Role of Racial and Geographical Bias in Rural Maternity Care

Racial bias happens everywhere; it happens, often implicitly, as decisions are made about access to childbirth care in rural America.

Both academic research and journalism have chronicled the recent rise in hospital closures in rural America, but they sometimes ignore the fact that rural America is increasingly diverse. One in five rural Americans is a person of color: 40% are African American; 35% are Latino; and 25% are Native, Asian, Pacific Islander, or multiracial. When a maternity care crisis hits rural America, it affects a portion of these people of color.

In April 2017, my colleagues and I at the University of Minnesota Rural Health Research Center published a policy brief showing that 179 rural counties (9% of rural counties) lost access to hospital-based obstetric services between 2004-2014. By 2014, more than half of rural counties had no hospitals where a woman could give birth. The media response was overwhelming, highlighting story after story after story of rural women who gave birth in precarious circumstances or who did not get the care they needed. The crisis is more acute in some states than others, and the most remote communities are hardest hit. That is, some pregnant women are worse off than others when it comes to accessing the care they need.

Today, my colleagues and I published a paper showing that rural counties with more black residents are more likely to lack obstetric care, and more likely to lose it. In fact, the percentage of black residents was the strongest predictor of whether a rural county had obstetric services available in 2004, and one of the strongest predictors of whether a rural county that did have obstetric services in 2004 would lose them over the next decade.

The role of structural racism in the allocation of healthcare services and the implications for health equity in the continuation of these patterns are clear. Some recent media coverage of maternity care access has zeroed in on the effects of obstetric care services loss in rural black communities in Alabama and Georgia. For example, Joy Baker, MD, is one of two obstetricians serving a 2714 square mile area in rural Georgia, and Nicole Arthur, MD, is a family physician caring for rural women in Alabama who are traveling further following each local hospital obstetric unit closure. Both of these physicians are African-American women serving socioeconomically and medically high-risk rural women in predominantly black communities. However, focusing on physician shortages and hospital finances alone obfuscates some of the broader systemic issues that pattern access—and loss of access—to maternity care services. These include, as our paper shows, state Medicaid policies as well as income and race in the community where a hospital is located.

The “traditional” narrative of rural America does not honor the long history of people of color in rural areas—like the Black Belt and tribal lands—nor the rapidly changing demographics of immigration in rural America. When attention turns to healthcare in rural communities, there is frequently an implicit or explicit focus on white people in these communities.

More than 10 million people of color live in rural US communities. New and emerging barriers to healthcare access—including rural hospital closures—do not affect all rural residents equally. Solutions to challenges facing rural communities need to include people of color. The loss of hospital-based obstetric services is an equity issue. As such, community discussions around hospital service line closures should include representation from communities of color, and efforts to mitigate the challenges that follow closures must address clinical, practical, logistical, and cultural concerns of people of color.

Above all, discussions of maternity care access should recognize that there are many factors that may render families vulnerable, and these include both race and geography.