Navigating geographical disparities: access to obstetric hospitals in maternity care deserts and across the United States

Each year in the United States, an estimated 60,000 birthing people experience unexpected outcomes during labor and delivery, or severe maternal morbidities, which have both short- and long-term impacts on their health [1]. Additionally, approximately 750 women die from pregnancy-related deaths [1]. Complications and deaths from pregnancy and childbirth are largely preventable [1, 2], indicating ample opportunity for improvement. Access to healthcare is critical during the perinatal period; however, hospitals that offer maternity care services are not equitably distributed across the country. Further, access to maternity care depends on several other factors, including the availability of obstetric providers, risk-appropriate care, and health insurance [3‐5].

More than 2 million women of childbearing age live in maternity care “deserts” ¹ [6], defined as counties without birthing facilities or maternity care providers [7]. Areas of inadequate access to maternity care are created through systems and policies that deplete community resources. Hospital and maternity unit closures [8, 9], obstetric workforce shortages [8, 9], inadequate Medicaid reimbursement rates [9, 10], and systemic racism and classism [11], have contributed to the increase in more counties with low or no access to care. One-third of all U.S. counties are maternity care deserts, and 60% are in rural areas [7]. Maternity care deserts are associated with an increased risk of pregnancy-related death up to one year postpartum [12]. Birthing people living in rural areas have a 9% greater risk of severe maternal morbidity and mortality from pregnancy and childbirth and are more likely to report difficulties in accessing quality care compared to urban residents [13‐16].

Across the nation, the closure of obstetric hospitals has played a role in the rise of maternity care deserts, resulting in increased distance to care [5, 7]. These extended distances not only discourage the use of preventive care but also impact the overall health and quality of care for individuals during pregnancy and childbirth [17, 18]. The period from early prenatal through late postpartum often necessitates multiple trips to obstetric hospitals to access care, particularly for hospitals that offer comprehensive services from pediatricians, midwives, obstetricians, and family physicians at a single location [3]. In addition to the financial strain and heightened stress and anxiety with increased distance to care [19], the risk of adverse maternal outcomes and neonatal intensive care unit (NICU) admission has been shown to increase with longer travel distances and time to care, even after adjusting for patient characteristics, pregnancy risk, rurality, neighborhood characteristics and delivery hospital NICU acuity [20]. Unlike established standards for reaching a hospital promptly in medical emergencies like stroke [21], there is currently no standardized guideline for the travel time to reach a hospital during an obstetric emergency or for prenatal and postpartum care [22, 23].

We identified 3,991,060 birthing people among 85,396 census tracts across the U.S., D.C., and Puerto Rico and 2,630 hospitals that provide obstetric care. Obstetric hospitals were geocoded with a match score of 99.0%; nine hospitals did not have a match and were manually reviewed using Google Maps to obtain point location data. Four hospitals were excluded after manual review yielded no location data. Drive-time routes were calculated for 99.6% of the total estimated births; eight census tracts did not have calculable road network routes, accounting for less than 0.4% of all estimated births.

Consistent with the findings of prior literature, we found that most of the U.S. population lived within one hour of their nearest obstetric hospital [15, 42‐47]. Our analysis revealed that nearly 94% of the birthing population in the U.S. lived within 30 minutes of an obstetric hospital; however, this percentage decreased to 86% among the birthing population who lived in maternity care deserts. Although the estimated mean travel distance and time to reach the nearest hospital with obstetric services were relatively low (8.3 miles and 14.1 minutes), this study is the first to characterize the geographic accessibility of maternity care deserts.

Birthing people living in maternity care deserts traveled nearly four times farther to reach their closest obstetric hospital than those living in full-access counties (28.1 miles vs. 7.1 miles). In some states, this difference exceeded 40 miles. It is well documented that healthcare access is limited in rural areas; however, our analysis further highlights access barriers for people living in maternity care deserts in urban areas (40% of all classified maternity care deserts). In contrast to the mean travel distance for those living in urban counties (7.8 miles) and rural counties (17.3 miles), the mean travel distance in an urban maternity care desert was 25.0 miles, a difference of 3.2 and 1.5 times farther, respectively. These findings highlight that living in a maternity care desert, whether urban or rural, significantly impacts travel distance to the nearest obstetric hospital. Given the relationship between poor maternal health outcomes and living in a rural area [12‐14], further research is necessary to assess health outcomes among birthing people living in maternity care deserts.

Analysis of mean travel distance and time to the closest obstetric hospital does not account for additional barriers that birthing people in areas of no or low access may face to reach risk-appropriate care. Apart from the journey required at the time of labor, individuals may need to travel multiple times to an obstetric hospital for prenatal, postpartum, or specialty care. Higher level care is typically available in high-volume hospitals with greater resources, including NICUs and specialized staff better equipped to handle rare maternal and infant complications. Studies have shown that maternal and infant outcomes are better in hospitals with high birth volumes than those with low birth volumes. For example, infant survival is greater in high-volume hospitals for both high- and low-risk infants [48]. Additionally, the risk of severe maternal morbidity is greater among obstetric patients who deliver at lower-volume hospitals in rural areas [19, 44]. High-volume hospitals are often located in metropolitan areas where most infants are delivered. In contrast, high-volume hospitals account for only 10% of all obstetric hospitals in rural areas where less than 20% of infants born had a high-volume hospital within 30 miles [44]. Future research should quantify barriers faced by birthing people living in maternity care deserts when seeking more comprehensive care, either by choice or necessity.

Our findings were consistent with others, which found disparities in travel distance by race/ethnicity [49‐51]. For birthing people living in predominantly AIAN census tracts that are located within maternity care deserts, the mean distance to reach obstetric care was 59.0 miles, 2.1 times farther than the distance traveled by those living in predominantly White census tracts in maternity care deserts. We found that, regardless of maternity care access designation, those living in predominantly AIAN census tracts travel the farthest to reach obstetric care compared to birthing people living in all other census tracts. Travel distance is exacerbated for birthing people living in rural areas and on American Indian reservations, where access is limited, and bypassing the nearest hospital to give birth is more common and necessary for risk-appropriate care [49]. States identified in our hot spot analysis for statistically high travel distances to care were overwhelmingly concentrated in areas with high AIAN populations compared to other U.S. states [Additional file 1]. AIANs are two times more likely to die from pregnancy complications than White mothers and Indigenous people living in rural areas have the highest rates of severe maternal morbidity and mortality [50, 51]. These findings highlight the need to address inequities and implement policies that support maternity care for AIAN communities with barriers in distance and time to care.

Our findings revealed disparities in access to obstetric hospitals, for birthing individuals residing in maternity care deserts, rural areas, and predominantly AIAN census tracts. These findings highlight the importance of finding solutions to support populations that reside farther away from maternity care to reduce the risk of adverse outcomes associated with extended travel during pregnancy, childbirth and postpartum. To mitigate these disparities, sustained investment in the obstetric workforce is crucial, along with implementing innovative practices and programs to expand access, especially in maternity care deserts. Addressing systemic inequities demands a multifaceted, multi-sectoral approach that prioritizes healthcare access as a fundamental right and actively dismantles disparities in obstetric care nationwide.