As more and more evidence links maternity care access to infant death rates, new research reveals a surprising twist: That finding is not equal across racial and ethnic groups, suggesting access alone won’t erase longstanding disparities.

A March of Dimes study, published in November, looked at more than 18.6 million live births and the mothers’ access to in-county maternity care. Babies born to mothers in “maternity care deserts” — counties with no obstetric hospitals or birth centers and no obstetric clinicians — had a 14% higher risk of dying than babies in counties with plenty of obstetric care options.

White babies in care deserts faced a 20% higher risk of dying. That effect, however, did not carry over to other races and ethnicities.

Hawaiian Native, Asian, and Pacific Islander infants showed some improved mortality risk with better care access, but Hispanic and Black infants showed no significant difference in mortality risk between full-access and no-access areas.

Black infants in no-access counties experienced the highest infant mortality rates at 11.2 deaths per 1000 live births. Racial disparities persisted even in full-access counties where the mortality rate for Black infants (10.2 deaths per 1000 lives births) was more than double that for White infants (4.1 deaths per 1000 live births).

“We were surprised,” said lead author Ashley Stoneburner, MPH, who heads the March of Dimes’ perinatal data team, “because the rates of infant mortality among many minority populations are much higher than those among white women. So we did anticipate that [lack of] access would make the risk even higher.”

Racial Disparities and Unequal Protection

The study builds on a growing pile of evidence showing that lack of access to maternity care — due to hospital closures, long travel distances, or provider shortages — is linked to higher infant death rates, particularly in rural communities.

But for racial minority mothers, geographic access alone is not the issue, said Shantesica Gilliam, PhD, MPH, maternal care researcher at Spelman College in Atlanta.

“There are the institutional factors like racism, care quality, social economic conditions — all of those needs play a major role beyond geography...and it’s something that we’re seeing nationwide. We’re seeing it in urban areas. We’re seeing it in rural areas.”

According to Gilliam, Hispanic and Black mothers are more likely to experience preeclampsia; to have their symptoms dismissed; and to get unequal treatment during pregnancy, delivery, and postpartum care.

As Access Decreases, Infant Deaths Rise

While the problem is more complicated across racial groups, the top-line finding is clear: Lack of access to maternity care isn’t just an inconvenience — it’s a risk factor. In the study, nearly 1 in 8 deaths in no-access counties and 1 in 9 deaths in low-access counties were potentially attributable to lack of access.

“Where you live really matters,” said Stoneburner. “Anytime you have to travel farther to find a doctor, anytime you have to just do more work to figure out where to go, it’s more stress. It’s hard financially.”

During her third pregnancy, 30-year-old Ally Lovell, also of Russell Springs, Kentucky, travelled 50 miles for prenatal care until her 20-week ultrasound found a severe heart defect. Doctors deemed her and her baby as high risk and transferred care to Cincinnati Children’s Hospital’s nearest partner hospital, almost 2.5 hours from her home.

Lovell travelled to two appointments a week for the final 8 weeks of her pregnancy, totaling almost 10 hours of drive time each week and $250 in gas.

“We definitely don’t have a huge savings account anymore,” she said. “It was triple the gas money every week. It was extra childcare paid, out eating on the road all the time.”

Fellow Russell Springs resident Joy Jones, a 35-year-old mom of three with another on the way, feels that pain. In her former home of Baton Rouge, Louisiana, she had access to four major hospitals and one birthing center, all within a 20-minute drive. But now the closest maternity ward is 30 miles away, and the nearest birthing center that Jones chose for this pregnancy is more than an hour away. Prenatal visits require at least half a day off work and childcare.

Dangers in the First Year of Life

Infant deaths linked to lack of maternity care are largely attributed to issues during pregnancy, labor, and delivery. But the study revealed another unexpected finding: Increased mortality risk for infants in no-access counties didn’t end with the neonatal period — the 28 days after birth. Instead, it carried on through the entire first year of life, with higher rates of congenital abnormality, sudden infant death syndrome (SIDS), and unintentional injuries.

This likely means these babies are up against other risks too, potentially including limits in pediatric care, a less supportive community structure, and fewer services such as home visits and SIDS prevention programs, Stoneburner said.

“Infant mortality really shows the overall status of the health of a population,” Gilliam said. “So if we’re seeing a lot of babies dying at high rates, it’s also showing that there are bigger seeds that should be addressed within the population.”

Making a Change

While the factors behind racial disparities are complex and still being investigated, efforts are underway to increase rural access to maternity care. In Texas and Kentucky, clinics are deploying mobile units to offer more accessible prenatal services. In Russell Springs, obstetric providers travel to the area once a week to provide an in-county clinic.

Telehealth can also go a long way to extend access, Stoneburner said. Digital visits and remote blood pressure cuffs and scales are all options that could potentially help cut back on the time and travel required of expecting parents.

More permissive midwifery policies that keep birthing centers open are also essential to prevent rural care from deteriorating further, she said.

“A lot of other countries use midwives as their primary source of care for pregnancies. And that is really something that we, for many, many reasons, are not doing well in the United States,” Stoneburner said.

Similarly, Gilliam said reimbursement for doulas would help because data show they are a cost-effective support option that improves mother and baby outcomes in a variety of delivery settings.

As for Jones, she’s grateful to be on her fourth pregnancy, rather than her first, with a better idea of what to expect. But her healthcare commute has already been an obstacle at 15 weeks. Both her second and third babies needed neonatal intensive care, and she recently learned that the closest NICU is another 60 miles from her birthing center.

If she were still in Louisiana, she wouldn’t hesitate to move her care to a larger hospital with those services. “But at this distance, that’s not sustainable,” she said. “I find it’s making me less proactive.”

There’s also the battle with her own worries. In Baton Rouge, she had the option to drop in and see a midwife whenever she had a question or felt nervous. Her new midwife in Kentucky is great, but “I’m not as willing to drive an hour there and back,” Jones said. “My anxiety...I just have to cope with it. And that’s terrifying.”