Since the early 2000s, a growing number of maternal care centers across the country have closed their doors – most of them in rural areas, creating dangerous care deserts. Maternal health care is already scarce in these areas as 45% of rural counties had no hospital maternity services before an additional 9% lost services between 2004 and 2014. Between only 2016 and 2020, an additional 70 counties were classified as maternity care deserts. More pregnant or recently pregnant people are going without both proper prenatal and postpartum care. People living in rural areas — many of whom are without insurance, Medicaid recipients, older adults, individuals with disabilities, and veterans — are already at greater risk for disease and death than those in urban areas, where it is far easier to access quality maternal care. While the lack of maternal care resources can gravely impact the physical health of a birthing person, it can also limit the amount and quality of maternal mental and behavioral health care.
Consequences of these closures on maternal mental health
In 2022, the United States’ maternal mortality rate was 22.3 deaths per 100,000 live births, with suicide being the leading cause of death. As both the country’s maternal mortality and mental health crises continue to worsen, women continue to struggle to access adequate care. Over 50 million Americans experience mental illness, and 1 in 10 women experience peripartum depression, characterized as recurrent depressive episodes that can occur any time during pregnancy and the first 12 months after delivery. With the prevalence of peripartum depression and other maternal mental health issues (10% of pregnant women and 13% of women who have given birth experience a mental health condition such as depression), it’s clear that there are not enough services available.
Although peripartum depression is incredibly common, only 28% of women seek support for the condition and report their symptoms to a healthcare provider. Even when they do, women who have been diagnosed or are identified as at risk of peripartum depression do not receive competent services or follow-up care as 70% of rural counties do not have sufficient maternal mental health providers or resources, leading to mortality or severe morbidity. Maternity care deserts undoubtedly contribute to the maternal mental health crisis, but increased training and resources outside of traditional hospital settings can support patients in these areas and improve maternal mental health outcomes.
Addressing the maternal mental health crisis in rural areas
Simply identifying maternal mental health issues can be a challenge itself. Many factors contribute to a person’s risk of peripartum depression including age, level of family or social support, whether a pregnancy was planned, a family history of depression, financial struggles, or an unstable home life or relationships. When care is limited, infrequent, or confined to a hospital setting, many of these risk factors can be missed and left untreated.
However, it is not enough for a provider to simply check a box in a care evaluation form indicating that a patient is displaying symptoms of peripartum depression. Our research from surveying obstetric care providers found that only 71-72% of organizations conduct follow-ups for identified maternal behavioral health risks. Some of this is due to a lack of resources (i.e., hospital closures), but it is also caused by a lack of proper clinical training and patient education. Compared to larger cities with more resources, fewer healthcare organizations in small cities (63%) and rural areas (65%) have a structured process to provide outpatient resources.
In rural areas especially, doulas and midwives can play vital roles in delivering maternal care, often offering assistance outside of traditional care settings, ideal for those in maternity care deserts. Midwives and doulas serve similar functions; however, midwives provide medical care during pregnancy, birth, and the immediate postpartum period, while doulas do not perform clinical tasks, instead providing personalized physical/emotional support and education to the birthing person and their family. Midwives commonly provide care in free-standing birthing centers, often associated with lower rates of cesarean births and medical interventions as well as higher rates of breastfeeding. Doulas, who often visit patients in their homes, may be more attuned to cultural differences and in communicating with families to bridge care gaps but are often underutilized. As there are limited traditional maternity care services available in rural areas, the inclusion of additional midwives and doulas — whose care has proven to lower the odds of postpartum depression and anxiety by 57.5% — can help support maternal mental health needs where hospitals are unable to.
The importance of interdisciplinary approaches
It is imperative that everyone in the care continuum knows the warning signs of peripartum depression. Interdisciplinary education, coordination, and communication among care teams is crucial in diagnosing and treating patients. Pregnant or recently pregnant people may see many different types of care teams including OB/GYNs, nurses, therapists, pharmacists, all providers who should be trained in recognizing peripartum depression symptoms. However, in maternity care deserts where there may not be a single obstetrician trained in maternal mental health, other healthcare professionals serving the pregnant or recently pregnant population must be prepared to identify risk factors and direct patients to the appropriate resources.
To ensure that no patient falls through the cracks, obstetric care teams must take a holistic approach to care, embracing resources that allow them to extend their reach beyond hospitals. Regardless of hospital and maternity ward closures, there is a fundamental issue in maternal mental health care: a lack of proper clinical training and education. Healthcare organizations should take effective steps to ensure their teams are equipped to identify who is in need of maternal mental health care and activate the proper measures to support these patients.
Photo: damircudic, Getty Images
Lora Sparkman, MHA, BSN, RN, is Partner, Clinical Solutions at Relias, trusted partner to more than 11,000 healthcare organizations and 4.5 million caregivers
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