or long travel times to

prenatal and postpartum care or birth sites. Previous

studies on the availability of obstetricians and CNM/

CM at the county level show distribution of providers

were mostly concentrated around metropolitan

areas.

31,32

Rural communities face further challenges

due to trends in obstetrician movement from rural and

impoverished areas to urban and wealthier areas.

Higher rates of maternal mortality and morbidity

and other adverse birth outcomes among women of

color, and Black women in particular, have prompted

interest in models of care that can improve outcomes,

including midwifery and speciic evidence-based

supportive and preventive care programs developed

and led by midwives.

March of Dimes supports eorts

to increase the number of midwives of color and

diversify the maternity care workforce with individuals

who represent the lived and cultural experiences of the

patients they serve.

In 2017, about half of the 3,139 U.S. counties lacked a

single obstetrician (n=1,512, 48.2 percent), and more

than half of the counties did not have a CNM (n=1,730,

55.1 percent). More than 1,200 counties had neither

an obstetrician nor a CNM (n=1,248, 39.8 percent) and

an additional 508 counties had 60 or less obstetric

providers per 10,000 births (16.2 percent) (Figure 4).

More than 2.9 million women of reproductive age lived

in counties without an obstetric care provider. In 2017,

there were almost 146,000 births in these counties.

Counties with more than 60 or more OB providers

had a higher median income ($55,866 compared to

$47,345) and a lower percent (16.7 percent compared

to 15.1 percent) of the population on poverty compared

to counties with less than 60 obstetric providers.

PROVIDERS

Source: U.S. Health Resources and Services Administration (HRSA), Area Health Resources Files, 2019

Figure 5: Distribution of obstetric providers by U.S. county, 2017

No obstetric providers [1248]

Fewer than 30 obstetric providers [129]

30-60 obstetric providers [379]

Greater than 60 obstetric providers [1383]

Obstetric providers (obstetricians, CNM/CM) per 10,000 births

MARCH OF DIMES MATERNITY CARE DESERT REPORT 14

Most babies in the U.S. are born in a hospital (98.4

percent) and attended by a doctor of medicine (MD,

80.9 percent) or doctor of osteopathic medicine (DO,

8.0 percent). Nationally, nearly 1 in 10 births is attended

by a certiied nurse midwife (9.4 percent) or other

midwife (0.8 percent).

24,35

Eorts to further integrate

health care professionals, such as midwives, into

maternity care could help improve access to providers

and quality of care. In a statement further reinforced by

research, the American College of Obstetricians and

Gynecologists (ACOG) and the American College of

Nurse-Midwives supported that the highest quality of

care for women occurs when physicians and midwives

are working together to provide maternal health care.

March of Dimes encourages states to ensure that their

laws foster access to midwifery care and also supports

eorts to further integrate their model of care, with full

autonomy, into maternity care in all states.

Considerable variation in births attended by midwives

is observed by state. In 2018, the proportion of births

attended by a certiied nurse midwife was 5 percent

or less in Alabama, Arkansas, Louisiana, Mississippi,

Missouri, Nevada, Oklahoma and Texas. More than 1 in

5 births was attended by a midwife in Alaska, Maine,

New Hampshire, New Mexico, Oregon and Vermont in

2018 (Table 4).

Births to American Indian/Alaskan Native women are

more likely than other racial and ethnic groups to be

attended by a certiied nurse midwife (CNM) (19.7

percent compared to 11.2 percent among non-Hispanic

White women). A lower percent of midwives is used

by other women of color (9.4 percent among Hispanic

women, 8.4 percent among Black women and 8.0

percent among Asian/Paciic Islander women).

This

may be because historical American Indian values

and birth practices are more aligned with the way

that midwives provide care.

There’s a long history of

intention behind incorporating CNMs into the Indian

Health Services across the country since the 1960s.

Over decades, changes to maternity care have

created educational pathways, programs and structure

for providers to work collaboratively between

obstetricians and CNMs, which have led to improved

infant outcomes.

