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Maternal Care, Social Vulnerability, and the Case for Better Regionalization: Why Obstetric Anesthesia Should Be Part of the Conversation

Updated: Apr 15

VJM Spring Edition 2026

Authors: Fady Attia, BS1, Catherine Lyons BS, BA1, Jessica S Sheeran2


Author Affiliation:

1University of Virginia School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA.

2Department of Anesthesiology, University of Virginia, Charlottesville, VA, 22908, USA.



Introduction

The United States maintains the highest maternal mortality rate among high-income countries. Additionally, pregnancy-related mortality and severe maternal morbidity (SMM) have both risen over the past decade, peaking during the COVID-19 pandemic.1,2 These adverse outcomes are not evenly distributed: Black, American Indian and Alaska Native, and Hispanic parturients, as well as those living in rural or economically marginalized communities, bear a disproportionate burden of preventable morbidity and mortality.3,4 Maternal access literature has increasingly recognized that “place” matters in maternal health. However, it has often failed to account for the complex nature of geography. Instead, many studies focus narrowly on distance to a birth hospital, overlooking the multidimensional concept of geography that includes social vulnerability, healthcare capacity, and the availability of essential services such as obstetric anesthesia.

 

We argue that obstetric anesthesia is an often overlooked but essential dimension of maternal access. It should be explicitly incorporated into maternal risk stratification, health system planning, and perinatal regionalization frameworks. To support this claim for including obstetric anesthesia in the study of maternal access, we present empirical evidence based on current research regarding the Maternal Vulnerability Index (MVI), maternity care deserts, and disparities in access to anesthesia services.

 

The Evolving Geography of Maternal Risk

Recent national analyses demonstrate a dramatic increase in pregnancy-related deaths in the United States from 2018-2021, with age-adjusted mortality rates exceeding 40 deaths per 100,000 live births in 2021.1,2 Severe maternal morbidity also continues to rise and is inequitably distributed across racial, ethnic, and socioeconomic groups.4 In response, efforts have focused on assessing risk at the community level using composite indices that incorporate economic, social, and health system determinants.

 

The Maternal Vulnerability Index (MVI) is a national county-level tool developed to identify where and how mothers are at risk for adverse outcomes in the United States.5 The MVI combines 43 indicators across six domains, including reproductive health, healthcare access, socioeconomic conditions, and physical environment, to generate a cumulative vulnerability score. Early applications of the MVI demonstrate a strong association between higher MVI quartiles and increased rates of severe maternal morbidity within 42 days postpartum, even after adjusting for individual-level confounders.6 These findings highlight its utility for both clinical risk stratification and policy planning.

 

However, current applications of vulnerability indices are largely descriptive. Few studies integrate these measures into broader systems frameworks that incorporate travel time, hospital capability, referral networks, and workforce constraints, particularly anesthesia capacity, which together shape the relationship between place-based vulnerability and maternal outcomes.

 

Maternity Care Deserts and Distance Alone

The concept of “maternity care deserts” has become central to understanding geographic barriers to obstetric care. The March of Dimes defines these as counties without hospitals or birth centers offering obstetric services and without obstetric providers.7,8 Recent estimates identify over 1,100 maternity care deserts nationwide, affecting more than 2 million reproductive-age women and approximately 150,000 births annually.7 These deserts are disproportionately located in rural, low-income, and racially marginalized communities. These geographic gaps are driven in part by a continued decline in hospital-based obstetric services, particularly in rural areas, further widening disparities in access to care.9

 

Individuals residing in maternity care deserts must travel significantly farther to access care. A national analysis found average travel distances of 28-33 miles (35-40 minutes) in deserts compared to 7-8 miles (12-15 minutes) in areas with full access.10 In North Carolina, longer travel distances to obstetric care were associated with higher rates of severe maternal morbidity, gestational diabetes, preterm birth, and cesarean delivery, even after adjusting for sociodemographic factors.11 These findings underscore that travel burden itself is a meaningful contributor to adverse maternal outcomes.

 

However, distance-based metrics alone may oversimplify access. Many studies rely on thresholds, such as 30- or 60-minute travel times, to define “adequate” access.12 While useful, these thresholds do not capture differences in hospital capability, critical care resources, or the availability of obstetric anesthesia, which are factors that are particularly relevant for high-risk pregnancies and emergencies.

 

Obstetric Anesthesia as a Missing Access Metric

Maternal safety is fundamentally dependent on obstetric anesthesia, which supports labor analgesia, cesarean delivery, hemorrhage management, hypertensive emergencies, and resuscitation during obstetric crises. National guidelines for levels of maternal care specify that Level III and IV centers must provide 24/7 anesthesia coverage by qualified providers.13 Despite this, many maternal access studies define “obstetric-capable” facilities based solely on delivery services, without accounting for anesthesia availability.

