Maternal healthcare is a critical issue in the United States. According to The
U.S. Maternal Mortality Crisis Continues to Worsen: An International Comparison, maternal mortality in
the U.S. is three times higher than most other high-income countries, and that gap continues to widen over
time. When considering intersecting factors such as race/ethnicity and rural geography, the mortality rate is
even higher. Black women in the U.S. experience twice the rate of maternal mortality than the aggregated U.S.
Access to consistent maternity care, reproductive services, postpartum support, and paid leave are some of the
issues rural women face. Rural counties that are socioeconomically disadvantaged and experience other health
disparities see higher rates of maternal morbidity and mortality.
As rural maternal health access has diminished, rural communities have been working to find innovative ways to
protect the lives and health of rural mothers and babies. Supportive policies and access to maternal health
programs and services help in addressing these health disparities. This topic guide covers rural maternal health
disparities, issues of access, barriers to rural maternal well-being, workforce challenges, and ways rural
communities are addressing these problems.
The Rural Maternal Health Toolkit is a step-by-step guide for
improving maternal health in rural communities. Includes evidence-based examples and methods rural
communities can adapt to fit their program's needs.
What disparities exist related to rural maternal and infant health?
Rural women and infants experience significant health disparities when compared to their urban counterparts.
According to the Pregnancy
Mortality Surveillance System from the Centers for Disease Control and Prevention, risks of
pregnancy-related mortality are highest for rural populations, with 26.1 pregnancy-related deaths per 100,000
occurring in noncore areas from 2017-2019 and 21.8 deaths per 100,000 in micropolitan areas.
Preconception health, or health status before a person becomes pregnant, also plays an important role in
maternal health outcomes. According to Impact of
Geography and Rurality on Preconception Health Status in the United States, rural areas were likelier
than urban areas to show higher abbreviated preconception health risk index (aPHRI) scores, with risk factors
such as poor nutrition, lack of influenza vaccine, and unhealthy weight being more common.
Rural women are also more likely to experience adverse effects related to pregnancy and mental health. A 2020 study shows that rural women have
greater odds of perinatal depression than urban women, after adjusting for race, ethnicity, and maternal age. Prevalence of
perinatal depression was 23.17% in rural women compared to 20.20% in urban women. For more information on mental
health disparities in rural populations, see our Rural Mental Health topic
Consistent with their mothers, rural infants experience health disparities as well. According to Infant Mortality in Rural and Nonrural Counties
in the United States, there are greater odds of infant mortality in noncore and micropolitan counties
compared to large metropolitan fringe counties. The study explains that the odds ratio of mortality increases
according to rurality, due to the increased socioeconomic disadvantage in rural counties.
Rural health disparities in mothers and infants are compounded for certain racial and ethnic populations. Infant Mortality Rates in Rural and Urban Areas in
the United States, 2014 shows that infant mortality rates, including neonatal (0-27 days post-birth)
and post-neonatal, are highest in rural counties and Black families. The infants of rural non-Hispanic Black
mothers had the highest infant mortality rate at 12.08 per 1,000 live births, which is nearly 3 times higher
than infant mortality rates for non-Hispanic White women in large urban counties.
A 2019 study showed similar
findings, with small, gradual declines and widening disparities in infant mortality in rural (7.78 deaths/1,000
live births in 1999 to 6.55 in 2017) compared to urban (7.29 per 1,000 live births in 1999 to 5.54 live births
in 2017). This study also showed that non-Hispanic Black rural infants (11.2 per 1,000) were more likely to die
compared to their White counterparts (6.1 per 1,000). Premature birth is another health disparity that
disproportionately impacts rural and Black families. Trends
in Singleton Preterm Birth by Rural Status in the U.S., 2012-2018 shows that a higher percentage of
singleton births were preterm in rural areas compared to urban (8.3% vs. 7.9%), and the highest rate of preterm
births was in the rural South (9.6%) and among rural (12.5%) and urban (11.3%) Black women.
