Delivery deserts: a reproductive justice challenge beyond abortion access

Ed. note: This post was originally published on the Community site.

If I had gone into labor last summer in my tiny guest house on a Maine island, I would have had to drive an hour to reach the nearest hospital with a labor and delivery (L&D) ward. That would have been under ideal conditions; bad weather could have prevented me from crossing the old bridge to the mainland.

A spike in gas prices could have left me unable to afford the trip at all.

This summer I will be moving to Alabama, where women in some rural areas must travel over twice that long to reach their closest L&D ward. In 2014, only 29 of Alabama’s 67 counties had a hospital offering obstetrical services. When you look at just the rural areas, that number drops to only 17 rural counties where women could visit a hospital with L&D services.

As of 2014, less than half of rural women nationwide lived within 30 minutes of a hospital offering perinatal services. As L&D wards continue to shut down or centralize across the country, maternity care is becoming scarcer and these distances are growing longer.

Most people are by now familiar with the concept of food deserts, which describes poor urban communities without ready access to nutritious food. In delivery deserts, rural women may have access to local clinics or family practices, but hospitals with adequate L&D capabilities are a privilege of more metropolitan areas with the population size to sustain the businesses that hospitals have become.

In 2002 a Canadian medical journal published an editorial begging hospitals to stop centralizing maternity care, as it unduly endangered women and children and destabilized rural communities. Yet the phenomenon of delivery deserts in the U.S. has been largely unrecognized up to this point, which is shocking considering the danger it presents to women and infants. This issue has implications for both public health and reproductive justice, and it deserves the attention of professionals and activists in those fields.

Delivery deserts jeopardize the well-being of pregnant women and their children. I met a woman  in Maine who had travelled the 40 miles to the nearest delivery ward, just to be told she had to return home to wait until her contractions were closer together. The hospital staff must not have understood what it meant for her to be back at home, an hour away, when her contractions reached the “acceptable” spacing for her to be admitted.

Women living in delivery deserts are encouraged to schedule planned Cesarean sections or labor inductions so that their labor won’t catch them off guard while they are far from care. Cesarean sections have become so commonplace that it is easy to forget this is a surgical procedure, and as a surgical procedure it carries inherent risk; higher-than-necessary rates of Cesarean section in the U.S. are a huge part of the reason that our maternal and perinatal mortality rates fall far below most of the developed world. Scheduling births also leads to a higher number of infants being born premature.

The danger of delivery deserts rises exponentially when it comes to high-risk births. One woman I knew on the island was pregnant and had diabetes. This meant many potential complications for her pregnancy. She had to travel even farther than the other women on the island for specialist care. The incredible cost — in gas and in work hours lost — put further strain on her family. It also meant constant concern when the due date came closer; being unable to reach an L&D ward in time was not an option for her.

My purpose here is not to inspire a crusade against women giving birth outside of a hospital setting. On the contrary, physicians and scientists such as the late Dr. Marsden Wagner have shown that for normal, low-risk births, midwifery care and even home births can actually be safer than having an obstetrician-attended hospital birth. It can also be more convenient and more affordable for women in delivery deserts.

Not all women choose to give birth in a hospital, and certainly not all women should. However, every woman should have the right to make that choice for herself. Delivery deserts can force women into having unplanned home births. Or, as in the case of one woman I met, unplanned car births.

Further, my own research has shown that women in delivery deserts are unlikely to choose a midwife or home birth due to the inaccessibility of immediate care should complications arise: an entirely justified concern. In areas where midwives are required to have physician backup, distance from practicing physicians may also limit this option. Midwives and home births are proven to be yet another right of the privileged rather than of those who could most benefit from it.

Delivery deserts put mothers and children at risk, and they limit the choices women are able to make about their pregnancies. This reality needs immediate attention by health care professionals and policy-makers. It is a bipartisan issue; this is about saving the lives of mothers and children, as much as it is about access to comprehensive reproductive health care for all.