Rural women are twice as likely to die from pregnancy complications than women in large metropolitan areas, federal data shows. The lack of obstetrics care at many rural hospitals contributes to the problem, said a Montana researcher.
“In our research we find that rural women lack access to the more specialty high-level, high-risk obstetrics care,” said sociologist Maggie Thorsen, Ph.D. of Montana State University. “That kind of equipment, the training, the staffing doesn’t necessarily exist in some communities.”
Because obstetrics units are expensive and require specialists, some are shutting down, according to Thorsen. Women unable to reach obstetrics units in time to give birth can end up delivering in an emergency room en route to the desired hospital. This can have deadly consequences for individuals with high-risk pregnancies.
Annie Glover, Ph.D. of the University of Montana calls these births “drive-by deliveries.”
Common complications associated with these births include hemorrhaging, preterm birth, and preeclampsia, Glover told the Daily Yonder.
“We’re known for our long and difficult winters,” said Thorsen. “And oftentimes this long distance to travel is not just that you’re traveling far, but you’re often traveling on windy country roads in potentially poor weather.”
People in Thorsen’s study drove an average of 42 minutes from home to give birth. But traveling hundreds of miles or several hours for maternity care was not unusual. One individual in her sample drove over 10 hours, she said.
Rural challenges in the state of Montana are significant since about 44% of the state’s population is rural. That’s more than twice the national percentage.
About half of Montana’s 56 counties are maternity-care deserts or counties without an obstetrics unit in a hospital. Ten percent of Montana’s total population lives in maternity-care deserts, which is about 93,000 individuals.
According to March of Dimes data, about 14% of Montana women have adequate access to care. The infant mortality rate in Montana is 4.8 deaths per 1,000 births, which is about 4% higher than the average mortality rate in the Western United States. In 2019, 53 Montana infants died before reaching their first birthday.
More than half of rural women in Montana lack health insurance, according to recent Census data. The data also reveals that maternal care deserts are associated with slightly higher percentages of individuals without high school diplomas. While about 15% of adults living in counties not designated as care deserts lack high school diplomas, over 20% of adults living in deserts do not have high school diplomas.
Experts call these associated characteristics “social determinants of health,” or environmental conditions that affect one’s health status.
The challenges associated with rurality are compounded by racism, said Thorsen and Glover.
Black women have the highest rates of pregnancy-related deaths nationwide. The mortality ratio for Black or African American women is over 40 pregnancies per 100,000 live births, almost three times higher than the ratio for white women.
“The biggest factor … in maternal health disparities is race,” said Glover.
That’s not because different races are predisposed to be healthy or ill. It’s because institutions treat racial groups differently, Glover said.
“Race is a social construct… When we measure race in healthcare, we’re not measuring genetic differences based on race. It’s a proxy measure for racism… Black patients have a much higher rate of pregnancy complications and death in pregnancy.”
Thorsen’s research focused on Native American populations specifically. Because tribal lands tend to be rural, Native American patients face the challenges associated with both rurality and race.
“So many of Indian Health Services, at least in Montana, do not provide obstetrics services,” said Thorsen. “American Indian women in our study tended to live in more rural places, so we start to see that they’re going to be more likely to deliver at places that don’t have obstetrics units.”
Thorsen said that two-thirds of the white women in her sample lived within an hour’s drive of a higher-level obstetrics facility while only a quarter of American Indian women lived within an hour’s drive.
Patients who need to travel long distances to an obstetrics unit must plan their deliveries carefully, but American Indian women often have more obstacles in the planning process than white women. Things like access to transportation and childcare can affect one’s ability to plan a careful delivery.
“American Indian women have higher rates of infant mortality, maternal morbidity … low birth weight, and preterm birth. All of these things … tend to exacerbate some of these issues,” said Thorsen.
Glover emphasized the same dynamics in her work.
“Pregnant people who are Native American and who are living in rural communities are experiencing a multiplicative effect,” she said.
Post Roe V. Wade Implications and Solutions
Thorsen and Glover both said they are concerned about how the end of the Supreme Court’s protection of abortion rights may harm the health of rural women.
“We’re going to see an increase in … especially high-risk pregnancies,” said Thorsen. “These issues are likely to just grow. So that’s a really important thing to be thinking about and what that means for maternal and infant health… We’re the only industrialized country in the world that has a growing maternal mortality rate.”
Glover said her research project with Montana Obstetrics and Maternal Support (MOMS) is looking for possible solutions.
“Our [grant] is really focused on both rural health disparities and health disparities experienced by Native American populations in Montana,” Glover said. “A big part of what we’re doing on this is that we’re trying to promote different innovative approaches that can expand access to care in rural communities.”
Glover and her team are working on expanding access to behavioral and substance abuse treatment for individuals who are pregnant and living in rural areas. She also advocates for a program called Project Echo, through which rural providers can get access to more specialized training.
“It started in New Mexico 10 or 20 years ago, and it’s expanded around the world. What they do is promote co-management of complex patients,” said Glover.
Specialists in urban areas meet with general practitioners in rural areas twice a month to review complex medical cases and possible solutions.
“It’s kind of like physician grand rounds that happen at a large hospital,” said Glover. “But they can’t do those at these smaller places. And they get the expertise from their colleagues from around the state who are essentially working through the complexities of a case.”
With this method, rural providers can implement the specialty care they learned from specialists in urban centers, thereby increasing the quality of care in their communities.
Rural and urban solutions for limited maternal care might look really different from each other, Glover said, “but they're both really important.”