We’ve had the privilege of working with mothers and birthing persons, their babies, and many federal, state, and community partners over our careers. We’ve seen first-hand the importance of high-quality, effective healthcare and the lasting benefits that this care brings to women, children, and their families. This January, as we mark Maternal Health Awareness Day, we’re reminded now more than ever of our collective responsibility to improve maternal healthcare. Despite advancements in care, the maternal mortality rate in the U.S. continues to be alarmingly high, particularly among Black women and those living in rural areas. The issue has only worsened in recent years due to legislative changes, hospital closures, and limited access to essential services. How did we get here and what strategies and innovations do we have to change course? Let’s take a look.
The State of Maternal Health in Rural Communities in the U.S.
By now, many Americans have seen or heard alarming news stories that the maternal mortality rates in this country are among the highest in the developed world. What’s more, according to the Centers for Disease Control and Prevention (CDC), more than 80% of pregnancy-related deaths in the U.S. are preventable.
Communities, doctors, nurses, and health administrators face tough choices. As many states passed restrictions on abortion care, the doctor-patient relationship quickly changed, and fewer providers could offer best practice, comprehensive reproductive healthcare. At the same time, rural hospitals and health centers have struggled to stay open. Since 2005, more than 180 rural hospitals have closed, and maternity wards have been some of the first services cut when hospitals face financial strain. This has created places without maternity care, forcing many expectant mothers to cope with long travel times without public transit options to reach the nearest obstetric facility. The March of Dimes recently reported that of 780 counties classified as having shortages in health professionals, nearly half lacked maternity care (Exhibit 1). The need to travel raises additional issues, from lost wages to child care needs.
Adding to these challenges is the disbanding of some state-level maternal mortality review committees. These committees play a vital role in collecting and analyzing data on maternal deaths. Without the work of these committees, it becomes difficult to track and understand the full scope of maternal health outcomes. That makes it harder to know where a community is making progress and where to implement effective, needed interventions for moms and babies.
Additionally, behavioral health services can be limited, making it difficult for moms to get mental health and substance use treatment during pregnancy, even when providers are available.
Taken together, it’s not surprising that maternal health outcomes are uneven in this country, even though the U.S. spends more on healthcare per capita than any other nation.
Solutions to Improve Maternal Health Outcomes
These are sobering realities to be sure. But states, communities, and partners are taking action to help. Many are actively searching for information and resources and developing or adapting programs to help. Since the launch of the Health Resources and Services Administration’s (HRSA) maternal health hotline on Mother’s Day in 2023, 1-833-TLC-MAMA, administrators report they have received approximately 50,000 calls and texts. With support from HRSA, several states like Texas and California are developing new strategies and innovations to improve maternal health outcomes in rural and other underserved areas.
In San Antonio, Texas, CommuniCare, a prenatal program for refugee families, hired a community health worker (CHW) to help. As a parent and former patient, the CHW is bridging the gap between patients and providers. She provides maternal health education and shares resources and referrals to community-based organizations. This allows time for providers to focus on clinical care. The CHW is an essential member of the care team, attending monthly provider meetings and helping to create and implement whole-person care plans.
Additionally, states like Texas are considering how to sustainably finance CHWs to improve maternal health. The National Academy for State Health Policy collected a snapshot of how states are defining, training, certifying, and paying for the CHW workforce. They have found that states are using a variety of approaches to pay for CHW services, including Medicaid state plan amendments, 1115 demonstration waivers, and managed care organizations.
Like CHWs, doulas can help expand care coverage. In San Marcos, California, TrueCare, a local healthcare network, launched a new doula program that provides comprehensive one-on-one support during all stages of pregnancy, delivery, and the postpartum period. To integrate doula services into existing workflows, TrueCare’s IT department embedded doula encounter templates into their electronic medical record. These templates create a comprehensive patient record, support collaboration between the doula team and clinical staff, and streamline billing and coding efforts for these services.
These are only a few examples of creative ideas emerging across the country. The Millbank Memorial Fund recently featured innovations in rural obstetrics units in Alaska, Colorado, Iowa, Massachusetts, North Carolina, and Texas. Additionally, HRSA released a final report, From Initiative to Impact, on the Enhancing Maternal Health Initiative’s work to bring together federal resources, rural health community expertise and other experts, and lived experience to address the nation's maternal health crisis. The Initiative convened HRSA maternal health grantees from Arizona, Alabama, Georgia, Illinois, Kentucky, Maryland, Michigan, Missouri, Montana, North Carolina, Oregon, and the District of Columbia to develop concrete approaches to improve maternal health care delivery and support. Among its achievements, the Initiative and its experts supported the:
- Development of training resources for maternal health professionals, including educational modules for nurse-midwifery students
- Strengthening of family-centered services to engage family members, including fathers, in maternal health support
- Launching new consumer-friendly tools on HRSA.gov for mothers and families to find free or low-cost services.
A Moment to Reflect on Support to Moms and Infants
Maternal Health Awareness Day is an opportunity to reflect on maternal health in the U.S.—both the needs and the innovations. We have a challenging road ahead to improve maternal health, but we can look to growing evidence on strategies to improve care, such as expanding transportation services, telehealth options, or remote monitoring. We can also listen to and trust mothers, their families, and providers in terms of their needs and recommendations, respectively. Recommendations have included assessing and addressing early risk factors through screening for hypertension, diabetes, behavioral health needs, and substance use. Treating these risk factors could significantly reduce preventable maternal deaths. Additionally, communities can strengthen or re-establish maternal mortality review committees to understand how to prevent future deaths.
Ensuring that all people, regardless of where they live, have access to quality maternal care is essential to improving outcomes for mothers and babies. Working together, we can take meaningful steps toward reducing maternal mortality rates and ensuring healthier futures for families across the country.
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