As maternal mortality skyrockets in the United States, a federal program created to improve rural maternity care has bypassed Black mothers, who are at the highest risk of complications and death related to pregnancy.

The grant-funded initiative, administered by the Health Resources and Services Administration, began rolling out four years ago and, so far, has budgeted nearly $32 million to provide access and care for thousands of mothers and babies nationwide — for instance, Hispanic women along the Rio Grande or Indigenous mothers in Minnesota.

KFF Health News found that none of the sites funded by the agency serves mothers in the Southeast, where the U.S. Census Bureau shows the largest concentration of predominantly Black rural communities. That omission exists despite a White House declaration to make Black maternal health a priority and statistics showing America’s maternal mortality rate has risen sharply in recent years. Non-Hispanic Black women — regardless of income or education level — die at nearly three times the rate of non-Hispanic white women.

“There’s a responsibility to respond to the crisis in a way that is more intentional,” said Jamila Taylor, chief executive of the National WIC Association, a nonprofit advocacy group for the federal Special Supplemental Nutrition Program for Women, Infants, and Children.

“Why isn’t HRSA stepping up to the plate, especially with this rural moms’ program?” Taylor said. According to a 2021 analysis of federal data, Black women living in rural areas also are more likely to die or experience more severe health complications during delivery than white women living in rural areas.

Experts say the failure of HRSA’s Rural Maternity and Obstetrics Management Strategies Program, or RMOMS, to reach predominantly Black communities in the rural South reveals structural inequities and underinvestment in a region where health care resources are scarce and have deteriorated.

Eric Harkleroad/KFF Health News

The steady closure of hospitals in the region and widespread medical staffing shortages have hindered the ability of cash-strapped agencies and care providers to provide more than essential services. Many “don’t have sufficient resources” to apply for the grants, said Peiyin Hung, deputy director of the University of South Carolina’s Rural and Minority Health Research Center. Hung is also a member of the health equity advisory group for the maternal grant program.

“RMOMS really means to invest in the most underserved and the most disadvantaged communities,” she said, but because the program demands applicants have a network of hospitals and other care providers, she said, “the odds are not there for them to even try.”

Hung said she favors basing the awards on need and not solely on the quality of an application.

Where the Help Is Going

The rural program launched in 2019 and has awarded 10 maternal health grants nationwide to bolster telehealth and create networks between hospitals and clinics. Despite the disruption of care due to the covid-19 pandemic, the program’s earliest grant winners helped more than 5,000 women get medical treatment and recorded a decrease in preterm births during the second year of implementation, the agency reported.

When KFF Health News first asked Tom Morris, associate administrator for rural health policy at HRSA, about the lack of grants in the rural South, he said the agency has an “objective review process” and regularly reviews the program to ensure it reaches the people who need it most.

“The rural rates of maternal mortality for African Americans is a real concern,” Morris said, adding, “I think you raised a good point there, and something we can focus on moving forward.”

So far, the maternal grants have gone to health care providers in Arkansas, Maine, Minnesota, New Mexico, South Dakota, Texas, Utah, and West Virginia, as well as two awards in Missouri.

Among the initial 2019 awardees, Texas reports that 91% of people it served were Hispanic; New Mexico reported 59% of recipients were Hispanic; and the Missouri project, which was in the southeastern part of the state known as the Bootheel, said 22% of beneficiaries were Black patients. In all cases, the majority were Medicaid enrollees. No data was available for other grant awardees. (Hispanic people can be of any race or combination of races.)

States across the rural Southeast have not expanded Medicaid coverage to larger numbers of lower-income residents, which often means lower shares of patients have health coverage.

Where Help Is Most Needed

The lack of Medicaid expansion in the region is "all the more reason funding should be going to these areas,” said the WIC association’s Taylor. She said the program’s failure to reach into the southeastern U.S. seems “incredibly odd.”

“The South is a hotbed — to be quite honest — of a whole host of chronic diseases and health challenges, particularly for people of color,” Taylor said.

Taylor, who previously worked on similar programs with community-based organizations while at the Century Foundation, said grant applications are often long and tedious and require intense data collection, adding to the “real challenges and barriers in the process of applying for the grants in the first place.”

