University of Minnesota Alumni Association


Labor Pains

Access to maternal health care is dwindling in rural areas.

Illustration by Gerard DuBois

Two years ago, the hospital in Grand Marais, Minnesota—a community far up Lake Superior’s North Shore—stopped offering obstetrical services. Although the town has willing medical providers, the hospital’s insurance carrier would no longer cover its childbirth services.

Since that time, the expectant mothers of Grand Marais have delivered their babies in Duluth, a change that has forced them to undertake—while in labor—a twisting and sometimes treacherous two-hour drive south along Highway 61, which hugs the lake’s shoreline. This 110-mile road, a famous scenic route, is frequently choked with tourists or covered with snow and ice. If expectant mothers prefer not to risk the drive, they must find and pay for housing in Duluth in the weeks preceding their due dates.

Situations like this are no longer rare in the United States. Indeed, daunting commutes to receive obstetrical services are increasingly common for women living in rural communities, according to researchers from the University of Minnesota’s Rural Health Research Center. In a study published last fall in the journal Health Affairs, center researchers showed that in the decade between 2004 and 2014, 9 percent of rural counties lost hospital obstetrical services, and that by 2014, fully 45 percent of all rural U.S. counties lacked such services.

“Everyone deserves care when they are giving birth and preparing to give birth,” says lead researcher Katy B. Kozhimannil, associate professor in the School of Public Health. “Yet for a long time we’ve seen declining access to hospital care in rural communities. Those with less generous state Medicaid programs are even more likely to lose services.”

The reasons behind this rural obstetrical gap are complex, according to coresearcher Carrie Henning-Smith. “There is no one culprit, nor one magic bullet to fix it,” she says. Among the reasons are low birth rates in aging rural communities; the soaring cost of malpractice insurance, especially for OB care; national guidelines that require obstetrical hospitals to be ready for emergency caesarean sections; rural areas’ ongoing struggles to attract and retain doctors and nurses; and rural hospital closures and consolidations.

To compound the problem, the researchers found that these gaps in rural obstetrical care are falling most heavily on women living in counties with larger African American and low-income populations. This finding exacerbates an already alarming racial disparity in maternal and child health, says Kozhimannil, with black women’s maternal mortality rate now four times higher than that of white women, and black infant mortality rates twice those of white infants.

Medicaid is vital to providing maternal care for rural women, says Kozhimannil, given that it pays for 59 percent of births in rural areas. “We as taxpayers are funding this and should be getting good value for our money,” she says. “Don’t we all want moms and babies to be healthy?” The U.S. currently has what she describes as “horrifying disparities” in health care quality and accessibility between rural and urban areas.

The challenges pregnant rural women face are daunting, says Kozhimannil. She thinks often of one particular Grand Marais woman she met, a patient with a high-risk pregnancy. The woman must take off a full day of work each time she has a 15-minute prenatal appointment in Duluth. Recently, an accident closed Highway 61, forcing Duluth-bound motorists to take a 27-mile detour. “All I could think about was that woman,” she says. 

When hospitals close in remote towns, there may be an uptick in emergency births (anecdotally, researchers have heard of such increases). Fortunately, in Grand Marais, physicians, EMTs, and the sheriff’s office have come together to help pregnant women. “They all have each other’s phone numbers and will drop everything to help each other and the women. It’s extraordinary,” says Kozhimmanil. “But, not all communities have that sort of coordination and commitment.”

Now, Kozhimmanil’s team is exploring the possible consequences of those closures, such as whether more women are giving birth in atypical settings like emergency rooms. They’re also trying to tease out infant outcomes from this trend, says Henning-Smith. “Is the baby at greater risk if the mother lives in a county without obstetrical services?”

Solving this growing rural maternal health problem is complicated, says Kozhimannil, and might include ideas ranging from paying for pregnant women’s housing and transit costs to making community-based financing and policy changes that “acknowledge both the realities and the strengths of rural communities.”

In Grand Marais, those strengths include a committed medical workforce; a top-notch local clinic; lactation support and birthing classes; as well as the aforementioned emergency coordination. Says Kozhimannil, “Grand Marais is amazing.” Whether all rural areas can meet this challenge remains to be seen.

Lynette Lamb (M.A. ’84) is a longtime Minneapolis writer and editor.

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