Collaborative care has become

the predominant model of maternity care and is a

way to provide culturally-aligned care.

One such

model showed a correlation between higher levels of

collaboration and signiicantly higher rates of positive

birth outcomes, such as vaginal delivery and vaginal

birth after Cesarean, as well as signiicantly lower rates

of Cesarean sections, preterm birth, low birthweight

infants and neonatal death.

Doulas are non-clinical professionals who provide

physical, emotional and informational support to

moms before, during and after childbirth, including

continuous labor support.

They oer guidance

and support around topics related to childbirth,

breastfeeding, pregnancy health and newborn care.

Supportive care during labor may include comfort

measures, information and advocacy.

While there’s

no reliable estimate of the number of doulas in the

U.S., a centralized online doula registration service, not

ailiated with any one certifying organization, had over

10,000 registered doulas in 2020.

Women who receive continuous labor support are

less likely to have medical intervention during delivery

and more likely to have a satisfying birth experience.

Moms who use doulas are also more likely to practice

healthy infant care by initiating breastfeeding and

practicing safe sleep for infants.

Increased access to

doula care in under-resourced communities can help

reduce the eects of social determinants of health by

addressing health literacy, improving patient/provider

communication, social support needs and decreasing

anxiety and depression.

Further evidence tells us that

women who are low income, socially disadvantaged

or who experience cultural or language barriers to

accessing care experience the positive eects of doula

care more strongly.

Women who utilize doula services tend to pay out of

pocket and work in urban areas.

42,43

Access to doula

care is further limited as services are not routinely

covered by health insurance providers. This can

leave those who may beneit the most from doula

care with the least access to it—both inancially and

culturally.

44,45

Insurance coverage for doula support

through Medicaid, the Children’s Health Insurance

Program, private insurance and other programs may be

a way to improve birth outcomes and close the gap in

birth outcomes between African American and White

MIDWIVES

DOULAS

MARCH OF DIMES MATERNITY CARE DESERT REPORT 15

women.

Just like midwives, doulas have the ability

to practice in the homes of patients, which can have

an impact for socially and economically vulnerable

families.

Increasing access to doula care, especially

in under-resourced communities, may improve birth

outcomes, improve the experience of care and lower

costs by reducing non-beneicial and unwanted

medical interventions.

47-49

March of Dimes supports increased access to doula

care as one tool to help improve birth outcomes

and reduce the higher rates of maternal morbidity

and mortality among women of color in the U.S. and

advocates for all payers to provide coverage for doula

services. Additionally, March of Dimes recognizes the

importance of increased training, support and capacity

development for doulas, including doulas from racially,

ethnically, socioeconomically and culturally diverse

communities.

Source: National Center for Health Statistics. Final natality data, 2018

Figure 6: Percent of births attended by midwives, by race/ethnicity, U.S., 2018

Source: National Center for Health Statistics. Final natality data, 2018

Table 5: States with the highest and lowest percentage of births attended by midwife (CNM), 2018

25.0

Percent of births covered by Medicaid

HISPANIC WHITE BLACK AMERICAN

INDIAN

ALASKAN

NATIVE

ASIAN

PACIFIC

ISLANDER

9.4

11.2

8.4

19.7

8.0

Maternal Race/Ethnicity

0.0

5.0

10.0

15.0

20.0

5 states with highest percent of births

attended by midwife (CNM):

Alaska 29.0%

New Mexico 27.5%

Vermont 24.7%

Maine 21.1%

Oregon 20.7%

5 states with lowest percent of births

attended by midwife (CNM):

Arkansas 0.4%

Alabama 1.2%

Mississippi 1.8%

Louisiana 2.8%

Texas 3.6%

MARCH OF DIMES MATERNITY CARE DESERT REPORT 16

Health insurance coverage is a critical aspect of

making health care accessible and aordable for

women. Health insurance is especially important

during a woman’s reproductive years. Lack of health

insurance can be a signiicant barrier to obtaining

regular preventive health care, which may identify

and manage adverse health conditions that may

aect pregnancy such as diabetes, hypertension,

obesity and sexually transmitted diseases.

addition, there’s evidence that adequate prenatal

care beginning in the irst trimester can decrease the

likelihood of adverse birth outcomes.

