Maternal mortality and rural access to services

This blog has recently touched on many topics concerning rural children, including newborns and opiate addictions, children and guns, education issues, child abuse, children with disabilities, and rural brain drain. But even before rural children begin facing these issues, pregnant women in rural areas must overcome multiple obstacles to give birth to these children.

Access to maternal health care in rural America is on the decline. Only 6.4% of OB/GYNs practiced in rural communities in 2008, and by 2010, 49% of the counties in the US did not have a single OB/GYN. These counties were predominately rural. As a result, "fewer than half of rural women live within a 30-minute drive of the nearest hospital offering obstetric services," and around 88% of women live an hour or more from such services.  

With the lack of access to maternal health care, both maternal and infant mortality are significantly higher in rural areas. In 2015, maternal mortality was 29.4 per 100,000 live births in rural areas, compared to just 18.2 in more metropolitan areas. 

Credit: Amanda Montañez; Source: CDC

According to researchers, there are a number of reasons for this disparity: geographic access, poor prenatal care, and/or underlying health conditions like diabetes or hypertension. However, one theory may be found by looking closely at what has recently happened in Texas.

While the worldwide rate of pregnancy related deaths is declining, Save the Children's 2015 report "State of the World's Mothers" showed that the United States performs worse than any other developed nation in maternal death. For example, a woman in the US is 10 times more likely to die from a pregnancy related cause during her reproductive years than a woman living in Austria, Poland, or Belarus.

One of the most shocking statistics I've seen recently is that the rate of pregnancy related deaths in Texas has more than doubled over the last few years. Between 2006 and 2010, the number of maternal deaths in Texas changed very little, with the lowest number being 69 in 2009 and the highest being 82 in 2008. However, the numbers rapidly increased to 148 in 2012, 140 in 2013, and 135 in 2014.

For those who have been following the blog for a while, you are probably very familiar with Lisa Pruitt's coverage of HB2 and it's effect on closing women's health clinics throughout Texas (see here, here, here, here, here, here, here, and here). As Pruitt points out, these closures are especially harmful in rural areas, where women were forced to travel over 200 miles to reach the nearest clinic. It's not difficult to link these clinic closures to the rise in maternal deaths. Yet, the Texas Department of State Health Services believes drawing a correlation between HB2 and the rise of maternal morality "isn't fair," that there is "no evidence," and the clinic closures "wouldn't have taken effect till September 2011 and it would have taken months to be reflected" in data.

Despite these data, in 2017 the Texas Legislature has only "sparingly mentioned" the issue of maternal deaths in the most recent legislative session, and the maternal mortality rate has not been listed as a top priority. (Meanwhile, two of the "top priority" issues that the legislature does have time for are: SB 8- "Fetal Tissue/Partial Birth Abortion" and SB 20- Prohibiting Abortion Insurance Coverage.")

While none of the data on the rate of maternal deaths in Texas has specifically investigated the rurality of the decedents, if we draw a connection between the closure of clinics and the increase in deaths, it would seem logical to infer that the closures may be disproportionately affecting rural women.

With this information in mind, we can zoom back out to the general issues of rural maternal healthcare throughout the US. Various groups have proposed solutions to his problem: allow telemedicine for prenatal care (though many rural areas struggle with access to internet), change laws so certified nurse midwives can take on more clinical responsibilities, launch OB/GYN residency programs in rural areas, and adopt the Improving Access to Maternity Care Act. The Act would provide student loan forgiveness for OB/GYN work in rural areas. (Interestingly, the Act was sponsored by a Texas representative who has strongly promoted the defunding of Planned Parenthood clinics.)

However, the problem still remains that OB/GYN care is difficult for rural hospitals and we are in a time where rural hospitals are floundering. Eighty percent of rural hospitals have closed since 2010, and the ones that remain open are underfunded and vulnerable to closure. In rural areas the typical hospital patient tends to be older, poorer, and less healthy than people who live in more metropolitan areas.

When rural hospitals need to cut their budget, OB/GYN units can be a tempting target. OB/GYN units are one of the pricier programs for a hospital and can account for more than 5% of the total hospital costs. Because of the older population in rural areas, fewer residents give birth at rural hospitals and it "makes it difficult for hospitals to financially justify having maternity wards at all."