Americans living in rural areas have worse health across a range of outcomes: heart disease, cancer, opioid use disorders, and pregnancy and birth. Pregnant people living in rural areas are more likely to have severe maternal complications or die than those in urban areas. Hospital and obstetric unit closures and workforce shortages are key contributors. When patients have to travel further to access care, they might skip appointments or even be forced to give birth outside of a hospital. Missing prenatal appointments can prevent physicians from identifying life-threatening complications early, and giving birth outside of a hospital is riskier for the mother. Babies born to mothers who did not receive prenatal care are five times more likely to die. Ensuring access to obstetric services by addressing obstetric unit closures and workforce shortages is the first step in improving maternal health outcomes in rural areas.
The number of rural hospitals that provide obstetric services has decreased since 2004, disproportionately in areas with lower income and higher proportions of non-Hispanic Black women. Fewer than half of rural counties have any hospital-based obstetric services at all. Medicaid covers about half of births in rural areas, a greater proportion than in urban areas. Low reimbursement rates from Medicaid, as well as insufficient grants and other funds to sustain long-term losses continue to threaten the viability of rural hospitals.
Obstetric units are especially difficult to maintain. They need to be staffed constantly by specialized providers, and in some states, Medicaid reimbursements do not even cover the cost of providing obstetric services. Medicaid pays about half of what private insurers do. Unlike in rural areas, in urban areas, reimbursements from private insurers and lucrative surgical services subsidize Medicaid beneficiaries. Lower revenue is not the only challenge though. Workforce shortages make it difficult to keep obstetric units open.
Rural hospitals often have trouble recruiting enough staff to keep maternity wards open around the clock. Fewer medical residents want to pursue obstetrics because this specialty requires regular on-call rotations and allows less work-life balance. Rural health systems have trouble competing with better-resourced urban ones, which do not require providers to do as many on-call rotations and generally have more advanced equipment. Rural providers also often feel isolated because they are less connected to other providers, like sub-specialists who have experience treating rarer conditions.
Because of workforce shortages, rural hospitals contract out for providers, which can cost two or three times as much. Workforce issues are expected to worsen over the next few years. HRSA estimates that by 2030, there will only be enough OB-GYNs to meet 50 percent of the expected demand in rural areas. The Dobbs vs. Jackson Women’s Health decision, as well as the continuing impacts of the COVID-19 pandemic could further complicate efforts to recruit and retain enough staff to maintain obstetrics facilities. States that already have or plan to have bans or restrictions on abortion have even fewer maternity care providers and more maternity care deserts. The pandemic exacerbated burnout issues in rural hospitals that already experienced worker shortages. This will likely have lasting implications on whether rural hospitals can remain staffed and financially viable.
Federal policymakers should consider the following options to expand access to care in rural areas:
- Increase funding to study how telemedicine can be integrated into maternity care: Remote consultations could allow local providers to seek guidance from specialists in larger hospitals or academic medical centers. This could increase opportunities for peer-to-peer collaboration and bring more advanced care to lower resource communities. Some prenatal and post-partum appointments do not require in-person exams. Instead, patients could be given at-home monitoring equipment, such as a blood pressure cuff, and meet with a provider virtually. This could ease transportation barriers and reduce the number of skipped prenatal and postpartum appointments. Additional research is needed to ensure that telehealth appointments provide the same level of care as in-person appointments and rural residents and providers have the tools, such as reliable access to internet, required to make these programs successful. AHRQ has already made strides to understand how digital technologies can be leveraged to improve maternal health. Additional funding would allow AHRQ to continue to support this work and identify opportunities to expand telehealth capabilities in rural areas.
- Enable HHS and academic institutions to research and develop innovative payment models: This research could help policymakers understand how public and private payers can sustain maternity wards in rural areas and ensure high quality of care. Findings from the Strong Start for Mothers and Newborns Initiative under the Center for Medicare and Medicaid Innovation highlighted the need to shift towards more midwifery-led care. Studies show that midwife-led care is associated with higher patient satisfaction, better health outcomes, and lower cost. Some states currently require that midwives practice under a physician or limit them to just one facet of maternal care (e.g., prenatal or labor). Currently, Medicaid is required to reimburse midwives, however, some states reimburse midwives at a much lower rate than physicians who provide comparable services. Additional funding could enable organizations, like AHRQ, to look at how payers can better integrate midwives into perinatal care. Other research might look at how episode-based payments or maternity care homes can improve access to and quality of care.
- Encourage more maternal health providers to practice in rural settings: Programs that provide scholarships, grants, and other financial incentives could enable more providers to practice in rural settings by easing the student debt burden associated with medical education. Other programs might increase rural training opportunities for students. Previous studies have found that residents in rural health-specific family medicine programs had double the chance of practicing in rural setting compared to other family medicine residents. The University of Wisconsin, for example, has a rural residency training program that aims to improve the health of rural women. Additional funding should be allocated to create rural residency and financial incentive programs.
Enabling better and more equitable access to care in rural settings is crucial to addressing the maternal mortality crisis. Increasing funding to develop telemedicine capabilities, innovative payment models, and training and financial incentive programs is the first step. By supporting these policy priorities, policymakers can ensure better access to high-quality, cost-effective care and more equitable maternal outcomes in communities that need them most.
The opinions expressed in this blog post are the author's own and do not necessarily reflect the view of AcademyHealth or of their respective affiliated employers/organizations.