Melanie Pierce works with many pregnant women who know they’ll have a long drive ahead of them when labor starts. 

One of her jobs as a doula living in Mansfield, Missouri, is helping families answer a question that may not be as fraught for women who live closer to a delivery hospital: When is it time to leave? 

Pierce’s clients often call as contractions begin, describing what they’re feeling and asking if they should head to the hospital. 

Across Missouri, this calculation is becoming more of a reality for many families as maternity care becomes increasingly concentrated outside of the state’s rural communities. 

More than half of Missouri’s counties are now considered maternity care deserts, or counties with no labor and delivery unit and no obstetric doctors, according to a new March of Dimes report.

“That’s one in two counties,” said Honour Hill, the director of maternal and infant health initiatives at March of Dimes in Alabama. “That’s more than a lot of states. Even some of our states with even worse maternal and infant health outcomes.” 

Nearly 140,000 Missouri women ages 15 to 44 live in counties that have no labor and delivery unit and no obstetric doctor, while more than 120,000 live more than 30 minutes from a hospital that has labor and delivery services. 

Missouri also fares worse than the country overall. Nationwide, 35% of counties are considered maternity care deserts. 

“Maternity care deserts are not just in rural areas, but a significant portion are,” Hill said. “So we’re seeing our rural moms and their families having to drive so much longer.” 

How did Missouri get here? 

Between 2010 and 2024, nine Missouri counties lost hospital-based obstetric services, researchers at the University of Minnesota Rural Health Research Center found. 

But maternity care was already disappearing from many communities before researchers began tracking county-level changes. 

“By 2010, when our data period started, a lot of places already lacked obstetrics,” said Emily Sheffield, a doctoral candidate and researcher at the University of Minnesota. 

The problem isn’t limited to rural areas. Urban hospitals have also stopped delivering babies, including Research Medical Center in Kansas City last year. But researchers have found that rural hospitals are particularly likely to lack obstetric services. 

Across the country, 718 hospitals stopped providing obstetric care between 2010 and 2024, either because labor and delivery units closed or the hospitals themselves shut down, a University of Minnesota analysis showed. By 2024, 57.5% of rural hospitals did not provide obstetric care, compared with 43.6% of urban hospitals. 

For small rural hospitals, keeping labor and delivery units open is particularly difficult. 

Obstetric care comes with high fixed costs, due to around-the-clock staffing requirements, dedicated labor and delivery space, anesthesia and the ability to perform C-sections — regardless of whether anyone is giving birth that day. 

At the same time, rural hospitals generally have fewer births to spread those high fixed costs across. They also tend to have a higher proportion of patients covered by Medicaid, which reimburses hospitals less than commercial insurance. 

“Rural hospitals already have lower patient volumes, just because they are located in areas with lower populations and a larger percentage of those patients are bringing those lower reimbursement rates,” Sheffield said. 

In a survey published in 2022, rural hospital administrators told University of Minnesota researchers they generally needed at least 200 births each year for obstetric services to be financially viable. 

The problem compounds as patients increasingly travel to larger hospitals for care. Fewer deliveries at a rural hospital can make it even more difficult to justify the cost. 

Of course, closing a labor and delivery unit doesn’t mean people stop having babies. It just makes it more difficult to do so. 

March of Dimes found that recent maternity ward closures increased the average travel times by 25 minutes for families living near the closure. Research also shows that the consequences go beyond a longer drive. 

The Minnesota researchers found that in the year after rural counties lost hospital-based obstetrics, the risk of preterm birth and out-of-hospital birth increased, as did the risk of giving birth at a hospital that did not have a dedicated obstetric unit, Sheffield said. 

The impacts were most pronounced in rural areas. Communities closer to urban areas and more hospitals could adjust more easily, data showed. 

“That’s when we really start to see the risks of maternal and infant health outcomes go up,” Sheffield said, “because people don’t have access to the services that they need.” 

In some of Missouri’s most rural communities, the nearest alternative is already more than an hour away. 

March of Dimes estimates that women in Reynolds and Douglas counties face drive times of more than 60 minutes to reach the closest hospital that has a maternity ward. 

Sarah Turnbow, the WIC coordinator at the Reynolds County Health Center, said families she works with typically travel 60 to 90 minutes to communities such as Farmington or Poplar Bluff for their prenatal and postpartum care. 

“There are about four or five OBs who are serving our whole population,” Turnbow said. 

But some routine care can now come to patients instead. 

A mobile integrated health program operating in the area can send providers to patients’ homes for some prenatal and postpartum visits. 

“As far as routine care and those types of things, it’s been very helpful,” Turnbow said. “I’m not quite sure the word has really gotten out as much as we would like it to have gotten out. It kind of still seems like a little bit of a foreign idea to a lot of our families here.” 

Bringing maternal healthcare to rural families across Missouri 

Missouri is trying to fill some of the gap by expanding the idea of mobile health units and bringing more services to patients, rather than making patients travel. 

March of Dimes points to telehealth, mobile health services and better connections to obstetric providers to high-risk patients as ways to make some care more accessible in communities that don’t have local providers. 

In Missouri, doulas are increasingly part of that effort. 

The state recently awarded more than $730,000 to the Missouri Doula Association through the Rural Health Transformation Program to expand rural Missouri’s doula workforce. 

The association is tasked with recruiting and training doulas and community health workers, building partnerships with rural health centers and helping workers navigate Medicaid billing, according to a press release from the state. 

When the state approved Medicaid coverage for doula services, Pierce began learning the world of Medicaid billing and opened her books to Medicaid patients. But the transition hasn’t been seamless. 

She said there are few doulas across most of the region, leaving providers like herself to cover wide geographic areas. Pierce lives in a town about an hour east of Springfield but works with clients as far away as Joplin, Branson and the Lake of the Ozarks. 

Medicaid pays doulas a set amount for a prenatal or postpartum appointment lasting at least an hour, even if the visit lasts longer. Pierce also said she cannot combine multiple sessions into one longer appointment.

“The visits they pay for are only an hour long, and we can only cover so much within an hour,” Pierce said. “If it takes me an hour to drive to somebody, an hour to meet with them, and an hour to drive back home, I’m only being paid for one hour but it takes me three.” 

The state recently added more doula visits for Medicaid patients to access, but Pierce said she still feels there are missing pieces for families who need her help the most. 

“The insurance clients are the ones on Medicaid,” Pierce said. “They’re the ones who are really more in need… Those people wouldn’t have a doula if it wasn’t for Medicaid.” 

Telehealth helps her bridge the gap for some families. Doulas don’t provide medical care, so much of the information and emotional support can be offered through virtual care. 

“It’s not ideal,” Pierce said, “but it’s what we have to work with.” 

Telehealth, mobile health units and doulas can help fill some of the gaps left by the absence of maternity care. But in Reynolds County, Turnbow said one of the most basic problems remains getting families to the care that has to happen somewhere else. 

“There just aren’t really very many options,” Turnbow said. “There’s no taxi service, you’re not getting a Lyft here to go anywhere.” 

For families in the area, getting time off work generally isn’t difficult, she said. Employers also have to travel for their health care. 

“It helps that we’re all on the same boat here in this county,” Turnbow said. 

More doctors practicing closer to Reynolds County would help, she said. So would transportation assistance and reducing some of the financial barriers that determine when and how families travel for their care. 

“If we could have some jobs and some money and some cars and some doctors, that would be great,” she said.