As maternal mortality skyrockets in the United States, a federal program created to improve rural maternity care has bypassed Black mothers, who are at the highest risk of complications and death related to pregnancy.
The grant-funded initiative, administered by the Health Resources and Services Administration, began rolling out four years ago and, so far, has budgeted nearly $32 million to provide access and care for thousands of mothers and babies nationwide 鈥 for instance, Hispanic women along the Rio Grande or Indigenous mothers in Minnesota.
蘑菇影院 Health News found that none of the sites funded by the agency serves mothers in the Southeast, where the U.S. Census Bureau shows the largest concentration of predominantly Black rural communities. That omission exists despite a to make Black maternal health a priority and statistics showing America鈥檚 maternal mortality rate has in recent years. Non-Hispanic Black women 鈥 regardless of income or education level 鈥 die at nearly three times the rate of non-Hispanic white women.
鈥淭here鈥檚 a responsibility to respond to the crisis in a way that is more intentional,鈥 said Jamila Taylor, chief executive of the National WIC Association, a nonprofit advocacy group for the federal Special Supplemental Nutrition Program for Women, Infants, and Children.
鈥淲hy isn鈥檛 HRSA stepping up to the plate, especially with this rural moms鈥 program?鈥 Taylor said. According to a 2021 analysis of federal data, Black women living in rural areas also are or experience more severe health complications during delivery than white women living in rural areas.
Experts say the failure of HRSA鈥檚 Rural Maternity and Obstetrics Management Strategies Program, or RMOMS, to reach predominantly Black communities in the rural South reveals structural inequities and underinvestment in a region where health care resources are scarce and have deteriorated.
The steady closure of hospitals in the region and widespread medical staffing shortages have hindered the ability of cash-strapped agencies and care providers to provide more than essential services. Many 鈥渄on鈥檛 have sufficient resources鈥 to apply for the grants, said Peiyin Hung, deputy director of the University of South Carolina鈥檚 Rural and Minority Health Research Center. Hung is also a member of the health equity advisory group for the maternal grant program.
鈥淩MOMS really means to invest in the most underserved and the most disadvantaged communities,鈥 she said, but because the program demands applicants have a network of hospitals and other care providers, she said, 鈥渢he odds are not there for them to even try.鈥
Hung said she favors basing the awards on need and not solely on the quality of an application.
Where the Help Is Going
The rural program launched in 2019 and has awarded 10 maternal health grants nationwide to bolster telehealth and create networks between hospitals and clinics. Despite the disruption of care due to the covid-19 pandemic, the program鈥檚 earliest grant winners helped more than 5,000 women get medical treatment and recorded a decrease in preterm births during the second year of implementation, the agency reported.
When 蘑菇影院 Health News first asked Tom Morris, associate administrator for rural health policy at HRSA, about the lack of grants in the rural South, he said the agency has an 鈥渙bjective review process鈥 and regularly reviews the program to ensure it reaches the people who need it most.
鈥淭he rural rates of maternal mortality for African Americans is a real concern,鈥 Morris said, adding, 鈥淚 think you raised a good point there, and something we can focus on moving forward.鈥
So far, the maternal grants have gone to health care providers in Arkansas, Maine, Minnesota, New Mexico, South Dakota, Texas, Utah, and West Virginia, as well as two awards in Missouri.
Among the initial 2019 awardees, Texas reports that 91% of people it served were Hispanic; New Mexico reported 59% of recipients were Hispanic; and the Missouri project, which was in the southeastern part of the state known as the Bootheel, said 22% of beneficiaries were Black patients. In all cases, the majority were Medicaid enrollees. No data was available for other grant awardees. (Hispanic people can be of any race or combination of races.)
States across the rural Southeast have not expanded Medicaid coverage to larger numbers of lower-income residents, which often means lower shares of patients have health coverage.
Where Help Is Most Needed
The lack of Medicaid expansion in the region is "all the more reason funding should be going to these areas,鈥 said the WIC association鈥檚 Taylor. She said the program鈥檚 failure to reach into the southeastern U.S. seems 鈥渋ncredibly odd.鈥
鈥淭he South is a hotbed 鈥 to be quite honest 鈥 of a whole host of chronic diseases and health challenges, particularly for people of color,鈥 Taylor said.
