Giving birth in rural America

Critical supports for women and babies are lacking

This story is part of our ongoing series on the Social Determinants of Health, and where they connect and interact with the Developmental Origins of Health and Disease. Here we explore the social determinants of maternal health care access, with a focus on rural areas. Maternal health is a fundamental driver for population health.  

Pregnancy is a time to celebrate the joy of bringing a new life into the world. The profound changes a woman undergoes during this time are nothing short of miraculous. As her pregnancy progresses, she experiences a deep awareness about the implications of giving birth – something singularly unique to her, yet commonplace among womankind. As the baby grows, reality sets in: this baby must come out one way or another. It can be a frightening prospect, and it’s one that every mother must face. Thankfully, most pregnancies and births are uncomplicated and mom and baby do fine.

Yet the U.S. has the highest maternal mortality rate in the developed world. Every year, tens of thousands of women need emergency treatment to save their lives or their babies’ lives during or immediately after birth. In the last 25 years the number of women who needed blood transfusions and interventions for heart failure, stroke or eclampsia rose dramatically.  At the same time, maternity care doctors and hospitals in rural areas have slowly been disappearing. These two trends have increased the risks for women living in rural and underserved communities. Some of the factors that make pregnancy and childbirth so unpredictable include:

  • Where a woman lives
  • Whether she has health insurance
  • How healthy she is before pregnancy
  • How healthy her own mother was during her childbearing years
  • Whether she gets early, regular and culturally relevant prenatal care
  • If she receives high quality care during labor, delivery and in the post-partum period

Nowhere to go
More than two million women of childbearing age live in ‘maternity care deserts’ – defined as a county where there are no hospitals, birthing centers or obstetric (OB) care units or providers. Over 120 rural hospitals have shut their doors since 2010. Those that have remained open are financially vulnerable and shutting down their OB units, leaving more than half of all rural U.S. counties without maternity care services. Combined with doctor and care provider shortages, it’s easy to see why rural women and infants are at greater risk for complications and death during childbirth and in the postpartum period.

Women who live in small towns, on farms, on Tribal reservations and in rural areas are also less insured. In general, they receive less primary care and have far less access to prenatal care. Black and Indigenous women already have the highest levels of complications and death during pregnancy and birth, and this risk is compounded if they live in a rural area. The U.S. Government Accountability Office found Black women in rural areas experience almost twice the number of severe health complications as white women in rural areas do. Indigenous, Black, Hispanic and women from other racial minority communities often have deep historical roots in rural America, yet they face cultural and linguistic barriers, oppression and racism – all of which contribute to poor outcomes, health care avoidance and ongoing health disparities.  

Consequences lasting 100 years
Viewed through a Developmental Origins of Health and Disease (DOHaD) lens, the barriers to medical care that rural women face are alarming because the consequences will be felt for generations to come. The so-called 100-year effect shows how chronic disease risk in elderly adults can be traced, in part, back 100 years to when they were an egg in the ovary of their mother. This tells us that the health of the mother before and during pregnancy, birth and in the postpartum period will affect the next three generations.

Some examples:

  • Women who don’t get prenatal care are 3-5 times more likely to have a low birthweight baby. Low birthweight babies are at greater risk for high blood pressure, kidney and heart disease, and Type 2 diabetes when they are older. This means the next generation of mothers will be at higher risk for pregnancy-related complications, and their daughters will too.
  • Newborns are 40% more likely to die within 28 days of delivery if their mother didn’t have prenatal care.
  • Severe complications like preeclampsia have long-term health implications for both the mother and child. Sometimes a woman won’t know she has high blood pressure that underlies the condition known as preeclampsia, which is why prenatal care is critical. 
    • Women who have had preeclampsia are 3-4 times more likely to have high blood pressure later in life, and twice as likely to develop heart disease and stroke.
    • Preeclampsia increases a woman’s risk for bleeding during childbirth, which can lead to shock and death.
    • If the preeclampsia is severe enough, the baby’s growth may become restricted in the uterus, or the baby may need to be delivered early to avoid more serious complications. Growth-restricted and premature babies are at higher risk for many chronic diseases later in life.
    • If a daughter is born to a mother with preeclampsia, she is more at risk for preeclampsia when she is pregnant, making childbirth more dangerous with each generation.
  • Eclampsia is a condition where a mother’s high blood pressure is associated with convulsions and is therefore an obstetric emergency. In the U.S. almost 2% of the women who develop eclampsia die from it. For the babies they’re carrying it’s even more deadly, with a fetal mortality rate of up to 30%.
  • Women who do not receive breastfeeding support in the postpartum period are less likely to breastfeed for the recommended time of at least six months (exclusively). The health benefits of breastfeeding are numerous, including lowering risks for asthma, childhood obesity, ear infections, diarrhea and vomiting, SIDS and Type 2 diabetes – to name a few.

Maternal health is public health
While having access to obstetrical care is but one piece of the experience, it is critical. The more ways in which women are supported before, during and after giving birth, the healthier society as a whole will become. A positive cycle of intergenerational health is possible. To find out more about the efforts Oregon is taking to ensure health care access in rural areas, visit these resources:

OHSU Oregon Office of Rural Health
Oregon Association of Hospitals and Health Systems: Rural Health in Oregon
Oregon Health Authority, Primary Care Office

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