Reducing maternal mortality in rural America

Women who live in rural areas of the United States are more likely to die from pregnancy-related deaths than urban women, although two thirds of these deaths are preventable. As former governors, we have seen firsthand how access to maternal health care is a major challenge in rural communities. We also know the situation will only worsen in the coming years if no action is taken at the federal level to address hospital closures, workforce shortages, and payment structure issues.  

To address these issues we joined the Bipartisan Policy Center’s Rural Health Task Force, which plans to develop policy solutions to improve access to affordable quality care in rural areas. Without serious policy changes, America will remain  one of the most dangerous places for women to deliver babies in the developed world.

Poor maternal health is a growing concern across the country with mortality rates doubling over the past two decades from 10.3 deaths per 100,000 births in 1991 to 20.7 deaths per 100,000 in 2017. Women in rural areas are experiencing even higher rates at 29.4 deaths per 100,000 compared to 18.2 deaths in urban areas. 

Pregnant women living in rural America face unprecedented barriers to maternity care. Over 100 rural hospitals have closed since January 2010 and nearly 700 rural hospitals are at risk of closure. Three out of four rural women give birth at local hospitals.

When these facilities close, women lose access and health disparities increase as most of these closures are in low-income areas with fewer resources to fill in gaps of care and serve a higher percentage of vulnerable populations such as black women who are four to five times more likely to die from a pregnancy complication than their white counterparts.

Perhaps more significant is the number of rural hospitals that are shutting down their obstetric care units. These hospitals tend to be smaller, privately owned, and in communities with fewer obstetricians. They often have lower number of births and staffing these units is expensive. As of 2014, only 45 percent of rural counties had obstetric services, and this has left many rural women needing to travel up to 65 miles to receive necessary care.  

In August, members of the task force visited a small independent health system in Iowa, Knoxville Hospital and Clinics, that does not offer obstetric services as they are struggling to operate. A top priority for the hospital is filling the 25 beds so they can receive the reimbursements needed to stay open. This story is not uncommon for rural facilities where providing obstetric care is simply not financially viable.

Nationwide, the cost of providing obstetric care is increasing. However, reimbursement rates have not increased with the trend. Medicaid, for example, is a primary payer for rural births but have lower reimbursement rates than private insurers. This environment creates a significant financial barrier for many rural facilities.

Rural areas also face workforce shortages across all provider types including those who practice maternal and primary care. According to the American College of Gynecologists, only six percent of ob-gyns practice in rural areas.

To strengthen access to quality care, we must expand the rural maternal care workforce. Healthier outcomes for moms and babies are more likely to occur with consistent and quality care. 

In September, BPC’s team traveled to Maine to visit a Critical Access Hospital which has struggled to retain qualified providers. However, Maine Medical Center in partnership with Tufts School of Medicine developed a program called Maine Track which is coming to the rescue. Now medical students from Tufts spend most of their time training and learning in Maine.

So far, the program has been successful in attracting and keeping physicians in rural health care. There is ample evidence that physicians are more likely to practice where they train. We need more pipeline programs like Maine Track that can help mitigate rural health workforce shortages. 

Maternal health and mortality are critical issues impacting families in rural areas and needs immediate attention. Improving access to health-care facilities, building a quality workforce, and providing adequate payment models for rural providers will significantly improve outcomes for moms and babies in rural communities across the country. 

Ronnie Musgrove served as governor of Mississippi from 2000 to 2004. Tommy Thompson is a BPC senior fellow who served as governor of Wisconsin from 1987 to 2001 and U.S. Secretary of Health and Human Services from 2001 to 2005. Both serve as co-chairs of the Bipartisan Policy Center’s Rural Health Task Force.