Rep. Robin Kelly (D-Ill.), whose district spans rural and urban areas, said it is her experience that “some of the neediest places don’t apply for the grants because they don’t have the personnel.”

“There needs to be special outreach,” said Kelly, who created legislation in 2018 to extend postpartum care after hearing from a constituent. “We need to take the extra steps that mean saving women’s lives.”

Several current grant winners said the federal agency does provide extensive technical assistance and is responsive to questions and concerns — but they also described how difficult it was to win the grants, which amounted to $1 million or less for last year’s winners.

“It’s an intimidating grant to apply for,” said Johnna Nynas, an obstetrician and gynecologist who wrote the maternal grant application for Sanford Bemidji Medical Center in Minnesota.

“I don’t want to admit how much of my own personal time I dedicated to this grant, writing it,” she said. Sanford won the grant in 2021.

Unlike applicants from smaller, cash-strapped health organizations, Nynas was able to solicit help from the internal grant team at Sanford Health, which operates a regional system including a health plan as well as hospitals, clinics, and other facilities in the Dakotas, Iowa, and Minnesota.

Nynas said four hospitals in the remote region of northern Minnesota, where Bemidji is located, have closed their labor and delivery units in recent years, leaving residents — including a significant number of Indigenous women — to drive 60 miles or more one way for care.

Meeting an application requirement to create a network that includes specific health clinics as partners in the grant was “the biggest challenge,” Nynas said, adding “when you look at the map, those can be very difficult to find.”

Try, Try Again

In South Dakota, Avera Health’s application stalled for two years because of grant criteria requiring state Medicaid agencies to sign on as network partners, said Kimberlee McKay, an OB-GYN and the program director for the South Dakota grant. Avera Health spans Iowa, Minnesota, Nebraska, North Dakota, and South Dakota.

It wasn’t until the third round, McKay said, and after “the climate around maternal health had changed,” when the state Medicaid agency committed to fully partnering on the maternity care grant.

South Dakota voters adopted Medicaid expansion in late 2022 and will implement it this summer. Avera’s South Dakota program will use grant money to reach more than 10,000 pregnant patients in the eastern part of the state and the region’s tribal communities.

Among the previous grant winners, only the Texas winner is from a non-Medicaid expansion state. HRSA spokesperson Elana Ross said 10 of 38 applications won grants since 2019. She declined to release a list of unsuccessful applicants, citing privacy concerns.

Ross said the requirement to partner with Medicaid “increases the likelihood that the pool of applicants, if selected, will be able to sustain services at the end of federal funding.” Medicaid, she noted, pays for nearly half of all births nationally and a greater share of births in rural areas.

The goal for the grants is that applicants can keep the program operating even after several years of federal funding runs out, HRSA officials said.

Stoking Change

In May, after KFF Health News began reporting this article, the agency released a new call for applicants and relaxed requirements. Only two awards will be given, and the applications, which demand detailed network plans, are due July 7.

In an emailed statement released after announcing the more flexible expectations, Morris said the federal agency’s mission was to provide care for “the highest-need communities, and that means dedicating significant funds towards addressing the Black maternal health crisis.” The agency will no longer require state Medicaid programs to be partners on initial applications. It also loosened language about which clinics needed to be in the network.

And in perhaps the most significant shift, the agency said it will use newly created criteria to determine “areas of greatest need.” Alabama, Louisiana, and Mississippi all qualify as areas with shortages of maternity health care providers, according to the funding notice.

Kelly, who works on Congress’ bipartisan maternity care caucus, said of the lack of grants in the rural South: “Money matters, resources matter.”

Despite the government-wide focus on maternal care, it wasn’t clear whether the rural program would award new grants in 2023. In April, Morris told KFF Health News the agency was “trying to figure out if we have enough funding to support our existing grantees and do a new competition.”

The rural maternity program’s initial fiscal year 2023 budget was $8 million — down from $10.4 million the year before, according to the agency’s operating plan. The release of grants in May came after the federal agency found an additional $2.4 million in its internal budget.

Even so, Kelly said, she “would love to see more money being put toward it” as well as evaluations of “where the money is being spent and where the holes are.”

This story was published by KFF Health News on June 22, 2023. It is republished with permission.