Maternal health in the United States faces its share of dire statistics—especially regarding access to healthcare. About 700 women die every year from pregnancy-related issues, and more than 80 percent of those deaths are preventable.1
It's not just mothers who are dying: In 2020, the infant mortality rate in the US was 5.4 deaths per 1,000 live births.2 Among the leading causes are maternal pregnancy complications and preterm births. For both babies and mothers, the U.S. ranks below many industrialized countries. Consider this:
- There were 17 maternal deaths for every 100,000 live births in the US in 2018. By contrast, there were 3 (or fewer) per 100,000 in the Netherlands, Norway, and New Zealand.8
- With 5.7 deaths per 1,000 live births in 2019, the U.S. ranked No. 33 out of the 38 Organization for Economic Co- operation and Development countries in 2019. Iceland had the lowest rate in 2019 with 1.1 deaths/1000.9
Maternal access to healthcare is fraught with challenges—challenges that may play a significant role in these outcomes.3,8,9
Obstetrics and Lack of Access to Healthcare in Rural Areas
Rural residents have a 9 percent greater probability of severe maternal mortality and morbidity (involving illness or an unhealthy condition) compared to the population at large.3 One reason is that more than half the counties in the US have no hospital-based obstetrical service. This is especially true for maternal-fetal medicine (MFM) specialists, who tend to be clustered in large urban centers.4
Not only are there shortages of obstetricians and MFMs in rural communities, but the number of family physicians who provide obstetric care is on the decline.3 It's part of a larger trend: In January 2013, approximately 2,260 rural hospitals were open; by February 2020, 101 of them had closed.5
It can seem to patients like a no-win situation. Even if a pregnant person opts to drive hundreds of miles to get better reproductive care, extensive travel is known to contribute to increased risks of infant mortality and pregnancy complications.3 So both choices pose risks.
The lack of access for all pregnant patients to high-quality obstetric care may likely be a key factor leading to the deaths of pregnant people and babies. Greater access to reproductive healthcare could help to decrease the incidence of maternity mortality rates, and telehealth and other digital tools that support virtual care could play a crucial role.
Turning to Technology to Bridge the Gap
Telehealth and other tech-forward developments are helping to improve access to obstetrics care. Innovations have led to the creation of regional partnerships where specialists from metropolitan cities work closely with providers in rural communities to ensure patients have access to excellent maternity care.6
This is particularly important for high-risk pregnancies. At-home monitoring can help ensure the patient is getting regular check- ins on vital signs and other key markers that might flag that something is amiss. In the office, digital collaboration tools can connect urban MFM specialists with rural doctors, allowing them to share data in real time. These tactics have been shown to lead to better health outcomes and improve patient satisfaction.7
When needed, virtual telemedicine visits could take the place of in-person ones. Patients can be trained and equipped to monitor their blood pressure, weight, fetal heart rate, and more at home. Programs that integrate telehealth can allow patients to maintain continuity of care with their OB/GYN providers without having to travel, including delivery of prenatal and postpartum care. This might include monitoring for conditions such as diabetes and hypertension or consultation with specialists—not just MFMs but lactation consultants, genetic counselors, mental healthcare providers, and more.6
Such efforts remain relatively rare to date, but stellar examples exist. One system that's making it work is Children's Hospital Colorado.
A Model of Connected Maternal Care
Children's Hospital Colorado has built partnerships in communities that don't have access to comprehensive specialty care, such as fetal cardiology clinics.10 This way, the patient can keep seeing their local doctor while Children's Hospital Colorado provides specialized diagnostics and virtual care.
The hospital's Fetal Care Center provides patients with easy access to experienced fetal specialists that may be located hundreds of miles away. Among the services it provides are:
- Virtual consultations and interpretations of fetal diagnostic tests, including fetal ultrasounds, fetal MRI, and echocardiography
- Diagnosis of rare conditions and congenital heart defects
- Real-time consultations with fetal cardiologists and MFM specialists
It works like this: A patient visits a nearby community partner site, and the ultrasound is live-streamed to a specialist. Then the clinicians at both sites and the patient collaborate on a care plan.
