An alarming new study by the Rural Health Research Center at the University of Minnesota shows a huge gap in a vital area of health services -- maternity care.
Giving birth is becoming more complicated and potentially more dangerous for the 28 million women of childbearing age who live in America's rural counties, according to the report, which looked at the availability of obstetric services in 1,984 rural counties over a 10-year period.
A major finding: More than half -- 54 percent -- of rural counties had no hospitals with obstetric services in 2014, a jump from 45 percent in 2004. The decline in maternity services was greatest in counties with large African-American populations and in states with strict rules for Medicaid eligibility, said Katy B. Kozhimannil, one of the study's authors and an associate professor at the University of Minnesota School of Public Health.
What does it mean to not have a hospital with obstetric services relatively nearby? For many women, it can mean a two-hour-plus car ride in labor to get to the nearest hospital for delivery. It also means the same long transportation times for prenatal doctor visits.
That means many rural mothers-to-be who can't take time off of work, can't find child care for their other children and don't have access to transportation simply don't get prenatal care, said Kozhimannil.
The results can be devastating. Kozhimannil is quick to point out that the Rural Health Center's study doesn't make a direct correlation between lack of obstetric care and outcomes. But other research, particularly from Canada shows that the further a woman has to drive to give birth, the higher the rate of neonatal complications and infant mortality.
This dearth of rural maternal care might be exacerbated by the recent push to make severe cuts in Medicaid. Few people realize that Medicaid pays for 50 percent of all births in the U.S., according to Kozhimannil. That number jumps to 59 percent in rural areas.
At the same time, rural hospitals are likely to depend more on Medicaid funds to operate in general. Under financial duress they may be the most likely to close their obstetric units. That's because babies are unpredictable and unprofitable. It takes a lot of money to staff an obstetric unit 24/7 with knowledgeable doctors and, importantly, obstetric nurses who can be on call at any time when a birth happens.
Rural hospitals in low-income areas don't have enough high-end maternity patients, whose fees can help subsidize Medicaid births, to keep operating. "We know that Medicaid pays half of what private insurers pay for births," said Kozhimannil.
In every state, pregnant women have a higher income eligibility status to receive Medicaid than regular adults. This is probably what keeps any obstetric units open at all in rural hospitals, speculates Kozhimannil. If Republican efforts to give states limited Medicaid block grants succeed, eligibility requirements for pregnant women may get stricter as states look to find ways to distribute fewer federal Medicaid funds.
At the same time, the Center's study reveals that counties in states with the strictest pregnancy eligibility requirements for Medicaid are more likely to have no obstetric care.
What can women do?
If you or a loved one lives far from a hospital equipped for birthing, here are some steps you can take to help increase your chances of a safe delivery.
First, talk you your primary care physician, or any midwives, doulas or other maternity care providers in your area about delivery plans and transportation. Determine that you have someone with flexibility who can drive you, that you have money for gas and you know exactly where to go.
Ask your doctor about possible programs in your state that will cover transportation costs for pregnant women.
And don't always follow the standard maternity advice. Waiting to go to the hospital until contractions are five minutes apart is a good practice in a big city, but for rural moms with two-hour drive times, that could mean a roadside delivery.
Also, consider this advice from rural moms who have been there: Try to find a place to stay nearby the hospital as you approach your due date. It may be the home of a friend or family member or someone who's part of a birthing network designed to help with this problem.
There are lots of inconveniences to leaving home so close to a new baby arriving, but if you can decamp, you may find the birthing is much safer and easier.
In Washington, the Improving Access to Maternity Care Act has passed the House and is waiting for introduction in the Senate. It would require the Department of Health and Human Services to collect data on areas that need maternity care and provide student loan forgiveness for obstetric work in those areas.
Despite the current budget-cutting push, Kozhimannil is optimistic this act will pass. "Rural health care access and supporting moms and babies are bipartisan," she said. "The spirit is this is something we can invest in right now."