Abstract
Purpose:
This commentary examines the complex maternal health landscape in rural America, highlighting the structural barriers to effective chronic disease management. We provide recommendations to center chronic disease management using a life course approach.
Conclusions:
Women in rural areas face significantly higher maternal mortality and morbidity rates than their urban counterparts, largely due to a disproportionate burden of chronic disease conditions such as gestational diabetes, preeclampsia, cardiomyopathy, and mental health disorders. These disparities are deeply rooted in the unequal distribution of systemic and structural determinants of health. We call for a system-level approach related to primary, secondary, and tertiary prevention efforts to improve maternal health in rural areas, based on the life course perspective.
Keywords
Introduction
Pregnant women in rural areas are twice as likely to die during childbirth than their urban counterparts. The rates of maternal mortality per 100 000 live births in rural America increased by an alarming 7.0% annually between 2016 and 2019, rising from 66.9 to 81.7. In comparison, urban rates rose less drastically from 38.1 to 42.3 over the same period. 1 This disproportionality in mortality is intrinsically linked to a higher chronic disease burden in rural communities, leading to higher rates of gestational diabetes, preeclampsia, cardiomyopathy, autoimmune diseases, stroke, and mental health problems relative to urban communities.1-3 Racial disparities also abound and significantly contribute to chronic disease prevalence and management in rural areas. Research shows marked differences in obesity, hypertension, elevated lipids, high cholesterol, gestational diabetes, pre-pregnancy diabetes mellitus, and infant outcomes among racial and ethnic minority rural dwellers compared to their urban counterparts.1,3,4 As chronic diseases—including mental health, cardiovascular diseases, and hypertensive disorders of pregnancy—are among the leading causes of maternal mortality in the U.S., accounting for over 57% of pregnancy-related deaths in 2020 alone, 5 issues endemic to rural America 4 create a magnified chronic disease-related risk for adverse maternal health outcomes. 3 Despite efforts to address this crisis, they fall short because they don’t adequately address risk factors in the preconception stage or during adolescence. Effectively mitigating chronic diseases during pregnancy or postpartum hinges on the early identification and intervention of these risks early in life because they have significant benefits as hormones fluctuate through the life of a women, regardless of pregnancy status. Thus, the life course perspective is a valuable framework for chronic disease prevention and management because it addresses the unique risks associated with each developmental phase in a woman’s life.
Chronic Diseases Through the Life Course
Maternal health outcomes do not occur in a vacuum. They result from complex interwoven systems across the developmental phases of a woman’s life that predispose her to adverse health outcomes. The life course perspective offers insights into how these interconnected systems, including the biological, behavioral, social, environmental, and psychosocial pathways that operate across a woman’s life and generations, influence the development of chronic diseases. It highlights the long-term risk of chronic disease from exposures in utero, adolescence, childhood, young adulthood, midlife, and later adult life. 6 Perak et al 7 found a strong association between maternal cardiovascular health during pregnancy and the offspring’s cardiovascular health in early adolescence. These effects last into midlife and older age, complicating menopausal symptoms. Furthermore, being overweight or obese early in life is strongly linked to a higher long-term risk of venous thromboembolism, Type 2 diabetes, gestational diabetes, cardiovascular diseases, and cognitive decline later in life.8,9 Thus, addressing chronic conditions such as, chronic kidney disease, chronic hypertension, chronic diabetes mellitus, venous thromboembolism, obesity, or mental health conditions during the preconception and interconception period can significantly reduce the likelihood of maternal chronic diseases such as hypertensive disorders of pregnancy, gestational diabetes mellitus, peripartum cardiomyopathy, or excessive gestational weight gain during pregnancy. Optimizing chronic conditions in the preconception period also transcends to optimal cardiovascular health for perimenopausal and menopausal women, leading to optimal quality of life. Mitigating the risks of chronic diseases can improve adolescent, maternal and infant health outcomes, and women’s overall health and well-being. 6 However, stark disparities across the life course in access to medical and non-medical determinants of health, treatment, care, and services for chronic disease between rural and urban dwellers have resulted in worse maternal and infant health outcomes, requiring renewed focus.1,3,4
Current Challenges
Delivery Systems of Care in Rural America