Taylor, who previously worked on similar programs with community-based organizations while at the Century Foundation, said grant applications are often long and tedious and require intense data collection, adding to the 鈥渞eal challenges and barriers in the process of applying for the grants in the first place.鈥
Rep. Robin Kelly (D-Ill.), whose district spans rural and urban areas, said it is her experience that 鈥渟ome of the neediest places don鈥檛 apply for the grants because they don鈥檛 have the personnel.鈥
鈥淭here needs to be special outreach,鈥 said Kelly, who created legislation in 2018 to extend postpartum care after hearing from a constituent. 鈥淲e need to take the extra steps that mean saving women鈥檚 lives.鈥
Several current grant winners said the federal agency does provide extensive technical assistance and is responsive to questions and concerns 鈥 but they also described how difficult it was to win the grants, which amounted to $1 million or less for .
鈥淚t鈥檚 an intimidating grant to apply for,鈥 said Johnna Nynas, an obstetrician and gynecologist who wrote the maternal grant application for Sanford Bemidji Medical Center in Minnesota.
鈥淚 don鈥檛 want to admit how much of my own personal time I dedicated to this grant, writing it,鈥 she said. Sanford won the grant in 2021.
Unlike applicants from smaller, cash-strapped health organizations, Nynas was able to solicit help from the internal grant team at Sanford Health, which operates a regional system including a health plan as well as hospitals, clinics, and other facilities in the Dakotas, Iowa, and Minnesota.
Nynas said four hospitals in the remote region of northern Minnesota, where Bemidji is located, have closed their labor and delivery units in recent years, leaving residents 鈥 including a significant number of Indigenous women 鈥 to drive 60 miles or more one way for care.
Meeting an application requirement to create a network that includes specific health clinics as partners in the grant was 鈥渢he biggest challenge,鈥 Nynas said, adding 鈥渨hen you look at the map, those can be very difficult to find.鈥
Try, Try Again
In South Dakota, Avera Health鈥檚 application stalled for two years because of grant criteria requiring state Medicaid agencies to sign on as network partners, said Kimberlee McKay, an OB-GYN and the program director for the South Dakota grant. Avera Health spans Iowa, Minnesota, Nebraska, North Dakota, and South Dakota.
It wasn鈥檛 until the third round, McKay said, and after 鈥渢he climate around maternal health had changed,鈥 when the state Medicaid agency committed to fully partnering on the maternity care grant.
South Dakota voters adopted Medicaid expansion in late 2022 and will implement it this summer. Avera鈥檚 South Dakota program will use grant money to reach in the eastern part of the state and the region鈥檚 tribal communities.
Among the previous grant winners, only the Texas winner is from a non-Medicaid expansion state. HRSA spokesperson Elana Ross said 10 of 38 applications won grants since 2019. She declined to release a list of unsuccessful applicants, citing privacy concerns.
Ross said the requirement to partner with Medicaid 鈥渋ncreases the likelihood that the pool of applicants, if selected, will be able to sustain services at the end of federal funding.鈥 Medicaid, she noted, pays for nearly half of all births nationally and a greater share of births in rural areas.
The goal for the grants is that applicants can keep the program operating even after several years of federal funding runs out, HRSA officials said.
Stoking Change
In May, after 蘑菇影院 Health News began reporting this article, the agency released and relaxed requirements. Only two awards will be given, and the applications, which demand detailed network plans, are due July 7.
In an emailed statement released after announcing the more flexible expectations, Morris said the federal agency鈥檚 mission was to provide care for 鈥渢he highest-need communities, and that means dedicating significant funds towards addressing the Black maternal health crisis.鈥 The agency will no longer require state Medicaid programs to be partners on initial applications. It also loosened language about which clinics needed to be in the network.
And in perhaps the most significant shift, the agency said it will use newly created criteria to determine 鈥渁reas of greatest need.鈥 Alabama, Louisiana, and Mississippi all qualify as areas with shortages of maternity health care providers, according to .
Kelly, who works on Congress鈥 , said of the lack of grants in the rural South: 鈥淢oney matters, resources matter.鈥
Despite the government-wide focus on maternal care, it wasn鈥檛 clear whether the rural program would award new grants in 2023. In April, Morris told 蘑菇影院 Health News the agency was 鈥渢rying to figure out if we have enough funding to support our existing grantees and do a new competition.鈥
The rural maternity program鈥檚 initial fiscal year 2023 budget was $8 million 鈥 down from $10.4 million the year before, according to the . The release of grants in May came after the federal agency found an additional $2.4 million in its internal budget.
Even so, Kelly said, she 鈥渨ould love to see more money being put toward it鈥 as well as evaluations of 鈥渨here the money is being spent and where the holes are.鈥
