Differences in Access to High-Risk Pregnancy Care May Widen Maternal Health Disparities

What are high-risk pregnancy specialists? 

High-risk pregnancy specialists are healthcare professionals who specialize in maternal-fetal medicine (MFM), also known as perinatology. This is a subspecialty of obstetrics that involves receiving additional training to handle high-risk pregnancies. 

High-risk pregnancies require a higher level of maternal and fetal care. That’s because they often involve a maternal health problem — such as a preexisting condition that can affect the mother’s health during pregnancy — or another pregnancy-related complication such as preeclampsia. High-risk pregnancies may also involve issues related to the fetus, including some in vitro fertilization pregnancies and twin pregnancies. 

High-risk pregnancy specialists may: 

• Perform prenatal tests

• Coordinate maternal care with other healthcare professionals

• Consult on pregnancy complications 

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For many mothers, having access to a high-risk pregnancy specialist is important to ensuring good health for both mother and baby.

Who is most likely to see a high-risk pregnancy specialist?

According to our survey, 21% of women who recently gave birth saw a high-risk pregnancy specialist. For 30% of these women, the high-risk pregnancy specialist coordinated most of their care during pregnancy and birth.

White mothers were more likely to see a high-risk pregnancy specialist than nonwhite mothers. Specifically, high-risk pregnancy specialists were seen by:

• 16% of Hispanic/Latino mothers

• 18% of Black and AI/AN mothers

• 19% of Asian mothers

• 23% of white non-Hispanic mothers

Women who live in urban neighborhoods were also more likely to see a high-risk pregnancy specialist than women in rural areas. According to our survey, only 18% of women in rural areas saw a high-risk pregnancy specialist, compared to 26% of women in urban areas.

High-risk pregnancy specialists tend to be located in more urban areas 

Currently, there are over 2,200 high-risk pregnancy specialists practicing in the U.S. Most hospitals and birthing centers try to employ one full-time, high-risk pregnancy specialist for every 1,500 to 3,000 deliveries. However, there is a shortage of trained professionals, and high-risk pregnancy specialists are distributed unevenly across the country. 

The map below shows where high-risk pregnancy specialists are located across the U.S. Some states, like Alaska, South Dakota, and Wyoming, have fewer than 10 high-risk pregnancy specialists in the entire state. Our data shows that there are no high-risk pregnancy specialists actively practicing in North Dakota, despite over 10,000 annual births there.

As the map shows, these healthcare professionals are much more likely to be located in more densely populated, urban areas. While mothers living in mostly urban areas live an average of 23 minutes away from the closest high-risk pregnancy specialist, mothers living in mostly rural areas need to travel an average of 62 minutes to reach the closest specialist.

Across the entire country, over 5.9 million women of child-bearing age live in a “high-risk pregnancy specialist desert.” In these areas, most of the population lives over an hour away from the closest professional. On average, people living in these counties have to drive roughly an hour and 45 minutes to reach the closest specialist. 

For many mothers, this geographic barrier is enough to prevent them from seeing a high-risk pregnancy specialist entirely.

High-risk pregnancy specialists are less accessible to those with greater need 

Digging deeper into the data reveals a concerning trend — high-risk pregnancy specialists are disproportionately located in areas with a relatively lower risk of pregnancy complications. This leaves many Black, AI/AN, and rural mothers at a distinct disadvantage.

As the map below shows, high-risk pregnancy specialist deserts have higher rates of risk factors for pregnancy and labor complications: 

• Obesity: 37.6% in deserts vs. 33.1% in nondeserts

• High blood pressure: 32.9% in deserts vs. 30.1% in nondeserts

• Coronary heart disease: 6.0% in deserts vs. 5.2% in nondeserts

• Diabetes: 10.8% in deserts vs. 10.1% in nondeserts

• Chronic kidney disease: 3.0% in deserts vs. 2.8% in nondeserts

• Asthma: 10.6% in deserts vs. 10.0% in nondeserts

• Chronic obstructive pulmonary disease (COPD): 7.4% in deserts vs. 5.8% in nondeserts

• Smoking: 19.3% in deserts vs. 14.8% in nondeserts

Still, in 2022 there were over 366,000 births in high-risk pregnancy specialist deserts. Many of these births took place in areas where there was a greater risk of pregnancy complications and a greater need for specialized care.