Hospital closures, maternity care deserts, high poverty levels, and shortages of specialty physicians such as obstetricians, gynecologists, and endocrinologists are widespread in rural areas.1,3,4 Between 2005 and 2023, 146 hospitals in rural counties were closed or converted to non-acute care, citing financial stress as a major driver of these closures.4,10 These closures have far-reaching implications for chronic disease prevention and management. In addition, despite technological advances in medical care, delivery systems in rural areas are ill-equipped to manage chronic diseases. Critical access and rural hospitals often lack the financial capacity, human resources, and wherewithal to fully implement and leverage electronic health records, data systems, or other health technologies. 3 Even in the context of telemedicine, rural areas often do not have reliable broadband services, which limits access to remote health services.3,4 Poor healthcare infrastructure leads to fragmented care, which is ineffective and inefficient, increases healthcare costs, and leads to missed opportunities to manage and treat chronic conditions.4,10
The Role of Social Determinants of Health (SDOH)
Social determinants of health (SDOH), or non-medical drivers of health, encompass the conditions in which people are born, grow, work, live, and age. 11 They interact with larger systems, often beyond individuals’ control, and significantly impact health. Adverse SDOH include social practices and diseases (eg, poverty, risky lifestyles, and poor living and working environments); socioeconomic status (eg, low income and educational status, poor access to reliable transportation, and food insecurity); environmental and neighborhood factors (eg, inadequate access to engage in physical activities, green spaces, and unsafe areas), and sociocultural norms (eg, religious beliefs and societal expectations) that influence the risk of exposure, degree of susceptibility, onset, course, of chronic disease and associated health diseases.1,2,6,11 The adverse impact of SDOH on women’s health is more telling and pervasive largely because of patriarchy, which subjugates girls and women to limited financial and economic opportunities. This inadvertently affects women’s social capital in seeking and utilizing care, a conundrum for rural populations. These determinants are pervasive in rural areas and seriously hinder access to evidence-based chronic disease prevention and management, thereby aggravating adverse maternal health.3,4,11
Compounding Factors: Mental Health and Behavioral Health
There is a bidirectional link between mental health and behavioral health (MHBH) and chronic diseases, which significantly impact maternal health. For example, undiagnosed and under-treated mental health diseases, including depression before and after pregnancy, as well as substance use disorders, are linked to gestational diabetes, preeclampsia, and other cardiovascular diseases. 12 Unfortunately, the US is currently experiencing severe shortages of MHBH providers, particularly perinatal psychiatrists, leading to a lack of accessibility to mental and behavioral health services in rural areas.3,4,10 Moreover, these conditions limit women’s ability to adhere to or manage chronic disease. Furthermore, sociocultural norms and barriers to MHBH care among women, particularly during pregnancy, discourage patients from seeking and utilizing care.1,3
Shifting and Uncertain Policy Landscape
Despite federally funded healthcare centers, Medicaid, Title V Maternal and Child Health Services Block Grants, as well as other state-specific funding mechanisms, increasing health needs and vulnerabilities in rural areas have led to more health demands chasing limited resources. 4 Due to the complexity of the US health systems, differences in state policies and priorities exaggerate the issues that rural populations encounter, leading to different outcomes even among rural communities. 4 Compounding these issues are the recent federal funding cuts to Medicaid and other federally supported programs, which will severely threaten rural populations and shift care delivery models, with devastating effects for sustainable clinical, public health, and social services for rural maternal health and chronic disease prevention and management. 13
Recommendations
Connecting Silos Using a Life Course Approach
Connecting silos of care across the life course is fundamental to chronic disease prevention and management for rural American women. It provides a strong foundation to systematically enhance patient engagement, coordinated care, and evidence-based practices to improve health. 6 The life-course perspective shifts focus from a single linear cause—single disease epidemiologic inquiry—to one that addresses multiple causes and outcomes during preconception, pregnancy, and the menopausal period that aggravate chronic diseases.2,6 This model calls for proactive primary, secondary, and tertiary intervention that connects medical and nonmedical health professionals for whole-person care and expands comprehensive maternal health services in rural practices. For example, efforts to improve the health of young girls must be framed to account for the benefits they will derive in later adulthood. Thus, connecting multiple systems where women and girls receive care or interact (ie, hospitals, community organizations, colleges, or school systems) can close gaps in access to chronic disease care.
