Jessica Grange lives in Ward 7 in Washington, D.C. A mom of one with another on the way, Grange has had regular prenatal appointments since January 2021 with her physician, who has an office in both Maryland and D.C.
Grange has had to travel to both offices for care. The office in Maryland is only 15 minutes from her home, but if she needs to be seen at the D.C. office, Grange has to drive 35 minutes or more to make the appointment.
The hospital where Grange will give birth to her daughter later this summer is also 35 minutes from her home. The distance is a source of stress, and Grange has decided she’ll stay at a friend’s house as her due date approaches.
“I fortunately have a friend who lives around the corner from the hospital, so when I go into labor, we’ve already discussed that I will go to her,” Grange says. “That way, [the hospital] will just be right around the corner.”
Grange, like millions of other women in the United States, lives in what’s called a “maternity care desert” — a term coined by March of Dimes to mean a U.S. county where access to maternity care is limited or absent.
“About 54 percent of counties in the country are considered full maternity care deserts or have very limited access to care,” says Stacey D. Stewart, president and CEO of March of Dimes. More than 2.2 million women of childbearing age live in a county that has no hospital offering obstetric care, no birth center and no obstetric provider. An additional 4.8 million women live in counties with limited access to care.
According to the organization’s 2020 report, maternity care deserts have a higher poverty rate and lower median household income than counties with adequate access to maternity care. And although most of these so-called “deserts” occur in rural areas as you might expect, a surprising number — about one-fifth — are in urban areas.
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Take Washington, D.C., where Grange lives: Although it’s one of the largest metropolitan areas in the United States, D.C. has experienced recent changes that have affected access to maternity care for many women.
“We actually had some hospital closures in D.C., and specifically around Ward 7 and 8, that decreased the amount of services available to women,” says Monique Stevens, a certified nurse-midwife and nurse practitioner in the D.C. area who works with March of Dimes on their Better Starts for All initiative to develop programs to increase access to quality health care for pregnant women around the country.
Like Grange, many women who live in maternity care deserts have to travel long distances in order to get prenatal care. “They may have to travel 50, 60, 70 miles, or may have to rely solely on public transportation, where it may take them, you know, 30 to 45 minutes or an hour not only to deliver their babies safely, but even to seek prenatal care,” Stewart explains.
How living in a maternity care desert impacts pregnancy outcomes
The D.C. hospital closures Stevens describes have forced many women in the area to limit how frequently they’re seen by a prenatal care practitioner, either because the distance is prohibitive or appointment availability is limited. As a result, Stevens says, some women are unable to get treatment until later in their pregnancies, which can mean that conditions such as gestational diabetes or high blood pressure have already gotten out of control.
By the time Stevens sees these women through the Better Starts for All program, “a lot of times, if anything is happening, it has already started,” she says, “and already affecting either the mom or the baby or both.”
This is a common problem that occurs in maternity care deserts, and one that Better Starts for All is working to address. The organization is currently running a three-year pilot program in Southeast D.C. and rural parts of Ohio with a goal to reach more than 7,000 pregnant women and provide support that’s lacking in their area through mobile pregnancy care units and telehealth visits.
Stevens works on a mobile health unit bus that provides care to pregnant women in D.C. who are unable to access it on their own. “We can check their blood, we check the baby [and] make sure the baby is growing well, making sure that mom is healthy, eating well,” she says. “We have all of the resources that she needs insurance-wise, pediatrician-wise, if she needs WIC services, those are the things that we help with, even after the baby is born.”
A program similar to the Better Starts for All initiative called the St. Joseph’s Maternity Outreach Mobile Unit, or MOMobile, has been running for the last 25 years in Maricopa County, Arizona which encompasses the cities of Phoenix and Mesa as well as more rural areas such as Prescott and Coconino. The MOMobile is a fully-equipped RV that provides prenatal services in areas of Phoenix with high numbers of uninsured women and those who are otherwise unable to access maternal care.
Guadalupe Herrera-Garcia, M.D., an OB/GYN and maternal fetal medicine specialist with Dignity Health of Arizona (St. Joseph’s Hospital and Medical Center in Phoenix, which operates the MOMobile, is a Dignity Health location), says services provided by these types of initiatives are critical because while most pregnancies are low risk, that status can change in an instant.
