Disparities related to quality healthcare access are a challenge in the U.S, and more often for women. That sounds a little difficult to imagine. It is shocking, especially since we are in the 21st Century, and considered by many to be in a country that has opportunity and equality for all.
The goal of this blog is to inform and bring awareness to an alarming issue that is facing women and infants: When women have limited access to high quality health care, the perinatal care their infants receive is also impacted.
National and state initiatives have been put in place around this issue. However, more is needed to support the unique needs of mothers and infants.
Why does this disparity occur in the first place? Complexities around “the why” are multifaceted.
Women have unique needs
Women’s healthcare needs are very different from men, and so is their access to healthcare.
Women have limited or no access to maternity care, or specialty women’s health services, in some areas of the country. Access to obstetric and reproductive care for women living in rural areas is a complex challenge related to distance, travel to care, and delivery of care.
The American College of Obstetricians and Gynecologists (ACOG)3, reported on the significant health disparities that exist between rural and urban women in their 2018 Committee Opinion on Health Disparities in Rural Women: “Rural America represents 75% of the national landmass, and is home to 22.8% of U.S. women aged 18 years and older.”3
The definition I am using for “rural” is the ACOG description. The reference to rural is often used interchangeably with “nonmetropolitan,” meaning low population areas located outside of towns and cities.3
Cost of care
The cost of care varies for women because they do not have insurance. Rural women report the highest rate of delayed care or no medical care due to cost, and no health insurance coverage. Many are unable to cover costs of care, and as a result in-home births are higher.3,4
Additional factors that cause challenges to healthcare access include: out of pocket costs, provider availability, logistical issues related to transportation, and finding time or work conditions to make medical appointments.6
When comparing women’s health and health care in the U.S. to other countries, the results are disappointing. We don’t measure up to the other high income countries as it relates to health care and health status. The Common Wealth Fund report reveals, “Women in this country have the highest rate of maternal mortality because of complications from pregnancy or childbirth,” and they go on to say, “More than one-third of women in the U.S. report skipping needed medical care because of costs, spending $2,000 or more out of pocket on medical costs for themselves or their family in the past year compared to 5 percent or fewer in most of the other countries.”2,6
Kaiser Women Health Survey6 also published their findings, indicating low-income women’s health care costs are a considerable barrier to care. Half (49%) of uninsured women go without or delay care because of costs. As a result of increased health care costs, nearly one in five women have postponed preventative care (19%), skipped a recommended test or treatment (20%), or made medication trade-offs such as not filling a prescription or cutting dosages (17%).6
Access challenges have a higher impact on women and children. Far too often, when specialty care is cut or consolidated within medical systems, maternal and/or pediatric care is the first to go.
Many hospitals are closing, and hospital shut downs across the country are occurring on a regular basis. Communities are left without immediate access to urgent and specialty medical care. Medical deserts are an increasing problem. U.S. News Health (2013) reported on this very important crisis, referring to it as an epidemic.4 A large reason as to why this is happening can be attributed to cuts in federal reimbursements to hospitals that treat uninsured.
Medical deserts are not only found in rural communities. They can be found in urban communities as well. Hospitals are closing in urban cities, and leaving little or no access to health care for residents who cannot afford insurance and have no access to government-run hospitals for primary care. The impact of hospital closures is causing doctors to relocate, seeking jobs in higher paying communities in more affluent areas.
Through it all, racial disparities in pregnancy-related mortality continues to be a huge issue for both rural, uninsured, and low-income women. During 2011-2014, pregnancy-related mortality ratios were disproportionally affected.1
- 12.4 deaths per 100,000 live births for white women.
- 40.0 deaths per 100,000 live births for black women.
- 17.8 deaths per 100,000 live births for women of other races.
It is not surprising that this correlates with the national data related to racial and demographic differences for breastfeeding. An increased number of infants are receiving breast milk. However, they are not receiving exclusive breast milk, as recommended by the American Academy of Pediatrics (AAP) for more than 6 months. Centers for Disease Control and Prevention (CDC) reports, “Fewer non-Hispanic black infants (69.4%) are ever breastfed compared with non-Hispanic white infants (85.9%) and Hispanic infants (84.6%)”8
What is being done to close the gap?
There is a range of initiatives systematized by both state and federal organizations. The initiatives include a wide variety of programs and incentives. At times, multiple community programs collaborate and work together to identify solutions and combine resources.
On a state level, perinatal and neonatal quality collaboratives have been conducted to improve the quality of care and patient safety. Statewide data collection and education programs have been implemented by these organizations. Many have included access to quality care for mothers and children, reducing the opioid crisis, and neonatal abstinence syndrome (NAS).
The University of Texas medical branch developed a regional maternal and child health program to serve geographical underserved women in multiple off-site clinics.3 Some states have activated legislation to offer financial incentive plans, such as state income tax credit for rural providers. Family medicine residency programs have added a rural training track to their programs.3 Telehealth is a state level program to consider expanding provider coverage for rural healthcare.
March of Dimes (MOD) supports urgent initiatives, including this health crisis facing moms and babies across the country. MOD is a global organization that is committed to improving outcomes for under-served populations, bringing awareness, advocating, and aligning federal tribal, state, and local and community policy initiatives. MOD has several workgroups working to achieve improvement in health equity and preterm birth by increasing effective use of evidence-based information in clinical and public health.9
Many hands make the work light, and much work needs to be done. We must continue making progress toward making women and children’s health a priority.
If you are involved in an initiative in your state or community, I would like to learn about what you are doing. Tell me about your efforts in the comments section below!
- Centers for Disease Control and Prevention (CDC). Racial and Geographic Differences in Breastfeeding: United States, 2011–2015. July 14, 2017. 66(27);723–727. https://www.cdc.gov/mmwr/volumes/66/wr/mm6627a3.htm?s_cid=mm6627a3_w&c_cid=journal_search_promotion_2018
- Commonwealth Fund International Health Policy Survey. What is the status of Women’s Health Care in the U.S. Compared to Ten Other Countries? December 19, 2018.
- American College of Obstetricians and Gynecologists. Committee Opinion # 586, Health Disparities in Rural Woman. 2014; reaffirmed in 2018.
- Williams, Joseph. What Happens When a Town’s Only Hospital Shuts Down? S. News Health. November 8, 2013.
- Fine-Maron, D. Maternal Health Care is Disappearing in Rural America. February 15, 2017.
- Kaiser Family Foundation. Women’s Coverage and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey. Published March 13, 2018.
- Mayes, L. Black Women Are Dying from a Lack of Access to Reproductive Health Services. Time. January 2018.
- Centers for Disease Control and Prevention (CDC). Breastfeeding Facts: Nationwide Breastfeeding Goals. (2018). https://www.cdc.gov/breastfeeding/data/facts.html#disparities
- March of Dimes. Health Equity Workgroup. marchofdimes.org