Women who do

not receive prenatal care are also 3 to 4 times more

likely to have a pregnancy-related death than women

who receive any prenatal care.

Although the rate of

uninsured women ages 19 to 64 has declined since

the passage of the Aordable Care Act, about 1 in 10

(11 percent) women in the U.S. still did not have health

insurance in 2018.

At the state level, the percentage

of uninsured women under age 64 ranged between

3 percent and 23 percent.

This variation is evident

when examining health insurance rates at the county

level (Figure 6). In 2017, about 45 percent (n=1,412)

of all U.S. counties had a greater than 10 percent

proportion of women without health insurance.

Across counties with full access to maternity care, the

variation in health insurance rates is evident. Half (52.7

percent) of the counties with full access to maternity

care have a high proportion of women without health

insurance (10 percent or more). In the U.S., the majority

of counties with a high proportion of women without

health insurance are located in the south.

Four

counties in Massachusetts and 1 county in New Mexico

have the lowest percentage of uninsured women in

the country (2.1 percent) (Figure 6). Counties with the

highest percentage of uninsured women were found

in Texas, ranging from 37 percent to 45.1 percent of

women uninsured (Figure 6).

HEALTH INSURANCE COVERAGE

AMONG WOMEN

MARCH OF DIMES MATERNITY CARE DESERT REPORT 17

Source: US Health Resources and Services Administration (HRSA), Area Health Resources Files, 2019

Figure 8: Counties with the lowest and highest proportion of women without health insurance, 2017

Hampshire, MA

Zapata, TX

Middlesex, MA

Cameron, TX

Plymouth, MA

Starr, TX

Los Alamos, NM

Webb, TX

Norfolk, MA Hidalgo, TX

2.1% 37.0%2.1% 37.7%2.1% 38.2%2.1% 39.0%2.1% 43.1%

Source: US Health Resources and Services Administration (HRSA), Area Health Resources Files, 2019

Figure 7: Women without health insurance, 2017

% Women 18-64 yrs without

health insurance

MARCH OF DIMES MATERNITY CARE DESERT REPORT 18

Access to health insurance is critical before, during

and after pregnancy to identify and treat chronic

health conditions, address behavioral health needs

and plan for a healthy pregnancy. Ensuring access to

continuous care is also important for addressing our

nation’s growing rates of maternal mortality and severe

maternal morbidity. In 2017, 39 states and the territory

of Puerto Rico collected information on insurance

status prior to pregnancy through the Pregnancy Risk

Assessment Monitoring System (PRAMS). The data

reveals that almost 1 in 7 (13.2 percent) women did

not have any health insurance coverage in the month

prior to their pregnancy. This is an increase in health

insurance coverage for women during this critical

period compared to the 1 in 5 women covered in 2015.

The rates of coverage widely range from a high of 95.1

percent in Massachusetts to a low of 69.5 percent in

Oklahoma.

In 2018, Medicaid covered the delivery care costs of

more than 1.6 million pregnant women, or 42 percent

of births in the U.S., who would have otherwise been

uninsured during a critical period for them and their

baby.

The proportion of births covered by Medicaid

varied by state and by county. Between 2008/2009

and 2015/2016, states that expanded Medicaid had

a much greater decline in the uninsured rates for

low-income adults living in rural areas and small towns

compared to states that did not expand (a decline

from 35 percent to 16 percent and 38 percent to 32

percent, respectively).

This inding suggests Medicaid

expansion as a way to help close the gap in health

insurance access between rural and urban areas in

states with disparities in coverage that haven’t yet

expanded.

By federal law, all states must provide Medicaid

coverage to pregnant women with incomes up to 133

percent of the federal poverty level (FPL) through 60

days postpartum. In states that have adopted Medicaid

expansion, many women are now able to remain on

Medicaid once they become moms because of the

higher eligibility threshold for parents in these states.

