Left with no other options, she hurriedly made her way to a nearby hospital that had shut down its birthing unit earlier this year. Upon arrival, the doctors concluded that Ellie needed to be transferred to a different hospital that had obstetric providers available.
Ellie requested to be taken to Texas Children's Pavilion for Women in Houston, where her own obstetrician, whom she had been seeing throughout her pregnancy, was located. However, due to a mix-up, Ellie was mistakenly taken to a different hospital, where she had to undergo an emergency cesarean section.
"The whole experience was incredibly traumatic," she recounted. "The stress of the transfer, ending up at the wrong hospital, and then suddenly developing preeclampsia – it was all very overwhelming."
Maternity Care Crisis in Texas and Across the U.S.
Hospital closures and a shortage of providers are among the factors worsening maternity care in Texas and across the U.S.
A 2023 report by the nonprofit March of Dimes considers more than one-third of counties in the nation "maternity care deserts," meaning they do not have a hospital or birth center offering obstetric care and or any obstetric providers.
In Texas, the statistic is worse, with 46.5% of counties characterized as deserts.
The March of Dimes' 2022 report found 2 in 3 maternity care deserts in the country are rural counties, and only 7% of obstetric providers work in rural areas.
Since giving birth, Ellie has suffered from postpartum depression. But Medicaid in Texas only provides coverage through 60 days postpartum, the current federal minimum. The state plans to extend that to a year postpartum, a change dozens of states have already implemented.
Ellie said she saw a therapist one time after giving birth, but was unable to get another appointment before her Medicaid coverage expired because of high demand. She cannot afford to pay for services out-of-pocket.
Postpartum Care and Maternal Health
Postpartum care is crucial for the mental and physical well-being of mothers, especially those with chronic health conditions. Shockingly, the March of Dimes reports that 1 in 3 pregnancy-related deaths occur during the postpartum period, and most of these deaths are preventable.
According to the Centers for Disease Control and Prevention, the maternal mortality rate in the United States was 32.9 deaths per 100,000 live births in 2021.
Last year, infant mortality rates in the country increased by 3% to 5.6 deaths per 1,000 live births, marking the largest increase in two decades, as stated by the March of Dimes. Unfortunately, the United States remains one of the most dangerous developed nations for childbirth.
Maternal and infant mortality rates are particularly high among Black women and babies born to Black women.
The recent Supreme Court ruling in Dobbs v. Jackson Women's Health, which overturned the landmark abortion decision Roe v. Wade, has created additional gaps in care for women in many states.
At the start of her pregnancy, Ellie considered having an abortion. She reached out to a friend outside of Texas who offered assistance, as the state has banned abortions with very limited exceptions. Ultimately, Ellie decided against it due to concerns about potential legal consequences in her home state. While Texas has criminalized performing abortions, there are no penalties for individuals seeking the procedure.
Despite recognizing the potential wisdom behind it, the speaker acknowledged that she couldn't legally entertain the idea. She mentioned that if it had been a legal option, she would have given it more serious consideration.
Dr. Bhavik Kumar, the medical director for primary and trans care at Planned Parenthood Gulf Coast, highlighted the negative consequences of states lacking both maternity care and abortion access. He stated that it's not a coincidence that states with highly restrictive abortion laws also tend to have limited access to maternity care. Furthermore, these states do not invest adequately in preconception, prenatal, and postpartum care.
The Association of American Medical Colleges reported a decline in the number of medical school students applying to residency programs in states with abortion bans. Specifically, there was a 10.5% decrease in senior OB/GYN applicants in states where abortion is banned in almost all circumstances. More information on this analysis can be found here.
While some maternity care providers, like Dr. Bhavik Kumar based in Texas, have chosen to remain in states where abortion is prohibited, others have decided to leave, exacerbating the crisis.
"How much pain do I really want to go through and endure?" asked Kim Taylor, a certified nurse midwife in Alabama. "I want to be here. I want to be in Alabama where my family is … and I'm being treated like I don't belong here and like I don't deserve to serve my community that I grew up in."
Kim Taylor, a certified nurse midwife in Alabama, expressed her frustration with the lack of support for her home birth practice, Prattville Midwifery, in a county with low maternity care access. She highlighted the fact that many women in the state already go through their birthing process unassisted, and with the recent abortion ban, there will be even more women in need of care. The only exception to the law is if the mother's life is at risk.
