The term “Rural America” invokes certain ideals and feelings on what it means to be American. The classic image that often springs to mind is that of American Gothic, which perfectly encapsulates what it is that so many in this country are nostalgic for. Family, arduous work, agrarianism, and even the woman being placed behind the man because she knows her place in that world: a perfect picture of an imperfect society. Yet, the yearning and desire to return to this simpler, more banal lifestyle is already taking a toll on its most vulnerable members: mothers and expectant mothers.

The current outlook for maternal health post-Dobbs v. Jackson has trended toward the negative. Maternal mortality rates have continued to rise in the U.S. without any sign of abatement and it is even worse for women specifically located in rural America. OBGYNs across the United States see worsened impacts on racial and ethnic inequities, management of pregnancy-related medical emergencies, mortality, and even attracting new OBGYNs to the field post-Dobbs.

This is just the general state of maternal health across the United States. In states that have enacted abortion bans the situation is becoming worse. In Idaho, there are fewer applications for OBGYNs seeking residency, in Texas more than half of its counties lack obstetrician-gynecologists, and in West Virginia, less than a third of its counties have hospital birthing centers. Among those states, the women who have access to reproductive care are often in the urban areas, whereas rural residents had a 9% greater chance to suffer maternal morbidity compared to urban residents, and the risks of preterm births (associated with issues such as intellectual disabilities, asthma, etc.) are higher without access to obstetrician care which rural women have less access to.

What’s more, the closure of rural maternity wards has continued to grow in a cyclical feedback relationship, with OBGYNs either not seeking employment in those communities or moving elsewhere due to conflicts with restrictive abortion bans which results in maternity wards closing.

As more maternal medical personnel leave a certain area, they create something called a maternity care desert. A maternity care desert forms when a county has no obstetric hospitals or birth centers and no obstetric providers. These maternity care deserts are going to continue growing and disproportionately impact rural women in the South and Midwest particularly. Further studies show that nearly two-thirds of the maternal deaths that occur are preventable had the expectant mother had access to a maternity ward. If the trend of rural maternity wards closing continues, then the number of dying mothers will also continue to grow even though their deaths are entirely preventable.

It is not enough that rural women already face poorer health outcomes and have less access to health care compared to urban women, but many live in states that have enacted the strictest bans on reproductive health while also providing the lowest support for maternal health. It would rise to the level of comedy if this issue were not impacting some of the most vulnerable citizens in the country. One counterargument to this is to point out that women and mothers can choose how to manage their health best, but that relies on the presumption that women have choices they can pursue in these situations.

Expectant mothers in rural America are often faced with a dichotomic choice: finance themselves by moving to a nearby urban area to safely give birth under the care of OBGYNs or attempt a homebirth with all the associated risks that come from the decision. This choice presumes that hopeful mothers can finance their way to give birth, but the issue is compounded when taking into account that rural areas in general have less financial support. This poverty, coupled with the fact that states that deny access to reproductive health care are condemning women and their children to deeper poverty, shows the powerlessness for many mothers in rural America from lack of financial support.

Without the financial backing that is consistent with higher education and careers that accompany women with access to reproductive health care, it will only continue to make women in rural America more likely to become mothers without being ready to care for a child. This leads to them to become less financially stable, undereducated, and reliant on marital ties to make ends meet.

With such a bleak picture presented, the natural inclination is to ask what can be done. For example, Idaho has led the way in a new heterodoxic approach by simply discontinuing its maternal mortality review committee, becoming the only state without one.  While novel, it is not the approach that helps mothers if we elect to stop reporting their deaths.

The most straightforward solution is to legalize access to reproductive health care via abortion and contraceptives. There is endless evidence that when women are able to control their own reproductive health, it improves economic and healthcare outcomes. Since abortion continues to find itself as one of the seeming controversies of this century, there are alternatives.

One solution is to approve out-of-state healthcare providers as state Medicaid providers. This would allow the state to reimburse expectant mothers who need to travel across state lines to access obstetrician care and leave more money in their pockets to provide for their families. The current situation of Medicaid across the U.S. is heavily dependent on which state you are residing in, but if women in Coeur d’Alene, Idaho could go across the border to Washington for obstetrician care without incurring large amounts of debt, then they could receive much needed maternal support and prevent being one of the two-thirds of maternal deaths that were preventable.

Another solution is for the state to provide housing for expectant mothers who live far from maternity wards akin to Ronald McDonald House Charities. Maternity housing is usually run by anti-choice crisis pregnancy centers and these maternity houses are usually in states that have the highest rates of maternal mortality and poverty. If states were to step in and provide government-sanctioned housing before, during, and after birth, then they would be able to remove these predatory institutions that seem to thrive on using vulnerable women who often have no other place to go. The mother would have their room and board provided for by the state while staying and then, after delivery and subsequent evaluations, would be able to return to their rural communities without incurring monolithic amounts of debt and save the mothers from predatory pregnancy centers.

One last solution would be to expand telemedicine and clinic networks to facilitate access to maternal medicine consultation services. In Idaho again, telemedicine has been at the forefront of bringing much-needed medical access to rural communities in a cost-effective manner that was even able to weather the COVID-19 pandemic. If telemedicine is possible for deeply rural communities, then it is not much of a stretch to add on obstetrician care as an addendum. This issue is now gaining more traction as maternal telehealth becomes more in need for women who require contraceptives in states that have banned access to reproductive services and are looking for alternatives.

Ultimately, the patchwork of abortion laws that has sprung up post-Dobbs has resulted in increased maternal mortality rates that disproportionately affect rural women. If this new American Gothic is to continue, then instead of the woman being behind the man it would have to leave women out of the painting entirely, since rural mothers are the ones impacted most and have the least say in decisions over their reproductive health. If this continues, and rural America keeps leaving its women behind, how can the nostalgia for the rural parts of the nation continue when they only support half of their population?