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The Additional Risks and Challenges for Pregnant Women in Rural and Underserved Communities

Posted on May 13, 2021

Note: This blog has been updated. The original version showed death rates as a percentage rather than a ratio. Information was also added to clarify estimates.

Pregnancy-related deaths have been increasing in the United States. In a 2020 report, we found that pregnancy-related deaths (or maternal mortality ratios) in the U.S. had increased about 3% from 2000-2015. Moreover, women in rural and underserved communities face additional risks and challenges that could lead to higher rates of maternal mortality and other severe health complications. 

Today’s WatchBlog explores our new report on maternal mortality in rural and underserved areas.


Pregnant woman in doctor's office


Maternal mortality in rural communities

According to the most recent data available from the Centers for Disease Control and Prevention (CDC), from 2011-2016, in the most rural counties (which includes areas with populations of less than 50,000 residents), the maternal mortality ratio was 23.8 deaths per 100,000 live births compared to 14.6 in large metropolitan counties (areas with a population over 1 million).

CDC data also showed that disparities exist by race and ethnicity. For example, in the most rural counties, Black women experienced 59.3 deaths per 100,000 live births, compared to 19.7 for White women in the same counties. This is consistent with our 2020 report on maternal mortality, which looked at national ratios of maternal mortality and found that Black women were more than three times as likely to die from pregnancy-related causes than White women.

Overall, we found that the more populous an area was, the lower the rate of deaths was among pregnant women. For example, from 2011-2016, maternal mortality ratios (deaths per 100,000 live births) were as follows:

  • 14.6 deaths in large metropolitan areas with over 1 million residents,
  • 16.2 deaths in mid-size metropolitan areas with 250,000-999,999 residents,
  • 16.2 deaths in small metropolitan areas with less than 250,000 residents,
  • 19.8 deaths in rural areas that had small urban clusters, and
  • 23.8 deaths in rural areas that had no urban clusters.

Severe health complications by race

We also looked at the rates of unexpected health outcomes of labor and delivery that result in significant health consequences for pregnant woman, like cardiac arrest, stroke, or eclampsia, among others. These are often referred to as “severe maternal morbidity.” In both urban and rural areas, women of color have higher estimated rates of severe health complications following pregnancy than White women. For example, we found Black women in rural areas experience an estimated 93.7 incidents of severe health complications per 10,000 deliveries, compared to 55.4 incidents for White women in rural areas.

In rural and undeserved areas (meaning areas with lower numbers of health care providers per capita), several factors affect maternal mortality and severe health complications following pregnancy. For example, many rural counties lack hospital obstetric services, meaning those hospitals or emergency rooms lack trained staff or the necessary equipment to manage prenatal care. This occurs in part due to difficulties recruiting and retaining maternal health providers in rural areas, as well as closures of rural hospitals and obstetric units. When hospitals or obstetric units close, rural and underserved areas lose the infrastructure that supports providers, like obstetrician-gynecologists, specialists, and licensed midwives. This means that pregnant women who lived in rural areas may have had less frequent prenatal and maternal care prior to delivery, if the long travel distances to obtain care are prohibitive or costly.

Federal efforts to improve maternal health outcomes

The CDC and Health Resources and Services Administration (HRSA) fund several maternal health programs that can be used to help reduce maternal morality and severe health complications from pregnancy in rural and underserved areas. For example, HRSA’s Rural Maternity and Obstetrics Management Strategies program provides funding to rural networks to develop models for maternal care in rural communities.  

HRSA collects data on its maternal health programs such as the percentage of women receiving prenatal and postpartum visits. But we think the agency should do more to analyze this data to track the needs, trends, and potential disparities that our analyses have shown. In our new report, we recommended that CDC and HRSA collect and analyze data in a way that will allow them to better ensure that program funding is being used to help address the unique maternal needs of rural and underserved communities.

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