By John Dube, JHBL Staff Member
Introduction
Maternity care in the United States inadequately serves pregnant people. Compared to all other industrialized nations, the U.S. has the highest rate of maternal mortality, with more than one infant death for every 5,000 births.[1] Structural inequalities permeating society are largely responsible for this healthcare crisis.[2] Federal and state governments, through policy reform, ought to resolve these issues by humanizing pregnancy and by providing equitable access to maternal care.[3]
Background
Maternity care deserts, or areas in the U.S. where no obstetric care exists, effectively illustrate the maternity care crisis in the United States.[4] These areas lack hospitals offering obstetric care, privately operated obstetric providers, or autonomously run birthing centers.[5] As of 2022, 36% of counties across the U.S. are considered maternity care deserts.[6] Approximately seven million pregnant people live in maternity deserts.[7] Generally, maternity care deserts are located in rural communities.[8] In 2020, nearly half of rural hospitals in the U.S. stopped providing obstetric care.[9]
Maternity care deserts exacerbate the high rate of maternal mortality in the U.S. A study conducted in Louisiana indicated women living in maternity care deserts are three times more likely to die during pregnancy or up to a year postpartum compared to those living closer to maternity care centers.[10] Another study conducted by the Centers for Disease Control and Prevention comparing thirteen states, suggests that communities with limited access to maternity care significantly contribute to the rising incidence of maternal mortality.[11] Moreover, compared to white women, the maternal death rate for black, indigenous, people of color (“BIPOC”) is nearly three times higher.[12] Furthermore, the maternal mortality rate is higher for women living in rural areas than for women living in urban settings.[13]
These deaths are not inevitable. A study conducted in 2020 suggested that two-thirds of pregnancy related deaths were preventable.[14] A lack of access to healthcare delays enrollment in prenatal care, thus increasing risk to the pregnant person’s health and the neonate.[15] Without this access to obstetric care, the risk of complications leading to death during pregnancy and at birth increases.[16]
The cost of healthcare is one factor contributing to the existence of maternity care deserts and consequently, the high maternal mortality rate in the U.S. Half of the pregnant people in the U.S. are on Medicaid.[17] Additionally, Medicaid covers 60% of pregnant people in BIPOC communities.[18] However, largely because of the lower rates it charges providers, Medicaid pays hospitals far less than private insurers for medical services rendered.[19] One study suggested that Medicaid paid just over $6,000 for one birth, while a private insurer paid over $18,000.[20] While wealthier communities include people whose private health insurance offsets Medicaid costs, low-income and rural communities have too few private insurance holders to effectively offset Medicaid costs.[21] Between March and June of 2022, eleven healthcare systems announced the closing of maternity units, citing rising costs of maternity care combined with low birth rates, as the reason for the closures.[22]
In conjunction with the costs associated with maternity care, structural racism also plays a significant role in the existence of maternity care deserts, and the lack of access to maternity care, generally.[23] In this way, structural racism contributes to the high maternal mortality rate in the U.S. Systemic racism creates segregated hospitals and leads to the inequitable distribution of resources, restricting low-income and BIPOC communities’ access to healthcare.[24] Therefore, when compared to white populations, people in BIPOC communities are more likely to live in maternity care deserts or places in the U.S. with restricted access to maternity care.[25] Moreover, one in four Native American babies, and one in six black babies, are born into areas with restricted access to maternity care.[26] Furthermore, black women, regardless of where they live, are twice as likely to experience health risks associated with pregnancy than white women.[27]
Analysis
Increased access to community-based care may remedy the maternity care crisis in the U.S. Community-based care is generally characterized by the integration of midwives and doulas into maternity care.[28] Midwives are trained obstetric providers that offer pregnant people support throughout their pregnancy.[29] Doulas offer similar care and support as midwives, but they generally are not trained to render obstetric care.[30]
Using doulas and midwives may decrease the cost of maternity care, and thus provide pregnant people more access to healthcare. One study calculated that, if 10% more midwives were used in low-risk pregnancies instead of an exclusive reliance on hospital services, the healthcare industry could save more than $10 billion annually.[31] Another study illustrated how using doulas throughout pregnancies saved Medicaid about $1,000 per birth.[32] These costs savings are logical consequences of community-based care considering how using midwives and doulas generally leads to fewer costly medical interventions during pregnancy.[33] Less medical intervention may result in fewer hospital bills for Medicaid to reimburse, consequently passing monetary savings on to providers and pregnant people.
