Q&A: How Does Where You Live Affect Maternal Health?

Dr. Tiffany Inglis, Carelon national medical director for maternal-child and women’s health, shared how geography can contribute to maternal health disparities before, during, and after pregnancy.   

Maternal health starts before someone gets pregnant — are they safe, healthy, thriving? — and it continues during their pregnancy and after labor. It also encompasses more than a person’s physical health, although that is definitely an important part of the equation. Behavioral and social drivers have a big impact on the health of people who are pregnant.

When it comes to social drivers, where someone lives is one of the factors that affects maternal health outcomes. How do geographic factors lead to maternal health disparities? Inglis discusses the challenges in further detail.

How does geographic access impact maternal health?

There is a very direct correlation between where someone lives and rates of preterm births. People who are pregnant and live more than 50 miles from a delivery facility are two times more likely to deliver prior to 37 weeks according to Elevance Health internal data. That’s based on a variety of potential factors. For instance, if someone has to travel a long distance for care and services, they might forego prenatal and postpartum services. That’s becoming more common as the number of people with limited or no access to maternity care is growing, according to a 2022 March of Dimes report.

What is a maternity care desert?

The March of Dimes defines a maternity care desert as a county where there are no hospitals or birth centers offering obstetric care and where there are no obstetric providers. It’s almost hard to believe that there are more than 1,100 counties where that’s the case, impacting 2.2 million people of childbearing age. Another 4.7 million people have limited access to hospitals or birth centers, meaning there are fewer than two hospitals or birth centers and less than 60 obstetric care providers for every 10,000 births. That makes it harder for the people who live in those counties to get maternity care. And a pregnancy without prenatal care is five times more likely to end in a pregnancy-related death than one that does receive prenatal care. These can be life-or-death situations.

Are there patterns of inequities in how those maternity care deserts are distributed?

Research has found that rural counties with higher percentages of Black people of reproductive age were more likely to lose obstetric services than other rural counties, leading to racial disparities in maternal health. Counties that are considered maternity care deserts are also more likely to have people living below the national median household income, compared to counties with full access [90% and 45%].

What are some of the unique circumstances that people in rural areas experience?

Two of the most common are access to healthcare — and that can even include telehealth if there’s a lack of broadband coverage — and transportation. If you don’t have a source of transportation, it can make it harder to get to the doctor. A lack of transportation can also be a barrier to accessing nutritious food. We know that eating nutritious food is crucial for supporting healthy pregnancies and healthy babies: Healthy dietary patterns decrease the risk of preterm births by 21% and low birth weight by 14%. Experiencing food insecurity, being hungry, is also stressful.

The opioid epidemic has taken a heavy toll on people who live in rural communities. There have been disproportionately higher rates of neonatal opioid withdrawal syndrome reported in rural areas, suggesting that perinatal opioid use disorder is a pressing concern.

Violence and abuse are critical problems in the United States. Their effects in rural America are often exacerbated by geographic isolation, transportation barriers, lack of available shelters and affordable housing, limited access to support care and services, and other barriers to health and well-being. All of these factors can lead to rural health disparities.

What about people who live in cities?

Urban residents may not have access to different care provider types (such as doulas or midwives), which can limit personal connections, and a lack of childcare for other children can make it difficult to attend appointments. People who live in cities can also experience food insecurity — particularly those who live in urban food deserts.

What are some strategies Elevance Health is exploring to address maternal health disparities?

One key step is to increase access to and diversity of care provider types through unique partnerships, including birthing centers, doulas, midwives, and telehealth. In response to our research and what we’ve heard from our partners, we’re advocating for improved coverage and access to services that close gaps in care and decrease health disparities. Another step is innovating around value-based care arrangements — rather than fee-for-service — that prioritize quality care and outcomes. 

Technology can also play a role in improving access: We’re prioritizing a data-informed, whole-health approach that integrates physical healthcare with behavioral healthcare. The digital transformation of care management pathways and programs gives us tools to improve access and health outcomes. That is always the ultimate goal.