The Rural Maternal Health Crisis: Efforts at Legislative and Executive Redress

In its 2024 White Paper titled “Maternal Health in Rural America” and the conclusions thereof, the National Rural Health Association highlights the established reality that “lack of access to obstetric care in rural areas is a known and growing concern.” ¹ The White Paper in question goes on to note the “long history of challenges accessing these services” as well as the fact that “recent closures of rural obstetric units and hospitals have exacerbated concerns about access to care for millions of women of reproductive age living in rural America.” ¹ Similar conclusions were arrived at by the 2024 “Report to Congress” wherein the Department of Health and Human Services (HHS) makes note of the reality that “millions of women find it challenging to access high-quality maternal health care because they live in areas with limited availability of maternity care providers and delivery facilities.” ² Just as significantly, HHS makes note of the fact that “fewer than half of all rural counties have a practicing obstetrician” or a “hospital with obstetric care services.” ² It is the objective of this Commentary to discuss the ongoing rural maternal health crisis as well as the efforts invested in its potential redress by recent executive and legislative initiatives.

At the time of this writing, as many as 36% of U.S. counties are deemed to constitute “maternity care deserts.” ¹ The counties in question are marked not only by the absence of qualified obstetrical providers but also by the paucity of maternity care resources such as a hospital or a birth center. ¹ Further note is made of the fact that hospitals that discontinue maternity services “are more likely to be smaller in size, privately owned, and located in communities with fewer maternal health providers.” ¹ Equally challenging to maternal health is the increasingly prevalent reality of rural hospital closures. ¹ As per the NHRA, “over 171 rural hospitals closed or discontinued inpatient services.” ¹ Moreover, approximately 420 rural hospitals remain vulnerable to closure since more than 50% of those are “operating with negative margins.” ¹ Furthermore, many rural areas are subject to a “shortage of providers with advanced training in maternity care” as well as to “long travel distances for obstetrics services and delivery.” ¹

Recognizing all too well the aforementioned realities, the 119^th Congress saw to the introduction of the “Rural Obstetric Readiness Act,” replete with the potential underwriting thereof.^3,4 It was February 4, 2025 when Sen. Margaret Wood Hassan [D-NH], along with 7 Cosponsors, introduced the “Rural Obstetrics Readiness Act” [S.380].^3,4 By February 12, 2025, the above Senate entry was complemented by an identical House bill sponsored by Rep. Robin Lynne Kelly [D-IL-2] replete with 29 Cosponsors. ³ Yet-to-be enacted, the “Rural Obstetrics Readiness Act” is to underwrite an “Obstetric Emergency Training Program” as well as “Equipment and Supplies.”^3,4 In addition, the bill will require the Secretary of HHS to “award grants, contracts, or cooperative agreements to eligible entities to integrate obstetric readiness training curriculum into rural health care settings, build workforce capacity, and purchase equipment necessary to manage obstetric emergencies.”^3,4 Apart and distinct from the above, the bill will require the Secretary of HHS to underwrite a “pilot program for teleconsultation” as well as “study obstetric units in rural areas.”^3,4 The latter is meant to map “maternity ward closures and regional patterns of patient transport” as well as examine “models for regional partnerships for rural obstetric care.” ³

Complementing the aforementioned plans of the legislative branch are maternal health funding proposals that are to be assumed by HHS agencies if and when included in the President’s FY 2025 budget. ² Obstetric emergency readiness is to be underwritten by the Health Resources & Services Administration (HRSA), an HHS agency, with an eye toward building “obstetric safety net capacity in health care settings that do not offer obstetric care, including those located in maternity care deserts.” ² HRSA is also to underwrite Workforce Development so as to grow and diversify the “maternal and perinatal health nursing workforce” and the “community-based doula workforce.” ² Under Access and Delivery of Maternity Care, HRSA is to fund the “Rural Maternity and Obstetrics Management Strategies Programs” intent on increasing access to maternal and Obstetrics care in rural communities.^2,5 New funds to improve maternal health care service delivery as well as address social determinants of maternal health will also be requested for HRSA. ² Yet another HHS agency, the Centers for Medicare & Medicaid Services (CMS), weighed in on November 1, 2024 with an eye to “reduce maternal mortality, increase access to care, and advance health equity.” ⁶ Specifically, CMS announced payment updates to Hospitals and Ambulatory Surgical Centers which, in-toto, are estimated to yield an additional $2.2 billion in calendar year 2025 as compared with its 2024 counterpart. ⁶

While far more financial support will likely be required to resolve the rural maternal health crisis, the latest Congressional and Executive initiatives are bound to improve the status quo when and if materialized. While much remains to be done, the aforementioned long overdue developments are bound to make a significant difference when and if consummated.