Maternal Health Awareness Day, observed Jan. 23, highlights the pressing issues facing maternal healthcare in the United States and the healthcare leaders who dedicate their careers to tackling systemic disparities and improving access to care, especially in rural and underserved areas.
Despite medical advances, the United States has some of the worst maternal health outcomes among high-income nations. Systemic disparities, compounded by racial, geographic and economic factors, leave millions of Americans without adequate care during pregnancy and childbirth.
The maternal health crisis in numbers
According to the Centers for Disease Control and Prevention (CDC), the U.S. maternal mortality rate soared to 32.9 deaths per 100,000 live births in 2021, more than doubling over the past two decades.1 For Black women, the figures are even more alarming: 69.9 deaths per 100,000 live births, nearly three times the rate for white women. Indigenous women also face disproportionately high maternal mortality rates, underscoring the devastating impact of systemic inequities.
A lack of access to care is also a significant factor in these outcomes. The March of Dimes 2024 Report2 reveals that 35% of U.S. counties are classified as maternity care deserts — areas without obstetric care providers or birthing centers. This leaves more than 2.3 million women of reproductive age without access to adequate maternity care. Another 4.2 million women live in areas with limited care, where local facilities are understaffed or financially constrained. More than 150,000 babies were born in maternity care deserts last year.
The impact of rural hospital closures and Medicaid
Since 2015, one in four rural hospitals has shut down its labor and delivery services, forcing pregnant women to travel hours for care.2 These extended travel distances can lead to delayed or missed prenatal care, often contributing to higher rates of preterm birth and maternal complications. The increased burden of travel also imposes financial and emotional stress on expectant parents, potentially deterring them from seeking necessary care.
Medicaid, which covers 42% of all U.S. births, is another critical factor.1 Low reimbursement rates make it financially unsustainable for many rural hospitals and clinics to offer maternity care, contributing to obstetric unit closures, leaving women in underserved areas without options.2
Mental health and maternal outcomes
Mental health has emerged as a leading underlying cause of pregnancy-related deaths, accounting for 22.5% of such deaths in 2020.1 The lack of integrated mental health services within maternal care further compounds this issue. Black women are especially vulnerable, experiencing higher rates of stress-related complications and preterm births compared to other groups.3
While comprehensive national statistics on pregnancy rates among transgender individuals in the United States are limited, existing studies provide some insight. A small study from the American College of Obstetricians and Gynecologists (ACOG) found that unintended pregnancies occurred in 32% of pregnancies among transgender men.4 Limited data suggests that transgender men and nonbinary people can experience similar pregnancy outcomes to cisgender women, but often encounter unique barriers such as stigma, limited provider knowledge and lack of inclusive care.5,6 These disparities contribute to higher rates of stress and worse overall health outcomes for this population. 5,6
A frontline perspective
As a practice administrator at Women’s Health Specialists, PLLC, in Tennessee, Kelley Rice, MBA, FACMPE, brings nearly three decades of experience managing healthcare clinics, navigating Medicaid challenges and advocating for systemic reforms.
Rice’s journey into healthcare began at an ENT practice in Kentucky. “I started out working front desk — check-in, checkout, answering phones, scheduling appointments — and then I worked my way up,” she explained.
“That long ago, it was a whole different world,” she said, reflecting on the healthcare landscape at that time. “You didn’t have issues with insurance companies; you went to the doctor, paid your copay, and that was it.
A chance recommendation from her administrator at the ENT practice led Rice to move into OB/GYN. Rice then gained diverse experience working in pediatric gastroenterology at the University of Louisville. Later, she transitioned to training practices in EHR implementation with Allscripts. “So, I was on the other side of the practice,” she said. “I was implementing and training EMR systems into various practices.”
After relocating to Nashville, Rice found work with a former client that then led her to work with an orthopedic group in the city. Over nearly a decade, she gained valuable experience in orthopedic and pain management practices before transitioning back to women’s health, where she has nearly four years in her current role at Women’s Health Specialists in in Murfreesboro, Tennessee.
Despite efforts to improve access to care, Tennessee faces alarming challenges in maternal health. The state reported a maternal mortality rate of 41.1 deaths per 100,000 live births, significantly higher than the national rate of 22.3.2 This grim statistic places Tennessee 39th out of 40 states with available data, underscoring the urgent need for systemic changes to better support parents and babies.
