Since the early 2000s, a growing number of maternal care centers across the country have closed their doors – most of them in rural areas, creating dangerous care deserts. Maternal health care is already scarce in these areas as 45% of rural counties had no hospital maternity services before an additional 9% lost services between 2004 and 2014. Between only 2016 and 2020, an additional 70 counties were classified as maternity care deserts. More pregnant or recently pregnant people are going without both proper prenatal and postpartum care. People living in rural areas — many of whom are without insurance, Medicaid recipients, older adults, individuals with disabilities, and veterans — are already at greater risk for disease and death than those in urban areas, where it is far easier to access quality maternal care. While the lack of maternal care resources can gravely impact the physical health of a birthing person, it can also limit the amount and quality of maternal mental and behavioral health care.
Although peripartum depression is incredibly common, only 28% of women seek support for the condition and report their symptoms to a healthcare provider. Even when they do, women who have been diagnosed or are identified as at risk of peripartum depression do not receive competent services or follow-up care as 70% of rural counties do not have sufficient maternal mental health providers or resources, leading to mortality or severe morbidity. Maternity care deserts undoubtedly contribute to the maternal mental health crisis, but increased training and resources outside of traditional hospital settings can support patients in these areas and improve maternal mental health outcomes.
In rural areas especially, doulas and midwives can play vital roles in delivering maternal care, often offering assistance outside of traditional care settings, ideal for those in maternity care deserts. Midwives and doulas serve similar functions; however, midwives provide medical care during pregnancy, birth, and the immediate postpartum period, while doulas do not perform clinical tasks, instead providing personalized physical/emotional support and education to the birthing person and their family. Midwives commonly provide care in free-standing birthing centers, often associated with lower rates of cesarean births and medical interventions as well as higher rates of breastfeeding. Doulas, who often visit patients in their homes, may be more attuned to cultural differences and in communicating with families to bridge care gaps but are often underutilized. As there are limited traditional maternity care services available in rural areas, the inclusion of additional midwives and doulas — whose care has proven to lower the odds of postpartum depression and anxiety by 57.5% — can help support maternal mental health needs where hospitals are unable to.