Childbirth is increasingly risky for mothers in the United States, especially in rural areas. In Minnesota, the state’s maternal mortality review committee, which had lapsed between 2017 and 2019, has recently reconvened, providing an opportunity to improve maternal health in Minnesota.

Access to care during pregnancy and childbirth is declining for people in rural areas, as hospitals stop providing obstetric care or close their doors entirely. Just this month, the Mayo Clinic announced additional hospital closures in the wake of a rural health crisis in Minnesota and nationwide.

Since 2010, 119 rural hospitals have closed across the country, and since 2014, nearly 200 rural counties lost hospital-based obstetric care. More than half of rural counties have no place to give birth. Losing obstetric care locally can lead to increases in emergency room births and — in remote rural areas — increases in preterm birth, the leading cause of infant mortality worldwide. In the U.S., the most rural infants are 7% more likely than urban infants to die before their first birthday.

Even as national headlines focus on maternal mortality and states set up maternal mortality review committees, the perspectives and experiences of rural residents are largely absent from the data and from the leadership of clinical and policy efforts to improve maternal health.

In a study in the December issue of the journal Health Affairs, our team used national hospital discharge data to examine severe maternal morbidity (or “near misses”) and mortality. Our analysis revealed a previously unknown and alarming fact: Rural residents had a 9% greater chance of experiencing severe maternal morbidity and mortality, compared with urban residents. Stated another way, we estimated that between 2007-2015, more than 4,300 rural women experienced a “near miss” or death during childbirth, which they likely would not have experienced if they lived in an urban area.

These data underscore that current efforts to improve the safety of childbirth are not fully meeting the needs of rural people. There are several important steps policymakers can take to address the needs and safety of rural mothers and families.

First, representation of rural residents on maternal mortality review committees and other decisionmaking bodies is essential. Of the 46 states with maternal mortality review committees, only two — Pennsylvania and Texas — require rural representation. This should change. It ought to be routine practice to ensure representation of those most deeply or disproportionately affected by maternal morbidity and mortality in the spaces where solutions are developed, discussed and decided. This includes the voices of black and indigenous women, especially those in rural communities. If rural voices continue to be absent, patterns of geographic inequity will likely persist.

Second, federal, tribal, state and local governments must ensure adequate funding to address rural maternity care access and care coordination as well as community response capacity. Programs and policies that provide financial and logistical support to rural families are crucial, but so are investments in community capacity to support pregnancy and childbirth via health care services, clinicians, peer support, mental health and substance use treatment, food security, domestic violence counseling and legal support, adequate housing and transportation, emergency services, child care, and educational and employment opportunities. Valuing maternal health starts with centering services and support around the needs of pregnant people, their families and their communities. Serious investment in rural community infrastructure, for example, as proposed by U.S. Sen. Tina Smith of Minnesota in the Rural MOMS Act, is necessary.

Finally, addressing rural maternal health realities requires attention to state Medicaid policies and practices. Medicaid finances more than half of births in rural communities, so each state’s reimbursement, coverage and eligibility policies have profound effects on rural residents. Medicaid expansion has been identified as a protective factor against rural hospital closures, and hospital associations and stakeholders across the country are vociferously arguing in favor of Medicaid expansion to support the continued financial viability of rural hospitals on the brink of closure.

Our research on rural maternity access indicated that rural communities in states with more restrictive eligibility criteria for pregnancy-related Medicaid coverage were also at higher risk of losing hospital-based obstetric care. Specific Medicaid policy reforms with the potential to alter the trajectory of maternal morbidity and mortality in rural communities include increasing reimbursement rates, especially in low-volume settings, extending pregnancy-related eligibility for one year postpartum, and expanding coverage for nonclinical support services, including transportation as well as doulas, community health workers and lactation consultants.

Geography affects maternal health risks, and policy changes aimed at reducing maternal mortality and its associated inequities must account for the challenges faced by rural patients and communities. As efforts to improve maternal health expand and take root, rural voices and perspectives are essential to ensure effective solutions in Minnesota.


Katy Backes Kozhimannil is an associate professor at the University of Minnesota School of Public Health and director of the University of Minnesota Rural Health Research Center. Follow her on Twitter: @katybkoz.