“Things can go from everything’s great, we’re going to have a vaginal delivery — to within a few minutes, you can have somebody who’s having a seizure from preeclampsia, a stroke from high blood pressure, they’re hemorrhaging or bleeding out,” she says. “Not having the ability to act on those complications is what really becomes very dangerous to women who are giving birth.”
Women who live in rural areas are especially at risk. The most recent March of Dimes report found that fewer than 10 percent of obstetric providers practice in rural areas, and the National Advisory Committee on Rural Health and Human Services noted in their May 2020 report that maternal mortality in rural areas is 29.4 percent per 100,000 live births compared to 18.2 percent in urban areas. Nationally, the maternal mortality ratio is 16.9 percent per 100,000 live births.
Dr. Herrera-Garcia says she sometimes works with patients through telehealth who live up to 200 miles away in a maternity care desert. And while she’s able to offer virtual support to these patients, being able to immediately treat someone who is either high risk or develops complications is preferable.
In an effort to reach these patients sooner and improve access to maternal care, the state of Arizona has developed a maternal transport line. Because availability of obstetric providers can vary across the state, any Arizona hospital provider can call this number if they have a pregnant patient who may need to be moved to a facility with an OB/GYN on staff.
“Several maternal fetal medicine specialists take those consult calls,” says Dr. Herrera-Garcia. “We can talk to those providers and say, okay, yes, this patient needs to be moved . . . or we can just let them know, okay . . . these are the steps that I want you to take . . . and if something changes, give me a call back.”
Connecting with specialists as soon as possible is crucial, Dr. Herrera-Garcia explains, since women in rural areas might see another provider, but involving a specialist who is better equipped to handle complications that might arise during pregnancy or childbirth can improve outcomes.
Heart disease, the leading cause of maternal death in the U.S., is one such complication. “A lot of times, these [negative] outcomes can be preventable,” said Rachel Bond, M.D., a cardiologist and co-chair of the Women and Children’s Committee for the Association of Black Cardiologists who frequently works with high-risk OB/GYNs to treat pregnant and postpartum patients with heart conditions. “Outcomes such as death or other complications during pregnancy are [often] preventable if you actually have the ability to diagnose them early. In maternal care deserts, a lot of these women unfortunately don’t have that opportunity.”
COVID-19 has impacted pregnancies in maternity care deserts
Even before the COVID-19 pandemic began, the U.S. maternal mortality rate was higher than that of many other developed countries. The stress of treating severe infection and illness, as well as dealing with the hundreds of thousands of deaths caused by COVID-19, has only exacerbated the challenges within our health care system in general, and increased risks for parents and pregnant women specifically.
During the pandemic, some hospitals had no choice but to limit care to pregnant women in order to focus on treating COVID-19 patients, causing moms to delay or miss prenatal appointments, Stewart says.
“At the earliest stages of the pandemic with the overabundance of the hospital staff really focusing in on the care of patients with COVID-19 disease, we know that a lot of the wards that were taking care of these mothers were overburdened and overwhelmed,” says Dr. Bond. In maternity care deserts, where care was already limited or unavailable, this was particularly devastating.
Fear of COVID-19 also meant that some women who could get to appointments were hesitant. For Grange, who learned that she was pregnant in November 2020 amid the third wave of increased COVID-19 infections and deaths in the U.S., going to early prenatal appointments was scary.
“Initially I was reluctant to go into the doctor’s office and then I kind of had to give up on being reluctant because I had to go,” Grange says.
A systematic review and meta-analysis of studies on the effects of the COVID-19 pandemic on maternal, fetal and neonatal outcomes published in The Lancet in March found an increase in maternal deaths, stillbirth, ruptured ectopic pregnancies and maternal depression during the pandemic. Some of these outcomes were also associated with “considerable disparity” between low-resource and high-resource care settings.
There is some good news. At March of Dimes, “we’ve learned a lot in this pandemic around what we could do better in a public health system to provide support for pregnant people and for new moms and babies,” says Stewart.
