Ellie was 37 weeks pregnant and an hour away from the nearest hospital with obstetric care when she began experiencing shortness of breath and tightness in her chest. An at-home test revealed her blood pressure was spiking, but her home in southern Texas was dozens of miles from proper treatment. Ellie, who did not want her real name used for this report, didn’t know what would happen if she made that drive — and she feared for the safety of the baby she was expecting.
Left with no feasible options, she rushed to a nearby hospital that closed its birthing unit earlier this year. There, doctors decided Ellie needed to be transferred to a hospital with obstetric providers.
She asked to go to Texas Children’s Pavilion for Women in Houston to be with her own obstetrician, whom she saw throughout her pregnancy. But Ellie was mistakenly taken to the wrong hospital, where she underwent an emergency cesarean section.
“It was incredibly traumatic,” she said. “The stress of the transfer and being at the wrong hospital and sudden preeclampsia, it was very intense.”
Hospital closures and a shortage of providers are among the factors worsening maternity care in Texas and across the U.S.
A 2023 report by the nonprofit March of Dimes considers more than one-third of counties in the nation “maternity care deserts,” meaning they do not have a hospital or birth center offering obstetric care and or any obstetric providers.
In Texas, the statistic is worse, with 46.5% of counties characterized as deserts.
In rural areas of the state, 28.4% of women live more than 30 minutes from a birthing hospital, while the same is true for just 3.8% of women in urban areas, according to the report.
The March of Dimes’ 2022 report found 2 in 3 maternity care deserts in the country are rural counties, and only 7% of obstetric providers work in rural areas.
Since giving birth, Ellie has suffered from postpartum depression. But Medicaid in Texas only provides coverage through 60 days postpartum, the current federal minimum. The state plans to extend that to a year postpartum, a change dozens of states have already implemented.
Ellie said she saw a therapist one time after giving birth, but was unable to get another appointment before her Medicaid coverage expired because of high demand. She cannot afford to pay for services out-of-pocket.
Postpartum care is essential for mothers’ mental and physical health, especially for women with chronic health conditions. The March of Dimes finds 1 in 3 pregnancy-related deaths happen in the postpartum period, and the majority of pregnancy-related deaths are preventable.
As of 2021, the maternal mortality rate in the U.S. was 32.9 deaths per 100,000 live births, according to the Centers for Disease Control and Prevention.
Infant mortality rose 3% in the country last year to 5.6 deaths for every 1,000 live births, the most significant increase in two decades, according to the March of Dimes. The United States is one of the most dangerous developed nations for childbirth.
Maternal and infant mortality rates are especially high among Black women and babies born to Black women.
The Supreme Court decision in Dobbs v. Jackson Women’s Health, which overturned landmark abortion decision Roe v. Wade, is leaving women in dozens of states with further gaps in care.
Ellie weighed getting an abortion at the beginning of her pregnancy. She spoke with a friend outside of Texas who offered to help her, since abortions are banned in the state with very limited exceptions. In the end, she was afraid of legal implications at home. Texas has criminalized performing abortions, though its law does not include penalties for the people undergoing the procedure.
“Even though it was something that I felt was potentially wise, I knew that it just wasn’t something that I could legally consider,” she said. “Had it been a legal option, I probably would’ve seriously considered it more.”
Dr. Bhavik Kumar, the medical director for primary and trans care for Planned Parenthood Gulf Coast, said states lacking maternity care and abortion access lead to a double whammy that causes bad outcomes.
“It’s not a coincidence that states that have highly restrictive abortion laws also tend to have the largest swath of maternity care deserts and also don’t really invest in maternity care, whether it’s preconception care, prenatal care or postpartum care,” said Kumar.
Fewer medical school students are applying to residency programs in states with abortion bans, according to the Association of American Medical Colleges. Its analysis shows a 10.5% drop in MD senior OB/GYN applicants in states where abortion is banned in nearly all circumstances.
Many maternity care providers, including the Texas-based Kumar, have chosen to stay in states where abortion is prohibited. But some are opting to leave, worsening the crisis.
“How much pain do I really want to go through and endure?” asked Kim Taylor, a certified nurse midwife in Alabama. “I want to be here. I want to be in Alabama where my family is … and I’m being treated like I don’t belong here and like I don’t deserve to serve my community that I grew up in.”