 

Significant regional variation exists in obstetric anesthesia utilization, alongside persistent racial and ethnic disparities. Black and Hispanic women are less likely to receive neuraxial analgesia and more likely to undergo general anesthesia for cesarean delivery compared to White women.14,15 Evidence also suggests that access to neuraxial labor analgesia may be associated with reduced severe maternal morbidity, further underscoring the role of anesthesia services as a determinant of maternal outcomes.16 Workforce analyses demonstrate persistent gaps in obstetric anesthesia availability, particularly in rural and lower-volume hospitals, further contributing to inequities in access to timely peripartum care.17

 

These disparities reflect both individual-level experiences and structural inequities in staffing, training, and resource allocation. The American Society of Anesthesiologists (ASA) has emphasized that disparities in peripartum anesthesia care occur at patient, provider, and system levels.18 The ASA also highlights the central role of anesthesiologists in reducing maternal mortality and calls for their incorporation into regionalized systems of care.19 Despite these recommendations, most maternal access models still classify hospitals as obstetric resources if they provide delivery services, regardless of whether they offer continuous in-house anesthesia coverage or the ability to perform emergent cesarean delivery within recommended timeframes.

 

Implications for Policy and Perinatal Regionalization

Reframing maternal access research to include obstetric anesthesia has important policy implications. At the health system level, incorporating anesthesia metrics into access dashboards could help identify “hidden deserts,” where obstetric services exist but lack critical support infrastructure.

 

State perinatal quality collaboratives and maternal mortality review committees could integrate anesthesia-related factors into case reviews, particularly in high-vulnerability regions.

Integrating MVI scores with maternity care desert maps and level-of-care designations could further guide targeted interventions. High-vulnerability counties with long travel distances to Level III/IV centers and limited anesthesia capacity could benefit from regional call-sharing models, tele-anesthesia consultation, and workforce recruitment incentives. Additionally, Medicaid payment reform may be necessary to support sustainable 24/7 obstetric anesthesia coverage in lower-volume rural hospitals.

 

Conclusions

The maternal health crisis in the United States is driven by intersecting factors, including social vulnerability, structural inequities, fragmented healthcare systems, and unequal access to essential services. Tools such as the Maternal Vulnerability Index and the identification of maternity care deserts have improved understanding of where risk is concentrated. However, many frameworks for assessing maternal access fail to incorporate obstetric anesthesia as a critical component of timely, safe, and equitable care. Moving forward, maternal access frameworks should explicitly incorporate obstetric anesthesia to better reflect the full spectrum of resources required for safe peripartum care and to support more effective risk stratification, policy development, and health system planning.

 


References

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  2. Chen Y, Shiels MS, Uribe-Leitz T, et al. Pregnancy-Related Deaths in the US, 2018-2022. JAMA Netw Open. 2025;8(4):e254325. doi:10.1001/jamanetworkopen.2025.4325

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  4. MATERNAL HEALTH. In: 2022 National Healthcare Quality and Disparities Report [Internet]. Agency for Healthcare Research and Quality (US); 2022. Accessed March 16, 2026. https://www.ncbi.nlm.nih.gov/books/NBK587184/

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  8. Adashi EY, O’Mahony DP, Cohen IG. Maternity Care Deserts: Key Drivers of the National Maternal Health Crisis. J Am Board Fam Med. 2025;38(1):165-167. doi:10.3122/jabfm.2024.240198R1

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  12. ACOG: Travel Time to Access Obstetric and Neonatal Care in the United States. OPQIC. August 31, 2020. Accessed March 16, 2026. https://opqic.org/acog-travel-time-to-access-obstetric-and-neonatal-care-in-the-united-states/

  13. Menard MK, Kilpatrick S, Saade G, et al. Levels of maternal care. American Journal of Obstetrics and Gynecology. 2015;212(3):259-271. doi:10.1016/j.ajog.2014.12.030

  14. Thomas CL, Lange EMS, Banayan JM, Zhu Y, Liao C, Peralta FM, Grobman WA, Scavone BM, Toledo P. Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery. JAMA Netw Open. 2024 Jan 2;7(1):e2350825. doi: 10.1001/jamanetworkopen.2023.50825. PMID: 38194235; PMCID: PMC10777252.

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  18. Statement on Reducing Maternal Peripartum Racial and Ethnic Disparities in Anesthesia Care. Accessed March 16, 2026. https://www.asahq.org/standards-and-practice-parameters/statement-on-reducing-maternal-peripartum-racial-and-ethnic-disparities-in-anesthesia-care

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