In particular, many practitioners have become more adept at treating patients through telehealth and virtual care — which is especially helpful for women in maternity care deserts who can benefit from this convenience and flexibility even in non-pandemic times.
“We have really utilized and benefited immensely from telemedicine,” says Dr. Bond. “It’s allowed us, to some degree, to have a better connection with the mothers through the convenience of their home and/or while they’re at work.”
Better Starts for All has also been leaning into telehealth by teaching mothers how to care for themselves and their babies through the computer. ”We can ship them or they can come pick up monitors to track their baby’s heartbeat,” Stevens says. “We provide measuring tapes. We’ll probably provide urine cups. We provide a lot of educational material.”
But there are drawbacks to tracking a woman’s pregnancy virtually.
“One thing that I will stress with a lot of the patients in maternal care deserts is these are vulnerable patient populations and sometimes telemedicine may not be as ideal because it does take a level of trust,” Dr. Bond says.
Dr. Herrera-Garcia agrees, recalling a time she was doing a telehealth visit with a pregnant mom during the pandemic. “I would be talking to a mom about her diabetes, and she’s driving on the highway,” Dr. Herrera-Garcia says. “I would say, ‘You know, this isn’t really an appropriate time because you’re distracted and I wouldn’t want anything to happen to you while you’re driving. You’re also not completely engaged in the conversation that’s happening.’”
In those situations, Dr. Herrera-Garcia says she does the best she can to treat patients, but she does notice that things fall through the cracks. “Prenatal care is the number one thing that’s going to decrease morbidity and mortality when it comes to maternal care,” she said. “It’s not just the talking to the doctor, that’s a big part of it, but it’s also the exam, seeing the patient, the patient becoming comfortable that they can be vulnerable and maybe share with you things that are going on that would affect their care, which can’t often happen when you’re on a video conference call. It’s just not the same.”
If you live in a maternity care desert, here’s what to do
It’s important for anyone who’s pregnant to feel empowered to advocate for themselves to their medical team, but it’s especially crucial if you live in a maternity care desert. All the experts interviewed for this story agreed that education is the number one tool pregnant women in areas with limited maternal care can use to their advantage.
When Grange was pregnant with her son, she was inspired to take a lot of childbirth education courses. She’s now a certified childbirth educator as well as a certified doula. “I have a deeper knowledge about what I need,” she says. “That allows me to be an even stakeholder in conversations with my doctor.”
Of course, it’s not necessary to become a doula in order to advocate for your care. Reading books (like What to Expect When You’re Expecting!) or taking a childbirth class — many of which are now offered online — can help you feel educated and prepared. Many hospitals also have access to additional reading material and virtual classes if you call and ask, Grange notes.
Still, “knowing who [and] where to get care — that’s the hard part,” Stevens says. “It’s hard to advocate for yourself if you don’t know where to go.”
If you live in a maternity care desert and need access to education materials or care, consider the following resources:
Doula services
Prenatal care services
- Better Starts for All: In addition to prenatal care, virtual prenatal education classes are available for the communities that the program works in. Learn more at betterstartsforall.com.
- March of Dimes: The organization can connect pregnant women with programs in their community where Better Starts for All is not available. Call 415-788-2202 to connect with your local office.
- Centering Pregnancy: Centering pregnancy is a group-based model of prenatal care that’s currently offered in 44 states. Learn more at the Centering Healthcare Institute.
Online birthing classes
- Lamaze: Lamaze has online courses, some of which are free. Learn more at lamaze.org.
- The Bradley Method: These courses cover prenatal nutrition, exercise, deep breathing and relaxation tips. Online hybrid courses are also available on their Facebook page. Learn more at bradleybirth.com.
- Alexander: Alexander instruction teaches women how to sit and squat for labor and avoid the natural reaction to tense the body during contractions. Learn more at alexandertechnique.com.
- HypnoBirthing: HypnoBirthing International offers online prenatal and birth education courses you can complete right at home. Learn more at us.hypnobirthing.com.
- Mayo Clinic: The Mayo Clinic’s Understand Birth eClass includes birth stories, comfort techniques, postpartum baby care and more. Learn more at mayoclinic.com.