However, in the 14 states that have not adopted

Medicaid expansion, many women lose Medicaid

coverage 60 days after the birth of their child because

their income is above the eligibility level for parents in

those states.

March of Dimes has long advocated in support of

eorts to extend postpartum Medicaid coverage

beyond 60 days to 1 year. The need for postpartum

services exists well beyond the current limit in

federal law of 60 days after the end of pregnancy,

which was established with the Social Security Act

of 1902. The need for extending Medicaid coverage

to 1 year is rooted in clinical evidence. Since 1986,

when Congress established the 60-day postpartum

period for Medicaid coverage for pregnant women,

we’ve learned much more about pregnancy-related

deaths and delivering postpartum care. Nearly 12

percent of pregnancy-related deaths—not counting

those that were caused by suicide or overdose—occur

43 to 365 days postpartum.

Some states’ analyses

of pregnancy-associated deaths, which include

behavioral health-related causes, ind that 50 percent

or more of deaths occur beyond the 60-day period.

56,57

Currently, the states that have expanded postpartum

Medicaid coverage past the 60-day period include

South Carolina and California with major restrictions.

South Carolina only covers care for addiction treatment

and California only covers care for mental health

conditions.

We must ensure that women maintain access to

coverage and are not subject to disruption in access

to insurance coverage.

Adequate postpartum

coverage enables new moms to obtain the services

they need for a full recovery and to prepare for future

healthy pregnancies. This includes postpartum visits

where their physical, emotional and psychosocial

well-being can be evaluated. For this reason, medical

professionals have recognized the importance of

providing postpartum care and supports during this

time based on each woman’s speciic needs.

This

allows women to receive the treatment needed to

manage chronic conditions that can put them at

higher risk for pregnancy-related complications,

including cardiovascular disease, diabetes and chronic

hypertension. A wide array of conditions, including

mental health challenges, domestic violence and

substance use disorders all play a role in maternal

mortality and broader maternal health outcomes.

Nearly 70 percent of women report at least 1

physical problem in the postpartum period and 1 in 7

experience symptoms of postpartum depression in

the year after giving birth.

60,61

In addition, women with

substance use disorder are more likely to experience

relapse and overdose 7-12 months postpartum.

HEALTH INSURANCE BEFORE, DURING AND

AFTER PREGNANCY AMONG WOMEN

Source: National Center for Health Statistics. Final natality data, 2018

42%

OF BIRTHS IN THE U.S.

WERE COVERED BY

MEDICAID IN 2018

MARCH OF DIMES MATERNITY CARE DESERT REPORT 19

Development of systems for perinatal regionalization

and for the provision of risk-appropriate maternal care

is a key strategy to decrease maternal morbidity and

mortality, including existing disparities, by providing

risk-appropriate care speciic to maternal health

needs.

Emerging data indicate disproportionate

rates of COVID-19 infection, severe morbidity and

mortality in some communities of color, particularly

among Black, Latino and American Indian people.

Social determinants of health, current and historic

inequities in access to health care and other

resources and structural racism contribute to these

disparate outcomes. These inequities also contribute

to disproportionate rates of comorbidities in these

communities that place individuals at higher risk of

severe illness from COVID-19.

The perinatal regionalization movement began in the

1970s when March of Dimes, along with other partners,

published a report entitled Toward Improving the

Outcome of Pregnancy (TIOP) which described an

integrated regional system that stratiied maternal and

neonatal care into levels based on complexity so that

high-risk patients would be referred to higher-level

centers with appropriate technology and specialized

health care providers to address their needs.

order to standardize an integrated system of perinatal

regionalization and risk-appropriate maternal care, this

classiication system establishes levels of maternal care

that pertain to basic care (level I), specialty care (level

II), subspecialty care (level III) and regional perinatal

health care centers (level IV). Similarly, neonatal levels

of care are organized beginning with well newborn

nursery (level I), special care nursery (level II), neonatal

intensive care unit (level III) and regional neonatal

intensive care unit (level IV). Levels of maternal and

neonatal care may not match within facilities, but a

woman who’s pregnant should be cared for at a facility

that best meets both her and her newborn infant’s

needs.