Additionally, doulas and midwives may increase access to maternity care by breaking down racial and cultural barriers.[34] Midwives and doulas are often members of the same communities to which their patients belong.[35] This gives them the experiential knowledge they need to act as allies and advocates for the people they serve.[36] With this knowledge, midwives and doulas can breakdown the systemic racial and cultural barriers that medicalized pregnancy, and work to humanize pregnant people in the eyes of other medical providers.[37] By being heard, and in having more control over their pregnancies through community-based care, pregnant people may experience less stress throughout their pregnancies, thus lowering the maternal mortality rate.[38]
Federal and state governments ought to play a role in promulgating policies that increase access to maternity care through community-based care. Pregnancy is a societal issue because it is heavily influenced by society’s medicalization of birth.[39] Therefore, the state, as a societal regulator, has a duty to mitigate the costs and structural inequalities that exacerbate the inequitable access to maternity care.[40] Today, the federal government already advocates for policies that expand community-based care, including advocating for the removal of barriers to licensure and insurance coverage for midwives and doulas, requiring implicit bias training for healthcare workers, and expanding Medicaid to cover maternity care services for longer periods of time.[41]
Conclusion
“Call the Midwife” is a TV series produced by the BBC that addresses many of the issues relating to maternity care that are discussed in this post.[42] In one episode, a midwife argues for increased public funding to support their efforts to provide community-based care.[43] During one scene, the midwife explains, “We value every infant, and every mother, equally. We are part of their world, and they are part of ours, because that is what happens when you enter people’s homes!”[44] May this model of community-based care similarly drive this country’s call to action to humanize maternal health, and thus provide equitable, unbiased healthcare that safeguards the value of all pregnant people.
Disclaimer: The views expressed in this blog are the views of the author alone and do not represent the views of JHBL or Suffolk University Law School.
John Dube is a 2L J.D. candidate at Suffolk University Law School. He received his B.A. in Political Science from the College of the Holy Cross. At Suffolk Law, John is a legal research and writing TA, and provides research assistance to a professor who writes extensively on law student health and well-being.
Sources
[1] See Roni Caryn Rabin, Rural Hospitals Are Shuttering Their Maternity Units, N.Y. Times (Feb. 26, 2023), https://www.nytimes.com/2023/02/26/health/rural-hospitals-pregnancy-childbirth.html [https://perma.cc/AX87-T4PT]. See also Andrea Sonenberg & Diana J. Mason, Maternity Care Deserts in the U.S., JAMA Network (Jan. 12, 2023), https://jamanetwork.com/journals/jama-health-forum/fullarticle/2800629 [https://perma.cc/3ADX-GSPJ].
[2] See Maeve Wallace et al., Maternity Care Deserts and Pregnancy-Associated Mortality in Louisiana, 31 Women’s Health Issue 122, 122-23 (2021). See also Nora Ellmann, Community-Based Doulas and Midwives, CAP (Apr. 14, 2020), https://www.americanprogress.org/article/community-based-doulas-midwives/ [https://perma.cc/T4KM-RM5D]; Cross-Cutting Initiative: CMS Maternity Care Action Plan, CMS (Dec., 2022), https://www.cms.gov/files/document/cms-maternity-care-action-plan.pdf [https://perma.cc/6VYL-GB63] [hereinafter Cross-Cutting Initiative].
[3] See Ellmann, supra note 2; see also Cross-Cutting Initiative, supra note 2. See also Grace Walter et al., Family Physicians Providing Obstetric Care in Maternity Care Deserts, Am. Fam. Physician (2022), https://www.aafp.org/pubs/afp/issues/2022/1000/graham-center-obstetric-care.html [https://perma.cc/LR6D-LYWD]; Jennifer Hickey, Nature is Smarter Than We Are: Midwifery and the Responsive State, 40 Colum. J. Gender & L. 245, 247, 289-300, 308-11 (2020).