For example, in many Southern counties, pregnant people have to travel over an hour to reach the nearest high-risk pregnancy specialist. But they also face above average risk factors for pregnancy complications, including obesity, high blood pressure, diabetes, asthma, and smoking. These states also have the highest maternal mortality rates, with Arkansas, Mississippi, Tennessee, and Alabama all exceeding 40 deaths per 100,000 births.

As a result, many mothers go without specialized care, despite seeking it out. In our survey, almost 8% of people who did not see a high-risk pregnancy specialist reported wanting to see one. The share of mothers who reported this unmet need was highest for Black and AI/AN mothers  (11%). 

Availability, timing, convenience, and distance were the most commonly reported barriers to getting care from a high-risk pregnancy professional. They were cited by nearly 47% of mothers who were unable to see a specialist but wanted to see one.

Cost was a major barrier for 33% of mothers who reported wanting to see a high-risk pregnancy professional. This may be related to differences in insurance coverage. Mothers who were unable to see a specialist were also more likely to have individually purchased health insurance or no health insurance at all. In addition, Black and AI/AN mothers were more likely to report financial barriers to high-risk pregnancy care compared to white mothers.

Poor access to high-risk pregnancy specialists can harm maternal health and widen disparities 

High-risk pregnancy professionals are specially trained to handle more complex maternal health conditions. Access to these specialists is critical for navigating complications during pregnancy and birth.

According to our survey, over 15% of mothers who recently gave birth reported an unexpected complication during labor. The rate of labor complications was roughly similar for mothers who saw a high-risk pregnancy specialist (15%) and women who did not want to see a specialist (14%). However, the rate of labor complications was over twice as high for women who were unable to see a high-risk pregnancy specialist but wanted to see one (36%).

Many mothers who had complications during labor also reported feeling dissatisfied with at least one area of their birthing care, including:

• How their complication and treatment options were explained

• The level of communication they received from their healthcare team

• How the complication was addressed

Black and AI/AN mothers had the highest rate of labor complications (20%) as well as a higher rate of dissatisfaction (36%). White mothers reported a lower rate of labor complications (14%) and were also the least likely to report dissatisfaction with their care (25%).

Differences in the rate of labor complications and how they are handled can affect the mother’s health as well. Black and AI/AN mothers who experienced complications had twice the rate of  longer postpartum hospital stays (of at least 4 days) compared to white mothers who experienced complications.

These disparities in birthing care — particularly for high-risk pregnancies — may be contributing to disparities in maternal mortality.

Why trust our experts?

Written by:

Amanda Nguyen, PhD

Dr. Nguyen is a health economist with a passion for creating actionable knowledge out of data. An expert in economic modeling and econometrics, she works to investigate and demystify pressing issues in healthcare.

Edited by:

Tori Marsh, MPH

Tori Marsh is GoodRx’s resident expert on prescription drug pricing, prescribing trends, and drug savings. She oversees the GoodRx drug database, ensuring that all drug information is accurate and up to date.

Reviewed by:

Lauren Chase

Lauren Chase manages the GoodRx drug database, ensuring that all data is accurate and up to date. During her time at GoodRx, she's improved the processes and quality of drug database management.

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Methodology

Survey: Our survey was run through Qualtrics from October 26, 2023 to November 15, 2023. A total of 1,015 responses were collected and analyzed. The survey screened in people who gave birth up to 24 months prior to the date of the survey and were at least 18 years of age. We also required that they saw a healthcare professional for their pregnancy, labor and birth, and post-birth care. We oversampled specific race groups (American Indian, Alaskan Native, and Black Americans) to ensure that we captured sufficient responses by race. 

To obtain nationally representative numbers, we created weights based on the race and ethnicity reported in the survey. Our weights were created using the race and ethnicity shares reported by the American Community Survey (ACS) 2022 5-year estimates (Table B03002: Hispanic or Latino Origin by Race). To evaluate the representativeness of our weights, we calculated the share of our weighted sample by region and by income groups in comparison to national shares using ACS 2022 5-year estimates (Tables B01003: Total Population and Table B19001 Household Income in the Past 12 Months (in 2022 Inflation-Adjusted Dollars). The comparisons can be found here.