The second and third editions of TIOP, published

in 1993 and 2010, respectively, have continued to

emphasize the importance of establishing both levels

of maternal and neonatal care. Further statements

from organizations such as the American Academy

of Pediatrics, American College of Obstetricians and

Gynecologists and Society for Maternal-Fetal Medicine

have provided clinical support for a coordinated

regional system of care.

68,69

Perinatal regionalization

is managed at the state level, and initiatives such as

the HRSA-led Collaborative Improvement & Innovation

Network (CoIIN) to Reduce Infant Mortality is working

to enhance perinatal regionalization to reduce infant

mortality and improve birth outcomes.

A meta-analysis found that very low birth weight or

very preterm infants born outside of a level III (higher

level of complexity) hospital are at an increased risk

of neonatal death or death before discharge from

the hospital.

A study examining geographic gaps in

access in the availability of obstetric and neonatal care

found that while the majority of women of reproductive

age in the U.S. have access to critical care, there are

signiicant dierences.

Nearly all obstetric and NICU

units were concentrated in urban areas with clusters of

hospitals operating close to each other, which meant

that the majority of the population did have access to

(deined as living within 50 miles of) perinatal critical

care units. However, large geographic areas in this

country were not covered by either of the perinatal

facility zones, indicating a signiicant gap in access for

women in rural areas. In addition, the fastest access

to both obstetric and neonatal critical care for almost

10 percent of women was in a neighboring state,

underscoring the need for coordination between states

as well as within. Also of note, access to obstetric

critical care lagged behind that for neonatal critical

care based on measures such as the number of

nearby maternal-fetal medicine specialists compared

to neonatologists, and the number of hospitals with

obstetric critical care units compared to neonatal

intensive care units (NICUs).

The clustering of

facilities and providers are barriers to accessing

needed services in maternal and neonatal critical care,

and addressing this access gap could help improve

outcomes for both mom and baby.

PERINATAL REGIONALIZATION AND

RISK-APPROPRIATE LEVELS OF

MATERNAL AND NEONATAL CARE

MARCH OF DIMES MATERNITY CARE DESERT REPORT 20

In early 2020, COVID-19, a novel coronavirus, was

identiied in the U.S. Active surveillance has increased

our understanding of the impact this virus has on

pregnant women. According to the CDC, pregnant

women may be at increased risk for severe illness

related to COVID-19 infections.

These women have a

greater likelihood to be hospitalized, admitted to the

ICU and require mechanical ventilation.

An increase

in risk of fatality has not been seen with pregnant

women as compared to non-pregnant women, based

on available data. Despite some studies documenting

possible vertical transmission of COVID-19, the overall

risk appears to be low.

More research is needed in

order to counsel patients on any pregnancy-related

risks of COVID-19 and intrauterine transmission. Among

pregnant women diagnosed with COVID-19, 46.2

percent were Hispanic, 23 percent were Non-Hispanic

White, 22.1 percent were Non-Hispanic Black and 3.8

percent were Non-Hispanic Asian.

Other aspects of this pandemic are indirectly aecting

women’s health care access. The loss of employment,

loss of health insurance and heightened food

insecurity have potential to exacerbate the challenges

in receiving adequate and quality maternity care.

The

inequities raised in this report result in higher rates

of maternal mortality, severe maternal morbidity and

poor birth outcomes and are intensiied with these

additional challenges that disproportionately aect

communities of color. Women in particular are facing

increased unemployment at a rate of 11.2 percent

compared to men (10.1 percent) as of May/June 2020.4

Job loss is also aecting women of color at a higher

rate (Latinas have a rate of 15.3 percent and Black

women at 14 percent).

Pregnant women are experiencing unforeseen changes

to the way they are receiving prenatal care and to

their birth plans.