[4] See Rachel Treisman, Millions of Americans are Losing Access to Maternal Care: Here’s What Can Be Done, NPR (Oct. 12, 2022), https://www.npr.org/2022/10/12/1128335563/maternity-care-deserts-march-of-dimes-report [https://perma.cc/G6DC-5UXV].
[5] See id.
[6] See id. See generally Nowhere to Go: Maternity Care Deserts Across the U.S., March of Dimes (2022), https://www.marchofdimes.org/sites/default/files/2022-10/2022_Maternity_Care_Report.pdf [https://perma.cc/TL9Q-KWFY] (setting forth study referenced in Treisman article).
[7] See Rabin, supra note 1.
[8] See id. Despite maternity deserts occurring mostly in rural areas, maternity deserts do exist in urban areas or in the suburbs where hospital closures may restrict access to maternity care for women and pregnant people. See Wallace, supra note 2, at 123.
[9] See Rabin, supra note 1.
[10] See id.
[11] See Wallace, supra note 2, at 123.
[12] See Sonenberg & Mason, supra note 1; see also Ellmann supra note 2.
[13] Kathleen Knocke et al., Doula Care and Maternal Health: An Evidence Review, ASPE 1, 1 (Dec. 13, 2022), https://aspe.hhs.gov/sites/default/files/documents/dfcd768f1caf6fabf3d281f762e8d068/ASPE-Doula-Issue-Brief-12-13-22.pdf [https://perma.cc/H9U6-LRP6].
[14] See Treisman, supra note 4.
[15] See id.
[16] See Rabin, supra note 1.
[17] See id.
[18] See Knocke, supra note 13, at 3.
[19] See Rabin, supra note 1; see also Robin Rudowitz et al., 10 Things to Know about Medicaid: Setting the Facts Straight, KFF (Mar. 6, 2019), https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/ [https://perma.cc/86DW-R999] (explaining lower cost of Medicaid for services rendered).
[20] See id.
[21] See id.
[22] See Sonenberg & Mason, supra note 1. See also Treisman, supra note 4.
[23] See Knocke, supra note 13, at 3; see also Wallace, supra note 2, at 123.
[24] See Wallace, supra note 2, at 123, 127.
[25] See Ellmann supra note 2; see also Rabin, supra note 1.
[26] See Treisman, supra note 4.
[27] See Wallace, supra note 2, at 127.
[28] See Treisman, supra note 4. Community-based care also includes healthcare services provided by independently practicing family doctors, many of whom currently work to mitigate the maternity care crisis. See Walter, supra note 3.
[29] See id.
[30] See id.
[31] See Sonenberg & Mason, supra note 1.
[32] See Ellmann supra note 2.
[33] See id.
[34] See Ellmann, supra note 2. See also Rabin, supra note 1 (providing example of community-based healthcare providers trained to respect Native American culture surrounding birth).
[35] See Ellmann, supra note 2.
[36] See id.
[37] See id.
[38] See Knocke, supra note 13, at 4-5; see also Ellmann supra note 2; Hickey, supra note 3, at 312.
[39] Hickey, supra note 3, at 289-300.
[40] See id., at 247.
[41] See White House Blueprint for Addressing the Maternal Health Crisis, White House 1, 3, 5, 6 (June 2022), https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf [ https://perma.cc/GL4T-UZQ2]. See also Cross-Cutting Initiative, supra note 2 (outlining similar policies as those set forth by the White House).
[42] See Q&A With Heidi Thomas, Creator, Writer & Executive Producer of Call the Midwife, PBS, https://www.pbs.org/call-the-midwife/q-a-with-heidi-thomas [https://perma.cc/HVJ5-ZLJQ] (last visited Feb. 28, 2023).
[43] See BBC, Facebook (Mar. 25, 2020), https://www.facebook.com/bbc/videos/565628094301667/.
[44] Id.