The March of Dimes reported that in 2021, almost a third of women in Alabama are Black, and according to the CDC, Black women are three times more likely than White women to die from pregnancy complications. Alabama also has one of the highest maternal mortality rates in the country.
Nancy Cohen, the president of the Gender Equity Policy Institute, emphasized the crisis of Black maternal mortality in the United States and pointed out that 7 in 10 Black women in America live in states that ban or restrict abortion.
Given the impending influx of people in need of obstetric care, Taylor stressed the importance of midwives and their role in guiding women through the birthing process.
Alabama Implements New Rules Restricting Midwives' Practice
New regulations imposed by the Alabama Department of Public Health are making it increasingly challenging for midwives to practice outside of hospitals. The department cites concerns over women's safety as the reason behind these rules. Under the new guidelines, freestanding birth centers, where low-risk patients receive care from midwives during childbirth, must now meet hospital licensing requirements to operate.
Additionally, the regulations stipulate that these birth centers must be located within a 30-minute radius of a hospital. However, according to data from the March of Dimes, 27.9% of women in Alabama do not live within this distance, and nearly 90% of women in rural areas of the state are not that close to a hospital.
In response to these restrictions, midwives and doctors, with the support of the American Civil Liberties Union (ACLU), have filed a lawsuit against the Alabama Department of Public Health. A judge recently ruled that birthing centers meeting national requirements can continue to be licensed while the lawsuit is ongoing.
The closure of maternity units in hospitals is also a growing concern in Alabama. In recent weeks, three more hospitals have shut down their maternity units. Medicaid coverage accounted for half of the births in the state in 2020. However, health care providers receive lower reimbursement rates for Medicaid-funded births compared to those covered by private insurance, which has contributed to the closure of obstetric units across the country.
In a related matter, North Dakota has the highest proportion of counties designated as maternity care deserts in the nation, alongside a strict ban on abortions.
The Dakota Hope Clinic, a nonprofit organization associated with anti-abortion rights groups, provides certain services such as free pregnancy testing, ultrasounds, and post-abortion and pregnancy loss support. These services are offered through their clinics located in Minot, a city with a population of just under 50,000 and home to Minot Air Force Base, as well as the smaller towns of Tioga and Bottineau. However, it is important to note that the medical services provided by the clinic are quite limited and do not fully meet the needs of women in North Dakota.
Nadia Smetana, the clinic's director, stated, "Abortion is still a topic of concern for many individuals, and approximately half of our pregnant clients are considering this option. Therefore, we engage in conversations with them about all available options, ensuring that they are fully informed about the advantages and disadvantages of each choice."
Smetana has aspirations to expand the clinic's reach beyond the current three locations in order to provide better care for women who reside in areas far from maternity care services. She expressed, "We understand that women in rural communities often lack immediate access to the same level of services that are readily available in larger cities. Even if women initially visited Dakota Hope during their pregnancy, they may not have access to adequate follow-up care."
Dr. Johnna Nynas, an OB-GYN physician at Sanford Health, practices in northern Minnesota, where abortion is legal. She works in an area surrounded by maternity care deserts that face similar challenges to those in North Dakota.
Nynas is based in Bemidji, a city with a population of over 15,000 people. She has witnessed four different labor and delivery units close within five years in the area. She and only a few other OB/GYN providers are trying to give care to the whole region.
There are three Native American reservations around Bemidji, where women are particularly vulnerable to maternal mortality and pregnancy complications.
In Minnesota, 42.3% of Native American women living in areas of high socioeconomic vulnerability have received inadequate prenatal care, according to the National Center for Health Statistics.
"There are so many moving parts. It's generational trauma, it's implicit bias and systemic racism that exists within our communities and within health care, and those are hard issues to overcome," said Nynas.
She is working with other health care organizations to bring more virtual care and education to people facing obstacles to proper maternity care.
Telemedicine should be a "standard of care" for women, said Dr. Elizabeth Cherot, CEO and president of the March of Dimes, but some states will not reimburse for those appointments.
"You're just continuing to close the door to access," she said.
Providing women with access to care "means that they can be a whole human being in their life," said Kumar. "They can be more present for the people in their life, oftentimes including the children that they already have at home."
