Proximity to Hospital-Based Obstetric Care in a Maternity Desert in the Deep South

Abstract

Objectives. To examine the accessibility of hospital facilities with maternity care services in 1 rural county in Alabama in preparation for the initiation of prenatal care services at a federally qualified health center.

Methods. We analyzed driving distance (in miles) from maternal city of residence in Conecuh County, Alabama to hospital of delivery, using 2019–2021 vital statistics data and geographic information system (GIS) software.

Results. A total of 370 births to mothers who have home addresses in Conecuh County were reported, and 368 of those were in hospital facilities. The majority of deliveries were less than 30 miles (median = 23 miles) from the maternal city of residence. Some women traveled more than 70 miles for obstetrical care.

Conclusions. Pregnant patients in Conecuh County experience significant geographic barriers related to perinatal care access. Using GIS for this analysis is a promising approach to better understand the unique challenges of pregnant individuals in this rural population. Public health policy efforts need to be geographically tailored to address these disparities. (Am J Public Health. 2024;114(S4):S330–S333. https://doi.org/10.2105/AJPH.2024.307692)

Rural communities across the United States encounter challenges limiting their ability to obtain needed health care. Geography is frequently an access barrier, and health care workforce shortages pose a particular problem. Roughly 20% of the US population lives in rural areas, but only 11% of physicians practice in these communities.¹ This uneven distribution of physicians negatively affects population health, as women in underserved areas are less likely to receive preventative health screenings compared with their urban counterparts.^2,3

Access to obstetric care is a growing concern in rural America. The prevalence of maternity care deserts in these settings is increasing the closure of labor and delivery units across the country.⁴ A county is considered a maternity care desert if it does not have a hospital or birth center offering obstetric care or any obstetric providers.⁵ More than 2.2 million women of reproductive age live in maternity care deserts in the United States.⁵ In Alabama, 55 of 67 counties (82%) are considered rural; of those, 35 counties (64%) do not have hospitals that provide perinatal services.⁶ Nearly 90% of women of reproductive age in rural Alabama must drive 30 minutes or more to hospital-based obstetric services.⁵ Also, rural women have demonstrated a 9% greater probability of severe maternal morbidity and mortality compared with urban residents.⁷ This inequity is often exacerbated by the distance traveled to receive care.

In preparation for the initiation of prenatal care services at a federally qualified health center in Conecuh County, Alabama, we investigated pregnant county residents’ access to obstetric-based hospitals using geographic information system (GIS) software. The use of GIS for this analysis is common in developing countries but not in high-income economies.⁸ However, maternal and neonatal outcomes in rural Alabama are worse than in many low-income countries,⁹ and it is likely that unequal distribution of services plays an important role in these outcomes. Understanding the barriers that pregnant patients face to obtain maternity care is vital to improving maternal health outcomes.

METHODS

Conecuh County is in the south-central portion of Alabama and has no maternity care—no delivery hospital or prenatal care providers. The current population is approximately 11 206 residents (51.2% female), of whom 22.4% live in poverty and 11.5% lack health insurance.¹⁰ Pregnant individuals living at 146% of the federal poverty level are Medicaid-eligible in Alabama and for 12 months following birth. The Alabama Department of Public Health Center for Health Statistics provided all data on verified live births between 2019 and 2021. These data contained all births to mothers who had home addresses in Conecuh County and the hospital facilities used by these residents. Out-of-state births were removed from the original data prior to analysis.

Using 2019–2021 vital statistics data, we analyzed driving distance (in miles) from maternal city of residence to hospital of delivery, including out-of-facility (home) births. We geocoded the addresses of medical facilities to latitude–longitude points using ArcGIS software (Esri, Redlands, CA). We calculated Euclidean distances (straight line between 2 points) between these points; we included the geographic centroid points (n = 6) of any city, town, or unincorporated space boundary limit in the study. We deemed Euclidean distance to be the best practice over potential road distance as we could neither guarantee a “most efficient route” from 1 locality to any specific hospital nor speculate on road conditions or driver preferences.

