Evaluating disparities in access to obstetric services for American Indian women across Montana

Abstract

Purpose: Pregnant women across the rural United States have increasingly limited access to obstetric care, especially specialty care for high-risk women and infants. Limited research focuses on access for rural American Indian/Alaskan Native (AIAN) women, a population warranting attention given persistent inequalities in birth outcomes.

Methods: Using Montana birth certificate data (2014-2018), we examined variation in travel time to give birth and access to different levels of obstetric care (i.e., the proportion of individuals living within 1- and 2-h drives to facilities), by rurality (Rural-Urban Continuum Code) and race (White and AIAN people).

Findings: Results point to limited obstetric care access in remote rural areas in Montana, especially higher-level specialty care, compared to urban or urban-adjacent rural areas. AIAN women traveled significantly farther than White women to access care (24.2 min farther on average), even compared to White women from similarly rural areas (5-13 min farther, after controlling for sociodemographic characteristics, risk factors, and health care utilization). AIAN women were 20 times more likely to give birth at a hospital without obstetric services and had less access to complex obstetric care. Poor access was particularly pronounced among reservation-dwelling AIAN women.

Conclusions: It is imperative to consider racial disparities and health inequities underlying poor access to obstetric services across rural America. Current federal policies aim to reduce maternity care professional shortages. Our findings suggest that racial disparities in access to complex obstetric care will persist in Montana unless facility-level infrastructure is also expanded to reach areas serving AIAN women.

Keywords: American Indians; driving time; health care access; obstetrics; rural perinatal care.

Figure 1. Obstetric Services Supply and Demand in Montana

SOURCE: Author’s analysis of data from 55,608 Montana birth certificates from 2014–2018 of birth to White and AIAN women residing in Montana at the time of the birth who were not missing information on birth facility, with information on the birth facility from the 2018 American Hospital Association (AHA) Annual Survey. NOTES: 1) Blue – Level 3 Facility, Orange – Level 2 Facility, Yellow – Level 1 Facility, Pink – Level 0 Facility 2) AIAN Reservation Borders are Outlined in Red 3) Large Water Bodies and Unpopulated Areas with no ZCTA are Black