Consider how this tech-enabled partnership might help in a case of fetal congenital heart disease (CHD), which is a significant cause of perinatal death. With CHD, access to expert care and early diagnosis is essential. Fetal cardiologists at Children's Hospital Colorado can evaluate images in real time—giving directions to the sonographer at the community partner site and even asking for additional scans if needed. It's not quite like the patient visiting the specialist directly, but it's a solution that can work.
Positive Outcomes, Satisfied Patients
Research backs up Children's Hospital Colorado's success in improving access to healthcare for pregnant people. A recent study found that the hospital was able to correctly identify and successfully manage CHD. Patients saw dramatic cost savings, both patients and physicians reported high satisfaction, and all the mothers preferred their fetal cardiac evaluation to take place locally rather than traveling to a distant site.7
"With these findings, we can now confidently say that neither diagnostic quality nor patient satisfaction were sacrificed with telecardiology as opposed to in-person visits," said Dr. Bettina Cuneo, lead author and the hospital's director of perinatal cardiology and fetal cardiac telemedicine, in a prepared statement. "The study also suggests that a telecardiology program is feasible and has economic advantages for the parents while keeping care close to home."11
Such technology supports collaboration among patients, their local clinicians and world-class specialists, connecting patients to life-saving expertise care no matter where they live.
Resources:
1. Pregnancy-related deaths: Data from maternal mortality review committees in 36 US states, 2017–2019. Centers for Disease Control and Prevention. Last reviewed September 19, 2022. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html. Accessed February 15, 2023.
2. Infant mortality. Centers for Disease Control and Prevention. Last reviewed June 22, 2022. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm. Accessed February 15, 2023.
3. Hostetter M, Klein S. Restoring access to maternity care in rural America. The Commonwealth Fund. Published September 30, 2021. https://www.commonwealthfund.org/publications/2021/sep/restoring-access-maternity-care-rural-america. Accessed February 15, 2023.
4. Nidey N, Haeri S, Greiner AL. Examining geographic access to maternal-fetal medicine care across the United States. American Journal of Obstetrics and Gynecology. January 2022;226(1):S564. doi: 10.1016/j.ajog.2021.11.934.
5. Maternal health: Availability of hospital-based obstetric care in rural areas. US Government Accountability Office. Published October 19, 2022. https://www.gao.gov/products/gao-23-105515. Accessed February 15, 2023.
6. Weigel G, Frederiksen B, Ranji U. Telemedicine and pregnancy care (issue brief). KFF. Published February 26, 2020. https://www.kff.org/report-section/telemedicine-and-pregnancy-care-issue-brief/. Accessed February 15, 2023.
7. Cuneo BF, Olson CA, Haxel C, et al. Risk stratification of fetal cardiac anomalies in an underserved population using telecardiology. Obstetrics & Gynecology. November 2019;134(5):1096-1103. doi: 10.1097/aog.0000000000003502.
8. Tikkanen R, Gunja M, Fitzgerald M, Zephyrin L. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries. The Commonwealth Fund Nov. 18, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-
countries.
9. International Comparison | 2021 Annual Report. America's Health Rankings. https://www.americashealthrankings.org/learn/reports/2021-annual-report/international-comparison.
10. "Maternal Fetal Telemedicine." Maternal Fetal Telemedicine | Children's Hospital Colorado. Accessed May 8, 2023. https://www.childrenscolorado.org/doctors-and-departments/departments/colorado-fetal-care-center/fetal-care-programs/
maternal-fetal-telemedicine/.
11. Childrenscolo. "Telehealth Effectively Diagnoses/Manages Fetal Congenital Heart Disease in Rural Patients." EurekAlert! Accessed May 8, 2023. https://www.eurekalert.org/news-releases/739604.
