Maternity ward closures exacerbating health disparities

Photo of a hospital building with a sign in front saying that it is closed.

December 13, 2023 — Obstetric units are closing at a growing number of hospitals across the U.S. As a result, many patients are being forced to travel farther to give birth and receive prenatal and postpartum care. Alecia McGregor, assistant professor of health policy and politics at Harvard T.H. Chan School of Public Health, has found that these closures disproportionately impact communities of color, further exacerbating the already high health risks Black and Hispanic women face when giving birth.

Alecia McGregor
Alecia McGregor

McGregor is currently looking at how pregnant people in the predominantly Black neighborhoods of Southeast Washington, D.C. have been navigating their care following the loss of their only two maternity wards in 2017, followed by the COVID-19 pandemic. She shared preliminary results during a Health Policy and Management department seminar on November 29.

Nationwide, 217 hospital obstetric units closed between 2011 and early 2023, according to health care consulting firm Chartis, creating many so-called “maternity care deserts,” defined as counties lacking obstetric care. The reasons cited for the closures include declining birthrates, staffing shortages, increased costs, and the chilling effect of new antiabortion laws. But McGregor noted common threads—hospitals that appear most likely to close are often those most reliant on Medicaid, which reimburses at lower rates than commercial insurers, and obstetric unit loss, specifically, is more common among those units that serve a larger share of Black patients.

Most research on maternity care deserts has focused on rural areas. A 2022 report from the March of Dimes found that more than two-thirds are in rural counties. But county-level analysis misses the more granular disparities that exist in urban settings, McGregor said. While people living in Southeast D.C. still have obstetric care available within their Census-defined “county,” the time and effort it takes to get to these facilities—particularly for those who lack a car or for whom paying for parking is cost-prohibitive—present a considerable burden.

Getting at these nuances requires qualitative research, McGregor said. She is currently working with partners at community health centers in D.C. on interviewing people about where they are going to give birth and for prenatal and postpartum care, whether they ended up at these facilities by choice, and the quality of care they receive. Most participants have had more than one child, so they have been able to describe changes over recent years to their birthing and care experiences, McGregor said. 

The study’s preliminary findings point to a two-tiered maternity care system in the city, with low-income Black and Hispanic patients more likely to receive care from underfunded facilities. Perhaps the most disturbing finding was that hospital overcrowding was frequently forcing patients to be diverted to another hospital while they were in the labor.

“In D.C., the maternity care system is operating in a state of emergency,” McGregor said. “Patients and providers are reporting various strategies of adaptation to promote safety where they can.”

In Southeast D.C., the city’s first new hospital in 20 years is currently under construction—and its plans include a maternity ward. McGregor said that she hoped her research findings “will help to inform the types of resources, supports, and other interventions that will be necessary to ensure equitable access at this hospital and other facilities throughout the district.”

McGregor has noted that midwife- and doula-led freestanding birth centers can help fill gaps in  maternity care deserts. “The kinds of lifesaving procedures that can only be conducted in a hospital are important for those very high-risk cases,” she said in a September AP article, adding that “for the majority of pregnancies, which are lower-risk, birth centers can be a very important solution to lowering costs within the U.S. health care system and improving outcomes.”

Amy Roeder

Photos: iStock / lawcain; Kent Dayton