Providers and health systems have

responded to the need for reduced in-person contact

for maternity care by incorporating telemedicine

into their prenatal care programs. While uptake for

telemedicine had occurred quickly, the transition to

virtual care has been more challenging for women

insured by Medicaid than those who hold private

insurance.

Barriers for all women include language

barriers, Wi-Fi access, child care and lower proiciency

with electronic software.

Social distancing and

child care center closures, school closures, stress

and working from home during the pandemic have

the possibility to further exacerbate challenges to

receiving prenatal care.

A recent survey of more than 14,000 pregnant women

shows the eect this pandemic has had on the way

women are receiving care. (Ovia Health, unpublished

data, 2020). Although the majority of visits appear to

be occurring as planned, with appropriate precautions,

approximately 20 percent of visits were altered. Of

those altered visits, 40 percent occurred online and

35 percent occurred by phone. Approximately 45

percent of women surveyed who received care either

online or by phone were asked to take measurements

at home (weight, belly measurements, blood pressure

or other) and over 60 percent were able to take

those measurements. In order to assure that during

a continued health crisis telemedicine is a viable

option for all women, additional studies are needed

to examine barriers within certain communities. A

worrisome result of the survey was that 40 percent of

the women reported not having received information

about the coronavirus from their provider or hospital.

One solution may be found in prenatal and postpartum

care via telehealth. March of Dimes supports

increasing access to telehealth services for pregnant

and postpartum women. Telehealth is increasingly

used across a range of health care specialties,

including obstetrics, maternal-fetal medicine and

mental health.

There’s reason to focus speciically

on telehealth in maternity care, as in recent years,

telehealth has been incorporated into many aspects

of women’s health care, including: virtual patient

consultation with specialists, remote observation of

ultrasound recordings by maternal-fetal medicine

experts, postpartum blood pressure monitoring using

COVID-19 PANDEMIC AND

ACCESS TO MATERNITY CARE

MARCH OF DIMES MATERNITY CARE DESERT REPORT 21

Wi-Fi connected devices and fertility tracking with

patient-generated data.

Additionally, a robust and

growing body of evidence shows largely positive

outcomes associated with the provision of telehealth

services in maternity care.

Evidence on a range of services and telehealth

domains suggests telehealth services provide

comparable outcomes to traditional methods of health

care delivery. A 2020 systematic review of telehealth

interventions

found that that a number of telehealth

interventions were associated with outcomes known

to improve the health of moms and babies. In

particular, telehealth interventions were associated

with improvements in obstetric outcomes related to

perinatal smoking cessation and breastfeeding.

For

pregnant women, concern over COVID-19 may be

even more heightened than the general public. Most

women have frequent interactions with the health

system during pregnancy for prenatal checkups.

Current COVID-19 precautionary measures of social

distancing, coupled with transportation and newly

developed health care oice procedures make routine

prenatal care more diicult for pregnant women. The

expanded use of telemedicine during pregnancy has

enabled some pregnant women to stay home and

participate in prenatal visits over videoconference or

the phone without coming into the clinic where they

risk COVID-19 exposure.

However, because some

moms will face barriers to using telehealth, additional

considerations on the part of the provider may help

these women to utilize virtual care and minimize

disruptions to care.

Coronavirus Preparedness

and Response Supplemental Appropriations Act,

which broadens coverage and reimbursement for

telemedicine services for Medicare and Medicaid

during this pandemic, is an opportunity to learn best

practices for the future of telehealth services, cost

sharing and reimbursement post-pandemic.