What issues of maternal health access and utilization exist in rural America?
Maternal health access and utilization are crucial to the ongoing wellness of mothers and their babies. Lack of
access to maternal healthcare can contribute to several negative outcomes:
Insurance Coverage: Access to insurance during all stages of the maternity cycle, from
prepregnancy through postpartum, is an important factor in maintaining health. According to Rural
and Urban Differences in Insurance Coverage at Prepregnancy, Birth, and Postpartum, rural mothers had
higher rates of uninsurance during all three maternal periods compared with their urban counterparts. Rural
residents had a 15.4% rate of uninsurance during prepregnancy versus 12.1% of urban residents, a 4.6% rate of
uninsurance at birth compared to 2.8% of urban residents, and 12.7% during the postpartum period compared to
9.8% for urban residents.
Many women access health insurance through Medicaid, which is the single largest payer for perinatal care, covering 41% of births. For those on
Medicaid, continued coverage is required for at least 60 days postpartum. Pandemic-related legislation provided
states the opportunity to expand postpartum coverage to 12 months, and more recent federal legislation has made
this option permanent. According to the Kaiser
Family Foundation, as of January 17, 2024, 43 states, as well as Washington, DC, have extended Medicaid
coverage to 12 months postpartum with 3 states planning to expand coverage and 1 states proposing limited
What are the workforce challenges in providing rural maternal health services?
Maternal healthcare services can be provided by several types of practitioners, including:
Advanced practice nurse midwives
Rural areas face challenges in sustaining a maternal healthcare workforce. A 2022 HRSA
health workforce brief shows that maternal health physicians disproportionately practice in large
metropolitan areas relative to the female population of childbearing age, with the exception of family medicine
Rurality of Maternal Health Physicians Compared to Female Population of Childbearing Age, 2020
The reliance on family physicians for maternal health may be a concern when considering the turnover of rural
family medicine physicians. According to Mobility
of US Rural Primary Care Physicians During 2000–2014, younger physicians, women, and those born in urban
areas are more likely to leave rural practices, which may compound the maternal health workforce shortage in
Utilizing many types of maternal health practitioners in rural areas may help to mitigate shortages. However, Access
to Maternity Providers: Midwives and Birth Centers discusses barriers regarding the utilization of
certified nurse midwives (CNMs) and birth centers due to issues such as payment policies and scope of practice.
Despite these barriers, a 2021 HRSA
report predicts a decrease in OB/GYN and family medicine supply, but an increase in CNMs and women's
health nurse practitioner (NP) supply by 2030 in nonmetropolitan areas. Educational tracks for the maternal
health workforce are also critical, and Understanding and
Overcoming Barriers to Rural Obstetric Training for Family Physicians suggests the need to promote
collaboration between family medicine and other obstetric practitioners while retaining and supporting family
medicine obstetric faculty.
What other barriers and issues affect rural maternal health?
Rural maternal health is impacted by a number of issues, including but not limited to social determinants of
health (SDOH), transportation barriers, intimate partner violence, and substance use.
Social determinants of health (SDOH) have negative impacts on maternal health and researchers
have identified links between the SDOH and obstetric outcomes. Social determinants that may disproportionately
affect rural women include insurance status, educational attainment, and median income. Public health agencies
continue to develop tools to understand the impacts of SDOH on maternal health. For more information on SDOH,
see our guide Social Determinants of Health for Rural People.
While substance use is an issue that can have negative impacts on maternal health for all
women, rural women are specifically challenged in terms of accessing rehabilitation care. According to Evidence-Based, Whole-Person Care
for Pregnant People Who Have Opioid Use Disorder, neonatal abstinence syndrome (NAS), which is a set of
conditions an infant may experience while withdrawing from a substance, was twice as high in rural areas
compared to urban areas, and the geographic disparity continues to grow. The article states that rural women may
have fewer financial resources to pay for rehabilitation care or transportation to get care, and they may also
experience stigma in their small communities for seeking treatment for substance use. Our Substance Use and Misuse in Rural Areas topic guide discusses this issue
in more detail.
