Consistent with the findings of prior literature, we found that most of the U.S. population lived within one hour of their nearest obstetric hospital [15, 39–44]. Our analysis revealed that nearly 94% of the birthing population in the U.S. lived within 30 minutes of an obstetric hospital; however, this percentage decreased to 86% among the birthing population who lived in maternity care deserts. Although the estimated mean travel distance and time to reach the nearest hospital with obstetric services were relatively low (8.3 miles and 14.1 minutes), this study is the first to characterize the geographic accessibility of maternity care deserts.
Birthing people living in maternity care deserts traveled nearly four times farther to reach their closest obstetric hospital than those living in full-access counties (28.1 miles vs. 7.1 miles). In some states, this difference exceeded 40 miles. It is well documented that healthcare access is limited in rural areas; however, our analysis further highlights access barriers for people living in maternity care deserts in urban areas (40% of all classified maternity care deserts). In contrast to the mean travel distance for those living in urban counties (7.8 miles) and rural counties (17.3 miles), the mean travel distance in an urban maternity care desert was 25.0 miles, a difference of 3.2 and 1.5 times farther, respectively. These findings highlight that living in a maternity care desert, whether urban or rural, significantly impacts travel distance to the nearest obstetric hospital. Given the relationship between poor maternal health outcomes and living in a rural area [12–14], further research is necessary to assess health outcomes among birthing people living in maternity care deserts.
Analysis of mean travel distance and time to the closest obstetric hospital does not account for additional barriers that birthing people in areas of no or low access may face to reach risk-appropriate care. Higher level care is typically available in highvolume hospitals with greater resources, including NICUs and specialized staff better equipped to handle rare maternal and infant complications. Studies have shown that maternal and infant outcomes are better in hospitals with high birth volumes than those with low birth volumes. For example, infant survival is greater in high-volume hospitals for both high- and low-risk infants [45]. Additionally, the risk of severe maternal morbidity is greater among obstetric patients who deliver at lower-volume hospitals in rural areas [41, 46]. High-volume hospitals are often located in metropolitan areas where most infants are delivered. In contrast, high-volume hospitals account for only 10% of all obstetric hospitals in rural areas where less than 20% of infants born had a high-volume hospital within 30 miles [41]. Future research should quantify barriers faced by birthing people living in maternity care deserts when seeking more comprehensive care, either by choice or necessity.
Our findings were consistent with others, which found disparities in travel distance by race/ethnicity [47–49]. For birthing people living in predominantly AIAN census tracts that are located within maternity care deserts, the mean distance to reach obstetric care was 59.0 miles, 2.1 times farther than the distance traveled by those living in predominantly White census tracts in maternity care deserts. We found that, regardless of maternity care access designation, those living in predominantly AIAN census tracts travel the farthest to reach obstetric care compared to birthing people living in all other census tracts. Travel distance is exacerbated for birthing people living in rural areas and on American Indian reservations, where access is limited, and bypassing the nearest hospital to give birth is more common and necessary for risk-appropriate care [47]. States identified in our hot spot analysis for statistically high travel distances to care were overwhelmingly concentrated in areas with high AIAN populations compared to other U.S. states [Additional File 1]. AIANs are two times more likely to die from pregnancy complications than White mothers and Indigenous people living in rural areas have the highest rates of severe maternal morbidity and mortality [48, 49]. These findings highlight the need to address inequities and implement policies that support maternity care for AIAN communities with barriers in distance and time to care.
Strengths and Limitations
There are several limitations of this study worth noting. We analyzed driving time and distance to the nearest obstetric hospital in the U.S.; however, the average birthing person may bypass their closest obstetric hospital to receive more comprehensive or better-quality care. In some circumstances, insurance coverage may not extend past a birthing person’s state of residence, and several of the closest points of care in our analysis included obstetric hospitals in states that crossed residential borders. We did not specify day start or stop times to account for fluctuations in traffic conditions or weather seasonality where driving conditions could impact travel time. GIS analyses of drive times were based on car transport calculations and are not generalizable for bus or public transit travel. Due to these limitations, in addition to using census tract weighted point locations rather than patient addresses, the results likely underestimate the actual travel distance and time to reach obstetric care.
