Intended for healthcare professionals


Declining access to US maternity care is a systemic injustice

BMJ 2023; 382 doi: (Published 07 September 2023) Cite this as: BMJ 2023;382:p2038
  1. Katy Backes Kozhimannil, distinguished McKnight university professor and director12
  1. 1Division of Health Policy and Management, University of Minnesota School of Public Health, Minnesota, USA
  2. 2University of Minnesota Rural Health Research Center, Minnesota, USA

The problem of medically underserved areas requires structural change, writes Katy Backes Kozhimannil

Access to healthcare is an internationally recognised human right, but the United States is failing at honouring this right for people who are pregnant.1 Research documenting the scope and consequences of declining access to maternal healthcare, especially in rural areas, has been amassing over the past 10 years.23 News stories have followed, and policy makers have paid attention. In 2018 Congress passed the Improving Access to Maternity Care Act.4 Yet, despite evidence, media attention, and policy action, the situation isn’t getting better.

Nowhere to Go: Maternity Care Deserts Across the US, a 2022 report from the non-profit organisation March of Dimes, highlighted ongoing and worsening gaps in access to care during pregnancy, childbirth, and the postpartum period, concentrated in rural and low income communities.5 For example, the report said that in 2022 more than 2.2 million women of reproductive age lived in counties with no maternity care access, an uptick since the organisation’s 2020 report—indicating that 15 933 women lost local maternity care access over those two years.

A poorly tackled problem

The central role of social determinants in health outcomes is now widely acknowledged, yet research and recommendations still often focus on individual and clinical risk factors. The structural and political changes necessary to reverse inequitable resource allocations across various areas of healthcare in the US haven’t been put into action, perpetuating the statistics bemoaned in report after report.6

In maternity care, the very language we use to describe this problem, such as “maternity care desert,” points to the errors we’re making in tackling it. Firstly, naturally occurring phenomena—such as deserts—are distinct from structurally designed inequities that result in medically underserved areas. The term “maternity care desert” obscures the deliberate policy decisions that allocate resources to some communities and not to others.

Additionally, the word “desert” is used in this context to imply a vacuous, empty space, when the US’s deserts are in fact thriving environments that have been home to Indigenous people for thousands of years. Indigenous people, especially those living in rural communities, have among the least access to care and some of the worst maternal health outcomes in the US.789 Using the term “desert” in this context is therefore not only inaccurate but a cause of further harm and erasure to Indigenous people and tribal nations living on desert lands. It would be more accurate to describe places without healthcare explicitly as such, while directing attention towards the decisions and structural inequities that have left entire communities without access to care.

Most areas lacking maternity care are rural.5 Structural urbanism, which sees healthcare systems built around the needs of people in heavily populated areas, means that many features associated with rurality are systemically under-resourced in healthcare financing.10 For example, volume based payments constitute the basis of revenue generation for facilities and clinicians. For obstetric services the fixed costs of staffing, equipment, and facilities are difficult to cover with volume based revenues when facilities and clinicians have few pregnant patients. This leads to workforce shortages and unit closures in more remote, less populated areas. Additionally, nearly half of births in the US are financed by Medicaid,11 a government programme of health insurance for people with lower incomes. Medicaid reimburses at substantially lower rates than private insurers, so facilities and clinicians caring for lower income patients in remote rural areas face exceptional challenges in generating revenue for obstetric services.

Another structural factor that plays a crucial role in maternity care access is racism.12 In rural and urban areas, maternity unit closures are more common in communities with higher proportions of Black residents,212 and racial inequities in access and outcomes are shamefully persistent and in need of explicit policy attention.13

Access and equity require ambitious policies

The March of Dimes report lists a number of potential policy solutions.5 The first recommendation is to expand Medicaid to cover everyone at or below 138% of the federal poverty level. This move has been found to improve many healthcare outcomes in states that have adopted it,141516 but it hasn’t reduced the number of obstetric unit closures17 and therefore isn’t a sufficiently targeted strategy to reverse declines in maternity care access.

Other Medicaid related policy recommendations—increasing income eligibility for parents and extending postpartum coverage—are well justified by extensive literature showing that Medicaid improves equity and maternal health outcomes.1819 Yet such incremental policy adjustments still don’t tackle fundamental challenges of maternity care financing: reliance on volume based payments and the discrepancy in reimbursement rates between Medicaid and private insurers.

The March of Dimes report recommends investing in data collection and quality improvement,2021 and state perinatal quality collaboratives can do many things to improve maternity care access, especially in rural areas.22 Yet the problem of communities lacking access to care before, during, and after pregnancy requires more ambitious policy goals, with a focus on structural risks and investing in community infrastructure.2324 For example, exploring options for cost based reimbursement, such as the Critical Access Hospitals programme, could support the financial viability of facilities in low volume settings. Similarly, the newly established designation of facilities as rural emergency hospitals under the Centers for Medicare and Medicaid Services could be expanded to include a wider range of basic and emergency obstetric services in communities without hospitals or birth centres.25

Not having access to care during pregnancy and childbirth is all too common in the US and often has dire consequences. As states enact abortion restrictions and curtail reproductive health services this has far reaching effects—including for all care related to pregnancy and childbirth.26 Many of the clinical, social, and psychological consequences of lacking maternity care are well known,3272829 but some are poorly understood and are intimately personal, affecting the life trajectories of individuals, families, and communities.

Local access to reproductive, prenatal, obstetric, and postpartum care is essential, and policy solutions need to focus squarely on the structural injustices and systemic failures that have created and reproduced the statistics that alarm us. As the closest place to give birth becomes further and further away for many people, these facts should no longer be surprising. Our dismay must give way to decisive action to ensure that all communities have access to maternal and reproductive health services.


  • Competing interests: I have received funding to conduct research on rural maternity care from the Federal Office of Rural Health Policy (FORHP), the Health Resources and Services Administration (HRSA), and the US Department of Health and Human Services (HHS) under PHS grant 5U1CRH03717. The information, conclusions, and opinions expressed in this paper are those of the author, and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.

  • Provenance and peer review: Commissioned; not externally peer reviewed.