TOPLINE:

Infants born in counties with no access or limited access to maternity care had a higher risk for mortality in their first year than those born in counties with full access, with disparities across racial and ethnic groups. 

METHODOLOGY:

• This cross-sectional study evaluated whether infants born to women in areas with limited or no access to maternity care had an increased risk for death.
• Researchers used birth and death records of infants born to US residents from 2017 to 2021 and included more than 18.6 million live births (29.2% of mothers aged 30-34 years; 51.4% non-Hispanic White).
• Access to maternity care at the county level was categorized as none, low, moderate, or full based on the availability of obstetric hospitals and birth centers, the ratio of obstetric clinicians to births, and the proportion of women aged 19-54 years who were uninsured.
• Overall, 3.8% of infants were born in counties with no access to maternity care.
• The primary outcome was infant mortality, defined as death occurring within the first year of life. The outcome was analyzed based on the timing of death and race and ethnicity of mothers.

TAKEAWAY:

• Infants born in counties with no access to maternity care had a higher risk for mortality than those born in counties with full access (adjusted risk ratio [aRR], 1.14), followed by those born in counties with low access (aRR, 1.12) and moderate access (aRR, 1.08; P < .001 for all).
• The risk for mortality in both neonatal and postneonatal periods was higher in infants born in counties with no access than in those born in counties with full access (P < .001 for both).
• Non-Hispanic White infants born in counties with no access had a 20% higher risk for mortality than those born in counties with full access (P < .001), and Asian, Native Hawaiian, or Other Pacific Islander infants born in counties with low access had a 37% higher risk (P = .005).
• American Indian or Alaska Native and Black infants born in counties with no access had the highest rate of infant mortality. Even in counties with full access, Black infants had more than double the rate of mortality than White infants.

IN PRACTICE:

“Expanding access is necessary but insufficient; solutions must address the broader social and economic conditions that shape maternal and infant health,” the authors of the study wrote.

SOURCE:

This study was led by Ripley Lucas, MPH, of Perinatal Data Center at March of Dimes in Arlington, Virginia. It was published online on November 11, 2025, in JAMA Network Open.

LIMITATIONS:

The definition of access to maternity care evolved over time. Behavior of caregivers, environmental exposures, and features of delivery hospitals were unmeasured. Vital records had inconsistencies, and maternal data were incomplete.

DISCLOSURES:

This study received support from the Elevance Health Foundation and the Association of Maternal and Child Health Programs Graduate Student Epidemiology Program. One author reported receiving personal fees from the University of North Carolina at Chapel Hill.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.