Despite these limitations, our results are derived from extensive and validated datasets and are generalizable to hospital deliveries, accounting for 98% of all U.S. births in 2022 [33]. In addition, response rates of the AHA hospital data vary across states and health systems; however, validation using CMS data allowed for accurate identification of hospitals with obstetric care available across the nation. Our GIS analysis used population-weighted centroid locations to account for where the majority of birthing people reside in each census tract. Census tract centroids allowed for greater granularity in calculations of travel distance and time. ArcGIS Pro Network Analyst Extension allowed us to obtain the shortest driving distance and times to care using live data for streets, railroads, and ferries. The use of transport network analysis enabled us to model real-time world phenomena in road travel and is the recommended method to estimate geographic accessibility instead of using straight-line Euclidian distance [40, 50–52].
Implications
A lack of access to maternity care is a complicated issue that requires innovative and diverse solutions. Although the mean distance and time to care is low in much of the U.S., additional barriers persist. Maternity care deserts deserve closer study to determine how we can continue and improve services in these areas. Continuing investment in healthcare infrastructure is critical—this includes creating a sustainable maternity care workforce and providing communities without sufficient access to a maternity care hospital with the additional resources needed to reach care. This research supports expanding programs and policies to address inadequate access to maternity care deserts, including those in urban areas. The White House Blueprint for Addressing the Maternal Health Crisis outlines several goals that target improvements in access for rural communities and investments in the maternal health workforce [53]. One program expanded under these goals is the HRSA-funded Rural Maternity and Obstetrics Management Strategies (RMOMS) program [54]. Rural communities across 11 states are working to identify innovative solutions that increase access to obstetric care and that can be applied to other communities nationwide.
Policymakers and hospital administrators should consider the impact of closures on the distance traveled for birthing individuals in both urban and rural maternity care deserts. Understanding the implications of closures on travel burden is essential for crafting effective policies and interventions to mitigate these challenges. Telehealth, which includes virtual visits, remote patient monitoring, mobile healthcare, and real-time telemedicine interactions between patients and providers, has proven effective in mitigating obstetric provider shortages, particularly in rural areas with limited access to specialty care [55]. Supporting and incorporating innovative telehealth initiatives ensures equitable access to obstetric care, regardless of geographical location. Despite having a limited impact on obstetric unit closures [56], policies such as Medicaid extension and expansion have shown positive effects on birth and maternal health outcomes for individuals in poverty [57]. Policymakers should consider expanding Medicaid coverage in all states to mitigate the travel burden for individuals with low income, ensuring access to a broader range of potential hospitals offering obstetric care services regardless of socioeconomic status. Moreover, Medicaid expansion allows for greater continuity in insurance coverage [58] and improved overall health even before pregnancy [59], thereby reducing the potential for complications during pregnancy.
The obstetric workforce must increase not only in number but also in geographic distribution and racial/ethnic diversity to meet the needs of the U.S. birthing population. One way to do this is to support expanding midwifery services, which can improve outcomes, increase culturally appropriate care and lower costs of obstetric care [60, 61]. Widespread acceptance of practices that eliminate cumbersome licensing requirements, increase reimbursement rates for midwifery care, and address hospital resistance to employing midwives could bolster the obstetric workforce [53]. Providing incentives and continued investment in training programs for clinicians in rural and underserved areas is imperative to sustain the obstetric workforce. Finally, HRSA’s development of Maternity Care Target Areas (MCTA) informs the optimal placement of obstetricians and certified nurse midwives in the National Health Service Corps [62]. MCTA’s present unique funding opportunities and internal research has shown a high degree of overlap between designated MCTA’s and maternity care deserts. Future research should explore the impact of living in areas with unmet need for maternity care, focusing on adverse health outcomes for birthing people and infants.
While access to healthcare should be a human right [63], this study shows that where a person lives greatly impacts the ability to access maternity care. Not only are maternity care deserts lacking the obstetric care facilities and providers needed to care for birthing people, living in these areas has a fourfold impact on the time and distance to reach maternity care. This study adds to extensive research that demonstrates inequities in access to maternity care across the U.S., which are created and perpetuated through the failure of our policies and systems. To enact change, we must address the underlying systemic issues that persist.