What policies, programs, or models address challenges with affordability, accessibility, and quality of maternal
health services in rural areas?
To improve access and affordability of maternal health, many states have extended Medicaid coverage for
postpartum care up to 12 months. Medicaid
Postpartum Coverage Extension Tracker tracks these policy changes. Expanding Medicaid coverage to
doula care is another effort to improve maternal health. Doula
Services in Medicaid: State Progress in 2022 states that doula care is particularly important for
underserved communities who see higher rates of maternal morbidity and mortality.
Another policy strategy is to provide paid family leave to help support maternal health during the postpartum
period. According to Rural/Urban Differences in Access to Paid Sick
Leave among Full-Time Workers, rural residents are nearly 10% less likely to receive paid sick leave
than urban workers. Sick leave is often used in place of maternity or family leave for full-time workers. Having
an employment situation without sick leave can therefore make recovery during the postpartum period more
difficult. For more information on paid family leave by state, see State Paid Family
Leave Laws Across the U.S., which tracks this issue.
In 2022, HRSA finalized a rule creating Maternity
Care Target Areas (MCTAs), which are areas that experience a shortage of maternity healthcare
professionals. The designation is determined by six criteria: 1) ratio of females aged 15-44 to full-time
equivalent maternity care professionals; 2) percentage of females 15-44 with income at or below 200% of the
federal poverty level; 3) travel time and distance to the nearest provider location with access to comprehensive
maternity care services; 4) fertility rate; 5) the social vulnerability index; 6) a Maternal Health Index
comprising prepregnancy obesity, prepregnancy diabetes, prepregnancy hypertension, prenatal care initiation
in the first trimester, cigarette smoking, and a behavioral health factor. These criteria will be used to create
a composite score of 0 to 25 to indicate extent of need. The intent in creating this designation is to allow for
direct federal support for maternity healthcare assistance to these target areas.
The CDC Levels of Care
Assessment Tool (CDC LOCATe) is an important assessment tool to help ensure that pregnant women and
infants receive risk-appropriate care by assessing the level of care and distribution of staff and services
available at different birthing facilities. Relatedly, in 2023, CMS implemented a rule providing a “birthing-friendly”
hospital and health system designation which indicates whether a hospital participates in a statewide or
national perinatal quality collaborative program and implements evidence-based quality improvement programs to
improve maternal health.
There are also federal and state programs that help reduce maternal health disparities in rural areas. The Maternal,
Infant, and Early Childhood Home Visiting Program (MIECHV) supports pregnant women and parents with
young children who live in communities with greater risk and barriers to achieve positive maternal and child
outcomes. Home visitors support healthy pregnancy practices, provide information on breastfeeding and safe
sleeping, and offer other supportive activities.
Maternal Outcomes Rapid Improvement Network – Provides resources and tools to advance high-quality
maternal care, improve population health, enhance quality improvement, and create collaboration opportunities.
From the Institute for Healthcare Improvement (IHI).
Black Mamas Matter Toolkit – Offers
resources aimed at equity in maternal health and ensuring safe and respectful healthcare for Black mothers and
their infants. Requires registration for access.
Toolkit – Supplies educational resources related to postpartum care. Focused on topics such as
long-term weight management, pregnancy complications, reproductive life-planning, reimbursement guidance, and a
sample postpartum checklist providers can use with their patients. From the American College of Obstetricians
and Gynecologists (ACOG).
HHS Office on Women's Health – Provides resources and programs
for women related to reproductive and maternal health as well as disease and general wellness.
Rural Maternal Health Toolkit – Presents rural communities with
resources and programs aimed at improving maternal health outcomes. Includes program models and resources for
implementation, evaluation, funding, and sustainability.