For many women and gender diverse people, access to care during pregnancy and birth is shaped by where they live. Living far away from maternal health services can delay care, increase complications, and affect outcomes for both women and newborns. In some parts of the United States,\u00a0this phenomenon has been given\u00a0a\u00a0name: maternity care deserts.\u00a0<\/p>\n
To better understand what this looks like in practice, we spoke with Mandy Steen, Board Chair, and Grace Fox, midwife and board member of South Dakota Birth Matters, an organisation working to expand access to midwifery and birth options across the state.\u00a0<\/p>\n
While the term\u00a0maternity desert\u00a0is widely used in the United States, the issue it describes is not unique. Across countries, many communities face the same challenge: essential maternity services are too far away, too limited, or not available at all.\u00a0<\/p>\n
A\u00a0System\u00a0Defined by\u00a0Absence\u00a0<\/p>\n
In the United States, maternity care deserts are defined by the absence of services. Entire\u00a0counties\u00a0\u00a0(a local government area within a US state)\u00a0are classified based on whether care exists at all. A county is considered a maternity care desert when there are\u00a0no midwifery birth centres,\u00a0no maternity care providers and no\u00a0hospitals offering\u00a0maternity\u00a0care.\u00a0<\/p>\n
This definition is useful for showing where care is missing, but it does not fully reflect how access is experienced. Distance shapes care. In South Dakota,\u00a0a state in the northern United States with a\u00a0relatively\u00a0small, dispersed population,\u00a0women travel an average of\u00a032 kilometres\u00a0to reach the nearest\u00a0hospital\u00a0with maternity\u00a0services;in\u00a0some\u00a0areas\u00a0that journey can\u00a0be more than160 kilometres.\u00a0<\/p>\n
More than half of counties in\u00a0South Dakota\u00a0are classified as maternity care deserts.\u00a0Nearly one\u00a0in four women (23.7%)\u00a0does not have a hospital with maternity services\u00a0available\u00a0within a 30-minute drive\u00a0from her\u00a0home;\u00a0\u00a0some\u00a0women must drive\u00a0over 60 minutes just to reach care.\u00a0<\/p>\n
As Mandy explained, distance in South Dakota shapes every part of maternity care. For many families, reaching care means long journeys, missed appointments, extra costs, and\u00a0difficult decisions\u00a0about when to leave home during labour. South Dakota is the 17th largest state geographically in the U.S., but it is the fifth least populated. It is also home to nine federally recognised tribal reservations, many of which\u00a0are located in\u00a0areas classified as maternity care deserts.\u00a0\u00a0<\/p>\n
\u201cIt\u2019s really scary that there are all of these women who can\u2019t access care near them,\u201d she said. \u201cA lot of these women\u2026don\u2019t even attend a single prenatal appointment because they simply cannot access one logistically.\u201d\u00a0<\/p>\n
To help contextualise the scale of the issue, Mandy explains that across the entire state there are only 18 out-of-hospital midwives, both Certified Professional Midwives and Certified Nurse Midwives, serving what is considered the second largest maternity desert in the country.\u00a0<\/p>\n
\u201cThey travel 90 minutes\u2026 just to reach care\u201d\u00a0<\/p>\n
For Grace, a\u00a0certified\u00a0professional\u00a0midwife practising in South Dakota, these challenges are part of everyday work.\u00a0<\/p>\n
\u201cI recently had a client that travelled 90 minutes\u00a0in labour to the hospital\u2026 and she just barely made it in time to give birth,\u201d she said.\u00a0In many cases, this kind of journey is not straightforward. Women often cannot drive themselves while in labour, which means they need a car, someone available to drive them, and support for any other children at home. These practical realities add another layer of complexity to accessing care.\u00a0<\/p>\n
She described women travelling two to three hours for appointments. Some temporarily\u00a0relocate\u00a0in the final weeks of pregnancy just to be closer to services. Others drive hundreds of\u00a0kilometres\u00a0throughout their pregnancy.\u00a0<\/p>\n
\u201cI delivered a baby for a family that lives just under\u00a0300 kilometres\u00a0away,\u201d Grace explained. \u201cThey would drive three hours to every prenatal\u00a0appointment, and three hours back.\u201d\u00a0<\/p>\n
These journeys are not just inconvenient. They come with financial costs, stress, and risk. Grace shared the story of a family who had a road accident while travelling in winter conditions during labour.\u00a0<\/p>\n
