People who are pregnant in rural areas generally have a harder time reaching a doctor. Dr. Anne Banfield saw this firsthand when she worked as an OB-GYN in rural West Virginia.
“We have a lot of mothers in our country who are suffering, because potentially in many cases, there are breakdowns in the prenatal care system,” Banfield said.
About half of all counties in the U.S. lacked a dedicated OB-GYN in 2019, according to data from the U.S. Health Resources & Services Administration analyzed by Louisville Public Media.
Since the Supreme Court ruled to overturn Roe v. Wade in June, states have begun implementing their own laws surrounding abortion and reproductive rights. There’s concern among physicians and public health experts that pending abortion bans in places already lacking maternal health resources could lead to worse outcomes.
Even before Roe was overturned, states with the strictest abortion laws — including Kentucky, Indiana, Kansas and Nebraska — also had some of the worst maternal and child health outcomes and lowest investments in at-risk populations. That’s according to an analysis of state-level data presented in an amicus brief filed this spring in the Dobbs v. Jackson Women’s Health Organization case. The analysis, signed by hundreds of public health and reproductive health researchers, accounted for state-to-state differences in poverty levels, education, and race and ethnicity.
The idea that people are more likely to die from childbirth if they live in states that restrict abortion is supported by research, including studies from Tulane University and Washington University.
It’s why some physicians are sounding the alarm, saying efforts to address rising maternal mortality rates, especially in parts of the Midwest, South and rural areas, could get even tougher.
“The post-Roe situation, and the issues we have with maternal mortality, and the issues that we have with access to care in rural areas of the United States… are all coming together in a way that is going to make [our] battle against maternal mortality 1,000 times worse,” Banfield said.
A shortage of rural providers – and other barriers to care
In Kentucky, a near-total ban went into effect as soon as Roe fell. The ban is currently blocked in court, but if it goes through, more people will be forced to bring pregnancies to term in a state with one of the highest maternal mortality rates in the nation. In recent years, Kentucky’s rate has been double the nationwide rate, with nearly 40 deaths per 100,000 live births, according to data from the Centers for Disease Control and Prevention.
Part of the concern is the overall lack of OB-GYNs in Kentucky, especially in rural areas.
Banfield, now the medical director of obstetrics and gynecology at MedStar St. Mary’s Hospital in rural Maryland, said she left her prior OB-GYN position in West Virginia after staffing shortages at her hospital led to an increase in workload that became unmanageable. The hospital struggled to recruit replacement doctors to the area, and Banfield decided to move on to a new opportunity.
While family doctors can help plug gaps in rural prenatal care, only about 8 percent in Kentucky do, said Dr. Lars Peterson, vice president of research for the American Board of Family Medicine, which collects data from physicians as part of its certification process. Kentucky lags behind every bordering state — Indiana, Illinois, Ohio, Virginia, West Virginia, Missouri and Tennessee — in which around 12 percent of family doctors do prenatal care, he said.
“There's a persistent pattern of rural family physicians in Kentucky doing prenatal care and delivering babies less than neighboring states and nationally,” said Peterson, who’s also a family physician and associate professor at the University of Kentucky.
Prenatal care services, which include physical exams, blood tests and ultrasounds to monitor fetal development, may also be provided by local health departments. But the shortage of health care providers and services is not the only barrier, said Melissa Eggen, a doctoral student at the University of Louisville and a senior policy analyst at the Commonwealth Institute of Kentucky.
A lack of insurance and systemic racism in health care can also prevent people from accessing prenatal care, she said.
Some patients may have negative experiences in health care settings that lead to a breakdown in trust.
“A woman may have seen her provider, and that provider may have expressed something that she perceived as being racist,” Eggen said. “And she may not want to come to that provider any longer. She may not trust that provider. She may stop using prenatal care altogether or may want to find another provider.”
Risky pregnancies could get riskier
Prenatal care is important even for low-risk pregnancies, said Banfield. It’s particularly important in rural communities, she said, where co-occurring illnesses like diabetes and high blood pressure are more prevalent — and can make pregnancy more dangerous.
“We may have a patient who… goes from having hypertension, to having preeclampsia or eclampsia, and now, maternal seizures, and maternal neurologic complications associated with that,” she said. “We may have a mother who has a placenta that’s inappropriately located and has bleeding outside the hospital that results in hemorrhage that is life-threatening.”
With the U.S. Supreme Court’s ruling last month, hundreds of thousands lost access to abortion in Kentucky, as the state’s trigger law went into effect. The law makes it a low-level felony for anyone to provide abortions in the state, except in life-threatening situations.
Providers took that to court, and abortion services resumed a week later. That fight continues, and access could again be taken away this year for people seeking services in the commonwealth.
Abortions are still legal in Kentucky and some surrounding areas. But the services, which were already limited, are getting harder to come by as many states are cracking down.
Some people may be able to access abortion by traveling out of state to places where it remains legal. But Banfield worries about the many who will lack the resources to do so and may be forced to carry their pregnancies to term.
“It's not women and birthing persons who have resources that are going to suffer post-Roe,” she said. “It is these patients and birthing persons who have lack of resources and they're just going to suffer more.”
Justin Hicks, data reporter for Louisville Public Media, analyzed data for this report.
This story comes from a collaboration between Side Effects Public Media, WFPL and the Midwest Newsroom — an investigative journalism collaboration including IPR, KCUR 89.3, Nebraska Public Media News, St. Louis Public Radio and NPR.