Stories from three states show higher risk of pregnancy and childbirth in rural areas, as abortion laws pose complications

Pregnancy-related mortality per 100,000 live births
(Daily Yonder graph, adapted by The Rural Blog)

"Rural women are twice as likely to die from pregnancy complications than women in large metropolitan areas, federal data shows," Sarah Melotte reports for The Daily Yonder. The lack of pregnancy and childbirth care in rural hospitals, especially for high-risk cases, contributes to the problem. And rural women of color and their babies face even worse odds. Stories out of Montana, Nebraska and Texas illustrate the overall trend, made more worrisome fears that that eroding abortion rights will increase the number of high-risk pregnancies. Montana State University sociologist Maggie Thorsen told Melotte that the U.S. is already "the only industrialized country in the world that has a growing maternal mortality rate."

Fewer than half of the nation's rural counties had obstetric services in 2019, a Commonwealth Fund study found. Many hospitals have shuttered them (a trend the pandemic has accelerated), citing expense, lack of personnel, and declining rural birthrates. "Women unable to reach obstetrics units in time to give birth can end up delivering in an emergency room en route to the desired hospital. This can have deadly consequences for individuals with high-risk pregnancies," Melotte reports. "Common complications associated with these births include hemorrhaging, preterm birth, and preeclampsia."

A recent study of Montana maternity deserts illustrates the trend. Thorsen and others found that pregnant Montanans drove an average of 42 minutes from home to give birth, but that trips of several hours were not unusual. About 44% of the state's population lives in rural areas, more than twice the national average, Melotte reports. About half of its counties are maternity-care deserts, and 10% of the state's population—some 93,000 people—live in those deserts.

Native American women in Montana have even higher rates of complications or death in childbirth. Indigenous women (who tend to live in rural areas) are less likely to live within an hour's drive of high-level obstetric services than white women; not many Indian Health Services hospitals in the state provide such services, Thorsen told Melotte.

A story from Nebraska highlights other facets of the issue. Emergency help can be hard to access in rural areas. One rural woman who had preeclampsia called an ambulance, but it took so long to get there that she ended up giving birth in the ambulance, assisted by an EMT who had never delivered a baby, Addie Costello reports for the Flatwater Free Press. Local primary-care physicians can provide some obstetric services, but many are retiring and not enough doctors are replacing them.

Many rural hospitals can't afford to maintain obstetric units since rural births are more likely to be covered by Medicaid than by private insurance. Nebraska Medicaid reimburses at half the private rate, Costello reports. The story also emphasizes health disparities for women of color and their babies.

In Texas, which leads the nation in maternity-ward closures, a recent story presents one of the more extreme examples of a maternity desert: Big Bend Regional Medical Center is the only hospital in 12,000 square miles. It has an obstetric unit, but for more than a year that unit "has closed routinely, sometimes with little notice. Some months it’s been open only three days a week," Claire Suddath reports for Bloomberg. "Big Bend doesn’t really have a choice. In the past two years, almost all its labor and delivery nurses quit. The hospital has tried to replace them, but the national nursing shortage caused by the pandemic has made that impossible. When Big Bend is too short-staffed to deliver a baby safely, its labor and delivery unit has to close."

The staffing shortages also extend to Big Bend's ambulances; the county has two, but only enough EMTs to run one. And when the hospital can't deliver babies, the ambulance must drive a patient to the nearest hospital that can. That means the area's only ambulance is out of pocket for at least five hours.