Improving Financial Access to Maternal and Infant Care in Rural Areas

June 20, 2023 | Lexa Giragosian

Pregnant people in rural areas are more likely to experience severe maternal morbidity and mortality than their urban counterparts. This population is more likely to deliver outside of a hospital, preterm, or in facilities without obstetric units in part due to limited access to obstetric services. Many rural counties do not have a practicing OB-GYN or any obstetric services, resulting in significant geographic barriers to care.

Rural populations have lower rates of health insurance coverage than urban populations, which often leads to difficulties in accessing primary preventative or immediate care and higher rates of hospitalizations. More than one-third of women delay needed medical care due to financial challenges such as poverty and lower incomes.

High rates of hospital closures and financial challenges to accessing quality care are health disparities that disproportionally affect maternal and infant health in rural areas. Financial challenges directly correlate with hospital closures, and the combination of financial and geographic barriers to care exacerbates negative health outcomes. This brief will address the financial challenges facing pregnant people in rural areas, while a related blog post addresses rural hospital closures.

Strategies to Improve Financial Access in Rural Communities

Initiatives focused on improving and extending Medicaid and adopting a value-based care system can reduce financial barriers to care. Applying these recommendations will support pregnant people in rural areas in accessing quality care and improving maternal and infant health.

Medicaid Initiatives

States can address the financial challenges of accessing care in rural areas by increasing their Medicaid reimbursement rates, which encourages additional facilities and providers to accept Medicaid. Improved reimbursement rates broaden available locations for Medicaid recipients to access and receive quality care without the burden of paying high out-of-pocket costs. The increased funds available from pandemic relief prompted many states to improve access to care by increasing reimbursement rates for all Medicaid providers.

Extending the coverage period under Medicaid is another method of improving access to quality care, especially for maternal care in rural areas. Over half of pregnancy-related deaths occur between one week and one year postpartum, with two out of three deaths being preventable. Extending Medicaid for longer than the standard 60 days postpartum can lessen these numbers through more affordable and accessible care during the riskiest time of pregnancy. Extended postpartum Medicaid coverage for up to 12 months after giving birth has been adopted or is in the process of being adopted by more than half of states.

Value-Based Care Systems

Embracing a value-based care system within state Medicaid programs can alleviate some financial barriers to accessing quality maternal and infant care. Value-based care systems can decrease financial barriers to care through alternative payment models emphasizing value and quality care provision. For example, incentive payments can be utilized to reward providers and hospitals for providing quality care and reducing the need for high-cost forms of care. Incentive payments are often disbursed when providers and hospitals meet certain measures, such as rates of low-risk cesarian, early elective deliveries, breastfeeding during neonatal hospitalization, and prenatal screening, to name a few. These incentivized performance measures ensure pregnant people receive the best affordable care while financially supporting hospitals and providers.

Utilizing blended payments can also alleviate the financial burden for patients with complicated pregnancies. This tool reduces barriers to care by maintaining stable care costs despite the delivery method and mitigating the burden of higher costs associated with higher-risk pregnancies.

Value-based care is still early in its implementation across the United States. However, several states are introducing new initiatives, and the Center for Medicare & Medicaid Services is releasing a roadmap to support these initiatives. Future utilization of value-based care systems that are accessible and financially rewarding for patients, providers, and hospitals has the potential to improve access to maternal and infant care, especially in rural areas.

Leveraging the Perinatal Workforce

Expanding doula coverage under Medicaid is a cost-effective initiative that leverages the perinatal workforce while improving maternal and infant health outcomes. In rural communities lacking providers and services, doulas are a valuable resource in navigating the complicated process of accessing quality care despite geographic barriers. Doulas act as advocates and educators for pregnant people, and their utilization results in lower preterm and cesarean birth rates and reduced complications and unnecessary procedures. Doulas are traditionally paid out of pocket, making them inaccessible to the large portion of people in rural areas with Medicaid. As of November 2022, eight states and Washington, D.C. are providing doula coverage under Medicaid, and more than half of states are implementing this expansion or pursuing a related agenda to improve doula accessibility.


To improve financial access to quality maternal and infant care in rural communities, state health agencies and policymakers can support insurance policy initiatives and care system reforms. Financing challenges in rural communities is an ongoing issue that will require collaboration and a systems-based approach to alleviate financial burdens and improve maternal and infant health in rural populations.

Thank you to the ASTHO Medicaid Team for their contributions to this ASTHOBrief.

This publication was prepared with funding support from the Centers for Disease Control & Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.