For women living in rural\u00a0areas, and in Indigenous communities, the barriers are even greater. Some are unable to attend regular antenatal care due to distance, transport, and cost.\u00a0<\/p>\n
\u201cThere\u2019s pretty\u00a0much\u00a0women from\u00a0half of\u00a0South Dakota\u00a0that can\u2019t access care,\u201d Mandy added.\u00a0<\/p>\n
These realities shape outcomes. They also reflect wider inequalities linked to poverty, geography, and access to services.\u00a0\u00a0<\/p>\n
Why\u00a0Maternity\u00a0Deserts are\u00a0Growing\u00a0<\/p>\n
In South Dakota, as in many parts of the United States, maternity care deserts are shaped by broader health system challenges.\u00a0<\/p>\n
Hospital closures, workforce shortages, and the concentration of services in urban areas have reduced access in rural communities.\u00a0The\u00a0complicated\u00a0health insurance system in the United States also adds a layer of complexity to the situation.\u00a0<\/p>\n
Mandy described how services have steadily disappeared:\u00a0<\/p>\n
\u201cThey\u2019ve been continuously closing maternity units\u2026 and it just makes it really difficult for women living in rural South Dakota to access care.\u201d\u00a0<\/p>\n
Midwives are also affected. Training opportunities are limited, and recruitment is difficult in remote areas.\u00a0<\/p>\n
\u201cWe just don\u2019t have enough midwives\u00a0working in\u00a0the state,\u201d Grace said.\u00a0<\/p>\n
For\u00a0certified\u00a0professional\u00a0midwives, the challenges are even greater. They often work independently, managing both clinical care and the\u00a0business aspects\u00a0of running a practice.\u00a0<\/p>\n
Cost is another barrier. Many families pay out of pocket for care because insurance systems are difficult to navigate.\u00a0<\/p>\n
\u201cPeople are saying we can\u2019t afford the\u00a0insurance\u00a0premiums\u2026 or it\u2019s not worth it,\u201d Grace explained.\u00a0<\/p>\n
Together, these factors create a system where access\u00a0to care\u00a0is not guaranteed, even in a high-income country.\u00a0<\/p>\n
A\u00a0Long\u00a0History of\u00a0Advocacy\u00a0<\/p>\n
In this context,\u00a0a civil society organisation that brings together women and midwives,\u00a0South Dakota\u00a0Birth Matters,\u00a0has played a key role in expanding access to care.\u00a0<\/p>\n
Founded in 1992, the organisation\u00a0emerged\u00a0in response to efforts to restrict midwifery practice in the state. Over more than three decades, it has worked to protect and expand birth options through legislation, education, and advocacy.\u00a0<\/p>\n
This work led to important milestones, including the legalisation and licensure of\u00a0certified\u00a0professional\u00a0midwives in 2017, allowing them to practise in the\u00a0South Dakota.\u00a0<\/p>\n
Their experience highlights an important lesson: improving access to care often requires sustained, long-term advocacy.\u00a0<\/p>\n
Policy\u00a0Barriers \u2013 and\u00a0Opportunities\u00a0<\/p>\n
Despite progress, key barriers\u00a0remain.\u00a0<\/p>\n
Current regulations limit the expansion of midwifery services. Certified\u00a0professional\u00a0midwives are not\u00a0permitted\u00a0to own or\u00a0operate\u00a0freestanding\u00a0birth centres, restricting the development of community-based care options.\u00a0<\/p>\n
Geographic restrictions add another layer.\u00a0Freestanding\u00a0birth centres must be\u00a0located\u00a0within 30 miles\u00a0(50 km)\u00a0of a hospital\u00a0that offers\u00a0obstetric services. In a state where large areas already lack care, this requirement prevents services from being\u00a0established\u00a0where they are most needed.\u00a0<\/p>\n
To address these barriers, advocates from South Dakota Birth Matters have proposed a new state law aimed at changing how maternity services are regulated and expanding access to care.\u00a0<\/p>\n
In practical terms, the bill focuses on removing specific regulatory barriers that currently prevent services from being\u00a0established\u00a0where they are most needed.\u00a0<\/p>\n
It would:\u00a0<\/p>\n
Update outdated birth centre regulations, including requirements that limit where centres can be\u00a0located, so that services can be set up in rural and underserved areas\u00a0<\/p>\n
Align legislation governing midwives and birth centres, removing contradictions that currently prevent\u00a0certified\u00a0professional\u00a0midwives from fully\u00a0participating\u00a0in birth centre care\u00a0<\/p>\n
Enable the establishment of new services closer to communities, reducing long travel times and making it easier for women to access antenatal, birth, and postnatal care\u00a0<\/p>\n