Transportation hurdles to maternal care
Rice’s clinic serves a growing Medicaid population, many of whom face challenging transportation hurdles due to closures of nearby obstetric units, highlighting the expanding crisis of maternity deserts across the country. "We have patients who drive two or three hours to see us," Rice shared.
One such example is Henry County Medical Center in Paris, Tennessee, which officially suspended its obstetric services on September 1, 2023, citing financial challenges, including low reimbursement rates.7 The closure forced many expectant parents to travel significant distances for care — an unfortunate reality for patients now relying on Women’s Health Specialists for maternal care.
“There weren’t any other birthing centers in that area,” explained Rice. “So, those patients started coming to us — which is great because now we know they're getting great care."
"But that is a long haul," Rice acknowledged.
Her clinic’s patient experiences reflect the broader maternity care crisis in rural Tennessee, where more than 32% of counties are classified as maternity care deserts.8 For many, the nearest birthing hospital is over 60 miles away, creating significant logistical and financial barriers that negatively impact maternal and infant health outcomes.
Challenges with Medicaid reimbursements
TennCare, Tennessee’s Medicaid program, covers approximately 50% of all births in the state, making it a critical safety net for low-income families. However, TennCare’s low reimbursement rates, complex bureaucratic structure and delayed payment processes add layers of difficulty for clinics like Women’s Health Specialists trying to deliver essential care in underserved areas.
"Many people in state of Tennessee can get TennCare," Rice explained, highlighting one of the unique challenges posed by TennCare's accessibility. While this broad eligibility offers temporary relief, care is disrupted when patients are removed from the program for various reasons.
"What happens with our patients is they either don't have coverage at all, they have coverage that doesn't offer maternity benefits, or they're younger patients who are on their parents’ [insurance] and don’t have dependent coverage," Rice said. These gaps leave clinics to navigate a patchwork system while ensuring patients still receive critical prenatal care.
In addition to these structural barriers, TennCare’s low reimbursement rates make it financially unsustainable for many providers to offer maternity care.
"The reimbursement rates are among the lowest in the country,” explained Rice. "The hoops we have to jump through, the challenges we have getting things approved and paid … it’s nearly impossible."
In fact, low reimbursements are one of the main reasons rural hospitals have closed their obstetric units.9 Rice agrees, stating, "They are not being reimbursed enough to pay the bills, or the physicians and all the necessary staffing."
Rice highlighted the importance of patient education as a core part of her clinic's approach to care. "We’ve learned that when you educate patients — when you explain what’s going on with their health and why they need this test or that treatment — they become active participants in their care," she said. "That can make a world of difference."
The ripple effect of these education and funding gaps is felt by patients and clinic staff. "Staffing shortages are a huge issue," Rice noted, pointing to the difficulty of offering competitive pay amid low reimbursement rates. "It’s harder and harder for us to do our jobs when really all we want to do is take care of the patient."
Partnerships and innovation in care
To help mitigate some of these challenges, Rice’s clinic leverages strategic partnerships with several different organizations to improve care access. “Outcomes have been great because we all put our patients first,” she notes. “So, we're able to work very closely together to make sure everybody's taken care of in the best way.”
"We have a very close relationship with a maternal fetal medicine practice, and we share a huge majority of patients,” she said. "They’re nearby, which is very helpful, because now we’re not concerned about where we’re going to send our high-risk patients."
Her clinic also works with sliding-scale organizations to provide care options for patients who might otherwise go without. "We see everybody," Rice explained. "Everyone is welcome in our practice.”
“But we cannot see patients for free,” she admitted. “We do payment plans ... and we have other clinics within the area that do a sliding scale."
Technology plays an increasingly important role in improving access and efficiency at Rice’s clinic, as well. The team uses systems like Phreesia and PatientPop to streamline tasks such as patient surveys, appointment scheduling, reminders via text and email, as well as patient registration before they come into the office.
Navigating legislative challenges
In addition to her leadership role at Women’s Health Specialists, Rice actively engages in advocacy efforts at the state level. “I sit on a committee for the Tennessee Medical Association (TMA),” she explained. “I’m also a fellow at MGMA, and I’m involved with Tennessee MGMA and Nashville MGMA.”