MARCH OF DIMES MATERNITY CARE DESERT REPORT 22

In 2020, March of Dimes re-examined the 2018

Nowhere to Go Report on Maternity Care Deserts in the

United States. The current descriptive analysis utilized

county-level data from the Area Health Resource

File 2017-18 (AHRF) which includes data from the

2017 American Hospital Association (AHA) Annual

Survey, 2017 Small Area Health Insurance Estimates

(SAHIE), and National Center for Health Statistics

(NCHS) natality data (2018). All variables were from

2017-2018 except where noted. Key variables from the

AHRF include hospitals (short term general hospitals

with obstetric care), providers (obstetrician, general,

providing patient care, certiied nurse midwives, 2013),

social determinants of health (median household

income, proportion of the population in poverty, urban

rural continuum, 2013) and health insurance (females

18-64 without health insurance). Urban was deined

as a county within a metropolitan area (1, 2 or 3 on the

urban rural continuum). Rural was deined as a county

with an urban population of 2,500 to 19,999, 20,000 or

more, not adjacent to a metro area, or completely rural

(4 on the urban rural continuum).

Data on population

of women ages 15-44 years was obtained directly from

U.S. Census data.

A county was classiied as a maternity care desert if

there were no hospitals providing obstetric care, no

birth centers, no obstetrician and no certiied nurse

midwives. Counties were further classiied as having

low access to maternity care services if there was one

or less hospital oering obstetric service and fewer

than 60 obstetric providers per 10,000 births, and the

proportion of women without health insurance was 10

percent or greater. Counties were classiied as having

moderate access to maternity care services if there

was 1 or less hospital oering obstetric service and

fewer than 60 obstetric providers per 10,000 births,

and the proportion of women without health insurance

was less than 10 percent. Counties with full access had

either 2 or more hospitals oering obstetric services

or more than 60 obstetric providers per 10,000 births.

Although level of health insurance was not part of

the deinition for access, a separate analysis was

conducted to examine the variation in this important

factor among those counties with full access. After

excluding 11 counties from the analysis because data

was missing from 1 or more components of the access

to maternity care were missing (obstetric hospitals,

obstetrician, CNM, health insurance or number of

births equaled zero), there were 3,139 counties in the

dataset.

Other data utilized for this report include data from the

Pregnancy Risk Assessment Monitoring System (health

insurance before pregnancy, 2017), NCHS 2018 inal

natality ile (Medicaid-covered births, type of provider

attending births). The proportion of women without

insurance by county from SAHIE was obtained through

the AHRF for use in the limited access to maternity

care indicator.

Dierences in methodology from the 2018 report

include the inclusion of birth centers. In the 2018

report the proportion of women without health

insurance was split into two categories greater than

10 percent and less than or equal to 10 percent. In

order to remain consistent with the deinition used in

the 2018 and 2020 report the proportion of women

without health insurance was recategorized to greater

than or equal to 10 percent or less than 10 percent. In

the 2020 report, urban and rural designations were

matched to metro and non-metro designation used in

the urban-rural continuum. Updated data indicates that

the proportion of women lacking health insurance is 11

percent in the U.S.; however, to remain consistent with

the 2018 analysis, 10 percent level was still utilized in

designations.

Limitations: The AHRF is a primary data source for this

report. Estimates in the AHRF come from a variety of

other data sources and are all reported by county.

Suppression criteria, other analytic decisions and data

source limitations are not known for every data source

represented in the AHRF and may skew estimates when

data are aggregated across counties. This report does

not use any geospatial analysis, so, actual distance

to a hospital providing obstetrician services is not

considered. Utilizing county as the level of analysis

provides access to data that’s not available at smaller

geographic areas, but it does not capture access to

services in adjacent counties. The use of OB hospitals

and birth centers do not account for the provision

of prenatal care in other clinical care settings (i.e.,

federally qualiied health care centers, hospital satellite

clinics). The three main components of the main

indicator (hospitals, providers and insurance) do not

account for the quality of the health care received, nor

the appropriateness of the level of care a woman might

receive given particular health conditions. Access by

health insurance for women is based on population

level proportions among women age 18-64 years and

does not account for women who have insurance

during and after her birth through Medicaid.

TECHNICAL NOTES

MARCH OF DIMES MATERNITY CARE DESERT REPORT 23

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MARCHOFDIMES.ORG

HEALTHY

MOMS.

STRONG

BABIES.