RESULTS

Between 2019 and 2021, 370 babies whose mothers lived in Conecuh County were born in Alabama. Of these 370, 70.3% of their mothers were covered by Medicaid, 27.6% had private insurance, and 1.6% were self-pay. Almost all births (n = 368) occurred in 14 hospitals in 7 counties in Alabama (there were 2 unplanned home births). Most deliveries (81%) occurred in 3 hospitals adjacent to Conecuh County, located 22–29 miles from the border. Median driving distance from maternal city of residence to delivery hospital was 23 miles (interquartile range = 22–29). Additionally, 18% of births occurred more than 70 miles away in hospitals with level 2 (specialty care) and levels 3 and 4 (subspeciality care) maternity services. A dot choropleth map (Figure 1) depicts the distance analysis in GIS, including aggregated median travel distance, number of births, and facility level of care.

FIGURE 1—

Median Distance and Number of Births Between Maternal City of Residence and Hospital Facility With Hospital Facility Level: Conecuh County, Alabama, 2019–2021

Note. Facility level of care indicates whether the facility offers basic care (level 1), specialty care (level 2), or subspecialty care (level 3), or qualifies as a regional perinatal health care center, offering services for the most complex cases and most critically ill patients (level 4).

DISCUSSION

These findings highlight the physical distance between maternity care and city of residence for Conecuh County mothers. Pregnant individuals in Conecuh County experience significant geographic barriers related to perinatal care access. Additionally, 7.1% of households in Conecuh County do not have a vehicle and there is no public transportation in the region, amplifying the negative effects and hardship of distance traveled.¹⁰ Although medical appointment transportation is available, it is reserved for nonemergency cases and costs upwards of $1.00 per mile outside city limits. Ability to travel to obtain care is heavily affected by socioeconomic and other factors, including need for child care, time off from work, and cost of travel.¹¹ The addition of telehealth services may reduce this disparity, particularly in the prenatal period; however, more focused intervention to generate solutions is warranted.

We found that a subset (18%) of patients in our population traveled more than 70 miles for delivery care. In some rural communities, more than 50% of deliveries occurred in facilities farther from the mother’s residence than the closest delivery hospital.¹² Although the reasons for bypassing the closest labor and delivery facility for our population are not yet known with certainty, such motivations historically include concerns regarding pregnancy complications with respect to the skill and resources of the delivering hospital staff.¹² Based on the geographic and socioeconomic barriers identified, our partnering federally qualified health center is endeavoring to bring antenatal services to the county and has since hired a nurse practitioner delivering prenatal care.

One limitation of the study is that the specific addresses of mothers, which would have yielded a more precise result than estimated distance from the city centroid, were unavailable because of the confidentiality protocols of the state health department. Nevertheless, this method has utility in explaining how far pregnant patients may travel from a specific city. Additionally, Euclidean distance is an imperfect measure of the potential travel for each patient, as it is only a direct distance calculation. However, because the provided data lacked exact addresses, and the authors could not guarantee that a patient would take an optimal route, Euclidean distance was deemed an acceptable method of measurement.

This baseline assessment of geospatial access can be repeated and compared across maternity deserts throughout the United States. These data can also be used as a tool for physicians, advocates, and health care organizations to strategize improvements to maternity care access. In the future, we plan to establish antenatal care services at a federally qualified health center in Conecuh County. However, further assessment is needed on prenatal care utilization and pregnancy outcomes within this population to evaluate the effectiveness and uptake of services in this maternity care desert.

PUBLIC HEALTH IMPLICATIONS

Similar to the case in much of rural America, prenatal and delivery care is unavailable in Conecuh County. Subsequent decisions regarding where and how to seek care are severely limited, unlike in urban settings. Women must travel long distances to receive needed care, often putting them at risk for pregnancy-related complications and death. This urban–rural health care disparity can only be addressed with broad policy changes to improve maternal health equity for residents in medically underserved areas. State Medicaid practices have the potential to reduce disparities and improve maternal outcomes. Unfortunately, labor and delivery closures are often seen as necessary cost savers because of declining reimbursements from Medicaid. In Alabama, 24.7% of patients are eligible for Medicaid.⁹ Alabama is 1 of 10 states that has not expanded Medicaid under the Affordable Care Act. If enacted, it would provide primary health care access to approximately 300 000 residents. Although Alabama has approved Medicaid 12-month postpartum coverage, this alone will not be sufficient to improve health outcomes in such vulnerable populations. Future policy and funding efforts must include solutions to the numerous challenges faced by rural pregnant patients and health care facilities to see lasting improvements in maternity care for these populations.