Dive Brief:

• The majority of southern states ranked among the worst in the nation for maternal health and reproductive services offerings, warns a recent report from the Commonwealth Fund, an independent research organization. 
• Mississippi, Texas, Nevada, Oklahoma and Arkansas ranked the lowest on 32 measures of healthcare quality and outcomes, access and affordability. Some Northeastern states — Massachusetts, Vermont, Rhode Island, Connecticut and New Hampshire — ranked the highest.
• Geographic divides in care access have deepened in the years following the U.S. Supreme Court’s 2022 Dobbs decision and could further sharpen without attention, the Commonwealth Fund said. The access disparities pose the greatest threat to low-income women and women of color.

Dive Insight:

Since the U.S. Supreme Court issued the ruling on Dobbs v. Jackson Women’s Health Organization, ending the constitutional right to abortion, access to reproductive services and maternal health landscape has rapidly shifted.

Twenty-one states have moved to tighten access or impose new limits or bans on abortions since 2022. In the most restrictive cases, like Florida, abortions are banned at six weeks.

In other instances, states sought to bar abortion even when the health of the mother was at risk. Idaho pursued such a law, teeing up a battle in the Supreme Court over conflicts with federal law, which require providers to offer medical services to patients during emergencies.

The Supreme Court struck down Idaho’s policy last month. However, the high court failed to extend its ruling to any other states — a move Justice Elena Kagan decried as a missed opportunity to clarify tensions between state and federal law. 

The Commonwealth Fund report suggests abortion bans have impacts on maternal health and may have ripple effects for broader care access.

The current study evaluated a variety of factors, including all-cause mortality, maternal and infant mortality, preterm birth rates, self-reported health status, postpartum depression and breast and cervical cancer deaths. They found abortion restrictions were correlated with a troubling trend: a statewide decrease in maternity care providers overall.

Arkansas, Oklahoma, Alabama and Idaho, which all have full bans on abortion, had fewer maternity care providers compared to states with more access to care, such as Vermont, Connecticut and Washington, D.C.

Separate studies suggest the problem may worsen, as medical students are less likely to pursue residencies in states with abortion bans.

“This is an ominous development for these states, where providers are already scarce,” according to the Commonwealth Fund.

The lack of providers could be associated with increased maternal mortality.

Maternal deaths were highest in the Mississippi Delta, which includes Arkansas, Louisiana, Mississippi and Tennessee. Each state had abortion restrictions prior to Dobbs and now have total abortion bans.

In these states, a “substantial percentage of counties don’t have a single hospital or birth center with obstetric providers offering obstetric care,” according to the report.

States that reduced maternal mortality tended to have more providers, fewer uninsured women and fewer women with no prenatal care.

Expanding Medicaid could help ensure women have access to such services, according to the report.

Medicaid has become a critical insurance option for pregnant women, covering 42% of births nationwide. Federal law requires state Medicaid programs to provide pregnancy-related coverage up to 138% of the federal poverty level, and 41 states have opted to make the income threshold even higher. 

However, some states with the lowest maternal health scores —  Alabama, Georgia, Mississippi and Tennessee — have opted not to expand their Medicaid programs. The Commonwealth Fund finds women living in these states are more likely to report skipping care because of costs than women in states with expanded Medicaid.

While some states may still expand Medicaid voluntarily, the authors pushed for a federal expansion of the program, citing the benefit to maternal health.

“A federal policy solution is needed to correct this major ongoing gap in insurance coverage for poor people, who are disproportionately Black and Hispanic,” concludes the report.