Healthcare professional data: The dataset on healthcare professionals is licensed through HealthLink Dimensions. Based in Atlanta, HealthLink Dimensions is the authority in healthcare professional data, serving hospitals, life sciences, and health insurers with innovative managed data services and enterprise engagement solutions. 

Professionals were included if they (1) had “maternal & fetal medicine” (MFM) or “perinatology” in their specialty description; (2) were located in one of the 50 U.S. states or the District of Columbia; (3) had an accurate location mapped to them (a professional may have more than one specialty and/or more than one active location); and (4) had a claim with an ICD-10 diagnosis code of O00-O9A (Pregnancy, Childbirth, And The Puerperium), Z32, Z34, Z36, and Z39 between September 2020 and September 2023. The claims source consists of both commercial and CMS claims data covering 350 million lives and over 5 billion claims per year. We added a claim requirement because we wanted to identify professionals who specifically treated people who were pregnant.

Many different types of professionals can be involved in maternal care. In this analysis, we included doctors, physician associates, and advanced practice nurses for the MFM specialty. The data set may undercount the number of professionals because the data is based on the NPPES NPI Registry.

We used the latitude and longitude to geolocate a professional’s address to a county using Census 2023 TIGER/Line ShapeFiles.

Census data: Data on total number of childbearing women (ages 15 to 44) by county was obtained from the American Community Survey (ACS) 2022 5-year estimates (Table B01001: Sex By Age). 

Data on the total number of annual births was obtained from the US Census County Population Totals and Components of Change files. Specifically, our county of births uses the variable BIRTHS2022, which represents births in the period July 1, 2021 to June 30, 2022. 

We linked a county to a core-based statistical area (also known as a geography type) using Census March 2020 Delineation files. The U.S. Office of Management and Budget defines areas as metropolitan (metro) if they have at least one urban cluster with a total population of 50,000 or more and as micropolitan (micro) if they have at least one urban cluster of between 10,000 and 50,000 people. Generally, metro counties are the most urban and nonmetro or micro counties are the most rural.

Analysis: All analyses reported above describing national representative numbers used the survey weights described above. All analyses comparing rates by race/ethnicity groups were unweighted.

For all data reported by race and ethnicity, we assigned a survey respondent to a group by first assigning anyone who self-reported as all or some part Black or AI/AN (American Indian and Alaskan Native) to the group “All or some part Black or AI/AN.” Then, anyone who self-reported as Asian, Native Hawaiian and Other Pacific Islander (NHPI), or Other was grouped as “All or some part Asian, NHPI, Other.” So if someone was to self-report as both Black and Asian, they would be assigned to the “All or some part Black or AI/AN” group. 

Deserts: We defined driving distance and drive time for each census tract as driving distance and drive time between a tract’s Center of Population to the nearest maternal-fetal medicine professional. We determined tract population based on the U.S. Census Bureau 2020 Center of Population report. All location metrics (distance and drive times) were computed using the Google Distance Matrix API based on average traffic conditions. We define a majority desert county as a county with over 50% of its population living over a 1-hour drive from the nearest maternal fetal management specialist. Tracts with a population of 0 were excluded from the analysis. Tracts with no valid closest driving distance to a maternal fetal management specialist were also excluded (often due to geographical constraints).

Disease prevalences are shown based on data from the 2021 CDC PLACES report, which are model-based, county-level estimates for (1) age-adjusted prevalence of current asthma among adults aged >=18 years, 2019; (2) age-adjusted prevalence of chronic obstructive pulmonary disease among adults aged >=18 years, 2019; (3) age-adjusted prevalence of chronic kidney disease among adults aged >=18 years, 2019; (4) age-adjusted prevalence of diabetes among adults aged >=18 years, 2019; (5) age-adjusted prevalence of hypertension among adults aged >=18 years, 2019; (6) age-adjusted prevalence of obesity among adults aged >=18 years, 2019; (7) age-adjusted prevalence of smoking among adults aged >=18 years, 2019; and (8) age-adjusted prevalence of coronary heart disease among adults aged >=18 years, 2019.