Rice also participates in Doctors’ Day on the Hill, an annual event organized by the TMA that brings healthcare providers together with lawmakers to advocate for improved healthcare policies. Through these meetings, Rice and her colleagues address systemic issues affecting maternal health, including Medicaid reimbursements and rural healthcare access.
In recent years, Tennessee’s strict abortion ban has introduced a new layer of complexity for maternal healthcare providers. Rice reflected on how her team engaged with lawmakers and healthcare leaders to address the implications of these laws. "When the ban first came out, several of my physicians and I went and talked to all the congressmembers and senators," she explained. "We met with other doctors in the different districts in town.”
For Rice’s clinic, she said they are dedicated to providing the best care possible in difficult times.
Advocacy and the path forward
Rice remains committed to advocating for systemic change. “I like to be involved, you know, I want to make a difference,” she said. “We're in healthcare to make a difference, whether it be for the patient, for the family, whatever that might look like.”
She advises that healthcare leaders get involved and stay on top of evolving legislation.
“Make sure that you attend all the educational experiences you can and join your local chapters, medical societies like ACOG, and join MGMA,” Rice said, adding “[MGMA] has been a huge and absolute resource for me and a lot of my colleagues.”
Looking ahead, Rice expressed cautious optimism but acknowledged the challenges. "Staffing shortages, rising costs and the growing influence of insurance companies are going to continue impacting care," she said. "But we’re here to support our patients and make a difference, no matter what."
As Maternal Health Awareness Day brings these issues to the forefront, Rice’s work exemplifies the dedication required to bridge gaps in maternal care. The statistics are sobering, but with the efforts of advocates like Rice and systemic reforms, there is hope for a future where every pregnant individual — regardless of race, income or location — has access to safe and equitable care.
References
- Centers for Disease Control and Prevention (CDC): Centers for Disease Control and Prevention. (2023). Pregnancy-related deaths in the United States: Data and research. Available from: https://www.cdc.gov/maternal-mortality
- Stoneburner, A., et al. (2024). Nowhere to Go: Maternity Care Deserts Across the US (Report No. 4). March of Dimes. Available from: https://www.marchofdimes.org/peristats/reports/united-states/maternity-care-deserts
- Mochumba, F., & Shah, N. (2022). Trends in racial and ethnic disparities in severe maternal morbidity. American Journal of Obstetrics and Gynecology, 226(1, Supplement), S730–S731. Available from: https://www.ajog.org/article/S0002-9378(21)02400-5/fulltext
- ACOG (American College of Obstetricians and Gynecologists). (2021, March). “Health care for transgender and gender-diverse individuals.” Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals
- Safer, J. D., et al. (2021). “Barriers to transgender and nonbinary individuals in accessing reproductive healthcare.” Journal of General Internal Medicine, 36, 3559–3561. Available from: https://link.springer.com/article/10.1007/s11606-021-07001-2
- Kukura, E. (2022). “Reconceiving reproductive health systems: Caring for trans, nonbinary, and gender-expansive people during pregnancy and childbirth.” Journal of Law, Medicine & Ethics, 50, 471–488. Available from: https://www.cambridge.org/core/journals/journal-of-law-medicine-and-ethics/article/reconceiving-reproductive-health-systems-caring-for-trans-nonbinary-and-genderexpansive-people-during-pregnancy-and-childbirth/4679FD1B301E463FAF3B166CB54B4C7B
- West Tennessee Healthcare – Henry County Hospital. (2023, May 26). HCMC suspending obstetric services, CEO John Tucker announces. Available from: https://www.hcmc-tn.org/news/hcmc-suspending-obstetric-services-ceo-john-tucker-announces
- Tennessee Department of Health. (n.d.). Healthy moms, healthy babies: Strong starts for children. Available from: https://www.tn.gov/health/health-program-areas/county-health-councils/tn-vitality-toolkit/strong-starts-for-children/healthy-moms-healthy-babies.html
- U.S. Government Accountability Office. (2022, October 19). Rural hospital closures: Increasing financial challenges and declining access to care. Available from: https://www.gao.gov/products/gao-23-105515
Explore Related Content
More Insight Articles
