Laboring in a desert

When Dr. Patti Giebink began her OB-GYN career in Sioux Falls, S.D., some of her patients had to drive up to two hours to attend their appointments. “We’re mostly a rural state, so we have Sioux Falls on the east side and Rapid City on the west side, and … not much in between,” Giebink said.

Giebink later moved about two hours west to Chamberlain, population roughly 2,500, in Brule County, surrounded by what the nonprofit March of Dimes designates as “maternity care deserts.” These communities do not have a birthing facility or obstetric clinician, compelling women to drive long distances to receive care.

In Chamberlain, Giebink partnered with a nurse midwife, a general surgeon who could perform cesarean sections, and several family medicine doctors who were certified to do obstetric work. The hospital did not have a neonatal intensive care unit and followed strict guidelines on when a patient should be transferred to a larger facility.

Now retired, Giebink says this system of doctors working together is common in rural communities where a small number of healthcare professionals serve a large, spread-out population. “It works as long as nobody goes on vacation or gets sick,” she said.

Across the country, more than one-third of all counties are maternity care deserts, and more than half lack a hospital that provides obstetric care, according to a March of Dimes’ September report. Hospitals in some rural areas have closed due to financial pressures. The organization estimates that more than 2.3 million women of reproductive age live in areas without easy access to prenatal care. Experts say closing the gap will require innovative efforts to increase the number of providers who are willing and able to serve women who live in these counties.

During a normal, healthy pregnancy, women will typically have 12-14 prenatal visits, according to the National Institutes of Health. That number increases if the mother has potentially dangerous complications, is carrying multiple babies, or if her baby has health complications. March of Dimes defines inadequate prenatal care as starting at or after five months of pregnancy or including less than half the recommended number of appointments.

Women who do not have consistent access to prenatal care are at a higher risk of developing pregnancy complications, premature delivery, and negative birth outcomes, according to the report.

In 2021, GoodRx Research estimated that 9% of U.S. counties have a shortage of primary care providers and over 20% lack sufficient access to hospitals. While a higher percentage of counties face shortages of pharmacies or trauma centers, the routine need for reliable maternity care underscores the dangers of maternity care deserts.

The United States has the highest rate of maternal deaths of any high-income country in the world, according to the healthcare research foundation The Commonwealth Fund. In a review of data from 2020, the U.S. Centers for Disease Control and Prevention found that over 80% of pregnancy-related deaths were preventable.

Prenatal care is about more than just tracking a woman’s pregnancy, said Honour Hill, director of maternal and infant health initiatives for March of Dimes in Alabama. “We’re also talking to [the] mom during prenatal care about her nutrition, about her access to food, about her home life,” she said. “Is there interpersonal violence? Is she in a situation that she doesn’t feel comfortable in?”

More than 200 hospitals in rural areas across the country have been forced to close their delivery services in the last decade, according to the medical industry trade journal Becker’s Hospital Review. Another 31 maternity services have announced plans this year to close, often due todeclining birth rates, low Medicaid reimbursements, and staffing shortages.

The Health Resources and Services Administration estimates that the United States will have a shortage of more than 78,000 registered nurses by 2025. In South Dakota, Giebink said rural hospitals struggle to find nurses. “It’s hard to recruit to small communities that don’t offer all the things that a big community does,” she said, adding that many hospitals have resorted to hiring travel nurses, who often receive higher salaries. “It’s expensive to keep these units open, and it’s hard to get trained, competent people.”

Dr. Steven Braatz, board member of the American Association of Pro-Life Obstetricians and Gynecologists, said scholarships and loan repayment programs for professionals willing to work in underserved areas could help fill the hiring gap.

Braatz has worked for nearly two decades in Northern California at what’s called a federally qualified health center, which focuses on caring for medically underserved communities. He said another way to recruit medical professionals to rural areas could be to market positions as missions or humanitarian service opportunities. “It could be a chance to get out of the city and into a beautiful rural area for a short time and help meet a critical need,” he said.

Some states and organizations have taken steps to bring maternity care to expectant mothers through mobile clinics. Though many state governments and nonprofit organizations already operate mobile medical units, few offer prenatal care. March of Dimes has launched mobile health centers to offer maternity care in Alabama, Arizona, New York, Ohio, and Washington, D.C.

The South Dakota Department of Health launched its Wellness on Wheels mobile clinics in April. The service offers risk assessments and prenatal and postpartum visits with a nurse. The state also provides home visiting nurses through the Bright Start Program and the Families First home visiting program.

Experts say communities also need more options outside of traditional OB-GYNs for maternity care. Rather than just focusing on recruiting OB-GYNs to work in maternity care deserts, March of Dimes’ Honour Hill said more family medicine doctors could be trained to provide obstetric care. And certified nurse midwives could be better equipped to serve rural communities. “It’s not just, ‘Do we have nurse midwives?’” she said. “It’s, ‘Are the nurse midwives able to be paid at a rate that attracts them compared to another state, and are they allowed to practice to the full scope of their ability?’”

More than 75% of states have a path for certified professional midwives, who complete a multiyear training and accreditation program through the National Association of Certified Professional Midwives, to become licensed to practice midwifery. These midwives provide care outside of hospitals and often help women deliver at home or in birthing centers. Unlike certified nurse midwives, CPMs do not have a nursing degree and are not overseen by the regulatory bodies that govern nurses.

In those states that do not recognize their midwifery certification, practitioners can face challenges. Brenda Parrish has worked as a CPM facilitating home births in Georgia for about 30 years. She spent the beginning of her career in south Georgia, where many counties do not have maternity care and she was one of the only local midwives. Georgia is one of 12 states that do not license CPMs, and when Parrish had to transfer a mother from a home birth to a hospital in May, a physician reported her for operating without a license and she was forced to retire early.

“Every one of us that are practicing as CPMs, we are one complaint away from losing our career,” she said.

Without licensure, it is difficult for expectant mothers to know the difference between a trained, capable midwife and someone who is not qualified to offer adequate care. “The fact that we’re not licensed … and because there’s not enough of us, has led to a lot of women either going unassisted and having no one there but their husband, or hiring someone who calls themselves a midwife but doesn’t have a clue,” Parrish said.

New mothers are expected to visit their doctor four to six weeks after birth to check for complications. In rural settings, women who live far from traditional medical care may hesitate to reach out if they have concerns because it is even more difficult to travel with a newborn, said Parrish. She said that’s another advantage of rural midwives because they offer postpartum care for mothers and babies.

“Georgia has one of the highest maternal mortality rates in the entire country, and a lot of it is stuff like this, the moms that slip through the cracks after they go home,” she said. “Mom is a forgotten entity in this whole thing until six weeks, but we’re coming back in the home.”

For women who do not have easy access to care, Hill with March of Dimes said it is critical that a new mother is supported by her family, church, and community. “We can’t have a healthy baby without a healthy mom,” she said, “even in the postpartum period.”