By doing this, the bill does not replace hospital care. Instead, it expands the range of safe options available for low-risk pregnancies, while\u00a0maintaining\u00a0clear protocols for referral and emergency transfer when needed.\u00a0<\/p>\n
For families, this could mean receiving care closer to home. For midwives, it could mean being able to practise more effectively within their communities. For the health system, it offers a way to address gaps in access without relying\u00a0exclusively\u00a0on hospital-based services.\u00a0<\/p>\n
A\u00a0Global\u00a0Issue\u00a0with\u00a0Different\u00a0Names\u00a0<\/p>\n
While the term maternity desert is specific to the United States, the issue is global.\u00a0<\/p>\n
Different countries measure access in\u00a0different ways. Some use administrative definitions based on service availability, while others focus on travel time or distance\u00a0\u2013 in\u00a0good weather, with a reliable vehicle and\u00a0navigable\u00a0roads. In global maternal health, a common benchmark is whether emergency obstetric care can be reached within two hours. This threshold is most often used in rural and hard-to-reach settings, particularly in low- and middle-income countries, where access to facilities can be severely limited. It reflects the critical window of time between the onset of untreated severe postpartum haemorrhage, a leading cause of maternal death\u00a0and is used as a practical way to assess whether health systems can respond in time to life-threatening complications.\u00a0<\/p>\n
Each approach highlights\u00a0different aspects\u00a0of access:\u00a0<\/p>\n
Service availability shows whether care exists\u00a0<\/p>\n
Travel time reflects real-life accessibility\u00a0<\/p>\n
Workforce measures highlight provider shortages\u00a0<\/p>\n
Together, they point to the same conclusion: access to maternity care\u00a0remains\u00a0uneven worldwide.\u00a0<\/p>\n
What\u00a0Midwives\u00a0Can\u00a0Learn\u00a0<\/p>\n
The experience of South Dakota offers clear lessons for midwives and advocates in other settings:\u00a0<\/p>\n
Access is not only about whether services exist.\u00a0Distance, cost, and system barriers shape whether people can\u00a0actually use\u00a0care.\u00a0<\/p>\n
Policy decisions matter.\u00a0Regulations can either expand access or limit it.\u00a0<\/p>\n
Midwives are part of the solution.\u00a0Community-based care and continuity of midwife care can help reach communities that are currently underserved.\u00a0<\/p>\n
Advocacy takes time.\u00a0As Mandy put it: \u201cIt\u2019s a long game\u2026 you have to continuously learn, grow and adjust.\u201d\u00a0<\/p>\n
Persistence is essential.\u00a0As Grace said: \u201cDon\u2019t be discouraged\u2026 it\u2019s a long process, but you keep moving forward.\u201d\u00a0<\/p>\n
Their experience shows that change depends on persistence, collaboration, and bringing together different voices to push for better care.\u00a0<\/p>\n
Looking\u00a0Ahead\u00a0<\/p>\n
There are signs of progress in South Dakota. Awareness is growing, and conversations with policymakers are starting to shift.\u00a0<\/p>\n
But the need\u00a0remains\u00a0clear.\u00a0<\/p>\n
Maternity deserts highlight where health systems are not reaching people. Addressing them requires investment, policy change, and stronger integration of midwives into health systems.\u00a0<\/p>\n
As South Dakota Birth Matters continues its work, their experience shows what is possible when midwives, communities, and advocates work together to expand access to care.<\/p>\n","protected":false},"excerpt":{"rendered":"For many women and gender diverse people, access to care during pregnancy and birth is shaped by where…\n","protected":false},"author":2,"featured_media":640258,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[18],"tags":[23,3,21,19,22,20,25,24],"class_list":["post-640257","post","type-post","status-publish","format-standard","has-post-thumbnail","category-united-states","tag-america","tag-news","tag-united-states","tag-united-states-of-america","tag-unitedstates","tag-unitedstatesofamerica","tag-us","tag-usa"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/640257","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=640257"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/640257\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/640258"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=640257"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=640257"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=640257"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}