Her home birth practice, Prattville Midwifery, is located in a county the March of Dimes finds has low maternity care access.
A lot of people go through their birthing process unassisted in the state, Taylor said, and there will only be more women in need of care because of Alabama’s abortion ban. The only exception to the law is if the mother’s life is at risk.
The March of Dimes reported that in 2021, the most recent data available, almost a third of women in Alabama are Black, and according to the CDC, Black women are three times more likely than White women to die from pregnancy complications.
Alabama has one of the highest maternal mortality rates in the country.
“We have an absolute crisis of Black maternal mortality in the United States,” said Nancy Cohen, the president of the Gender Equity Policy Institute. “What our demographic analysis shows is 7 in 10 Black women in America live in states that ban or restrict abortion.”
“There’s going to be an influx of people who need obstetric care and there are not very many obstetric providers, so we need midwives,” Taylor said. “We need people to guide them through.”
But new rules under the Alabama Department of Public Health would make it extremely difficult for midwives to practice outside of hospitals, citing concerns over women’s safety. It now mandates freestanding birth centers, facilities where low-risk patients are guided through the birthing process by midwives, must meet hospital licensing requirements to operate.
Another regulation would require the centers to be within 30 minutes of a hospital. However, 27.9% of women in Alabama don’t live within that distance, and nearly 90% of women in rural areas of the state are not that close to a hospital, according to the March of Dimes.
Midwives and doctors are suing the department with the backing of the American Civil Liberties Union. In early October, a judge ruled that birthing centers that meet national requirements can be licensed while the lawsuit plays out.
Hospitals are shutting down maternity units at alarming rates in Alabama. Three more have closed their doors in recent weeks.
In 2020, Medicaid covered half of the births in the state. Health care providers are reimbursed less for Medicaid-funded births than those paid for by private insurance, a significant force behind obstetric unit closures across the country.
North Dakota has the highest proportion of counties designated as maternity care deserts in the nation, as well as a strict ban on abortions.
The Dakota Hope Clinic, a nonprofit affiliated with anti-abortion rights groups, offers some services including free pregnancy testing, ultrasounds and post-abortion and pregnancy loss support through its clinics in Minot, a city of slightly less than 50,000 and home to Minot Air Force Base, and the much smaller towns of Tioga and Bottineau. However, the clinic’s medical services are very limited and do not compensate for the full range of care women need in North Dakota.
“Abortion is still on a lot of people’s minds and we continue to have about half of our pregnant clients considering abortion, so we talk to them about all their options and make sure they are fully informed of the pros and cons of each,” said Nadia Smetana, the clinic’s director.
Smetana hopes to expand beyond their three clinics in the future to further serve women far from maternity care services.
“We know that the women in the rural communities, they often don’t have the kind of services immediately available that are present sometimes in larger cities,” she said. “We find that even if women came to Dakota Hope when they were first pregnant, they don’t necessarily have a lot of follow-up care.”
Dr. Johnna Nynas, an OB-GYN physician for Sanford Health, works across the border in northern Minnesota, where abortion is legal, in an area surrounded by maternity care deserts facing similar difficulties as North Dakota.
Nynas is based in Bemidji, a city with a population of over 15,000 people. She has witnessed four different labor and delivery units close within five years in the area. She and only a few other OB/GYN providers are trying to give care to the whole region.
There are three Native American reservations around Bemidji, where women are particularly vulnerable to maternal mortality and pregnancy complications.
In Minnesota, 42.3% of Native American women living in areas of high socioeconomic vulnerability have received inadequate prenatal care, according to the National Center for Health Statistics.
“There are so many moving parts. It’s generational trauma, it’s implicit bias and systemic racism that exists within our communities and within health care, and those are hard issues to overcome,” said Nynas.
She is working with other health care organizations to bring more virtual care and education to people facing obstacles to proper maternity care.
Telemedicine should be a “standard of care” for women, said Dr. Elizabeth Cherot, CEO and president of the March of Dimes, but some states will not reimburse for those appointments.
“You’re just continuing to close the door to access,” she said.
Providing women with access to care “means that they can be a whole human being in their life,” said Kumar. “They can be more present for the people in their life, oftentimes including the children that they already have at home.”