Legislation and Policy
A life course-informed chronic disease prevention and management framework for women’s health can be most successful when supported by supportive health policies and legislative frameworks to strengthen delivery. Without meaningful federal investments in rural areas, it is unrealistic for local governments to address chronic diseases across the care continuum, including supporting social services, public health, access to clinical care, and social determinants of health. While existing policies exist, such as Medicaid and the Children’s Health Insurance Program, there is a need for policies that emphasize the unique developmental phases and risks for women, particularly for younger females, considering gaps in access to chronic disease prevention and management among this group. 14 Ensuring data interoperability and coordinated care policies can bridge care gaps for young people transitioning to adult health services. The Got Transition initiative, a cooperative between the Maternal and Child Health Bureau and the National Alliance to Advance Adolescent Health, offers a framework for agencies to harmonize care and eliminate data silos. 15 Furthermore, reimbursement models must be prioritized nationally for medical and non-medical pregnancy-related services, which are critical in advancing maternal health equity. These include doula, midwifery care coordination, homebirth and home visiting services, childbirth and parenting readiness classes, community health care worker navigation, and pregnancy-related telehealth services.2,3,10 Federal legislation that improves access to the aforementioned services can have positive implications for a steady national workforce and economic growth. According to the Bureau of Labor Statistics, approximately 58% of women in the U.S. participate in the civilian workforce, potentially increasing the healthcare workforce. 16 With a chronic shortage of nurses, primary care, and specialty physicians in the US, particularly in rural areas, such policies have serious implications for rural women’s health and optimize chronic disease prevention. Legislative policies must also focus on expanding programs and funding to improve the dietary quality of school lunches for school-aged children in rural communities, given the stark variability in the quality of school lunches between rural and urban areas. In addition to comprehensive sex education in K-12, states and school systems must consider expanding their policies and guidelines to chronic disease prevention and management. School and health systems can use the life course perspective to emphasize the importance of physical activity, healthy nutritional habits, and adopting positive mental health behaviors on immediate and future health. Adolescent routine preventive health screening can be leveraged to identify risks, screen, treat, or refer patients at risk of chronic diseases.
Research and Surveillance
Women’s health research remains underfunded. Therefore, there is an urgent need for more equitable and culturally responsive research and surveillance to measure and understand the magnitude of chronic diseases in rural areas. Addressing mental health issues, obesity, and other heart-related conditions among young girls and women during the preconception phase can prevent gestational diabetes and other cardiovascular diseases during pregnancy and in midlife. As a result, funding mechanisms that specifically support research, data collection for policy development, and public health programs and interventions focused on women, families, and communities are a positive step toward managing chronic diseases.2,4 While collecting longitudinal data in rural areas can be notably challenging due to issues such as transportation barriers, lack of trust leading to poor participation in research, and other community and cultural nuances, innovative approaches such as the use of community-based healthcare workers (CHWs), mobile health units, telehealth, and remote monitoring can be leveraged to increase research and surveillance in rural communities. While research on adolescent pregnancy prevention abounds, few have been dedicated to chronic disease prevention and management for adolescents and young adults. Thus, research, policies, and guidelines supporting adolescents in improving chronic disease risk factors are particularly warranted.
Patient Engagement and Community Awareness
To enhance women’s health in rural areas, diverse community-centered initiatives must focus on increasing knowledge, awareness, counseling, lifestyle changes, and understanding of family history related to chronic diseases. 2 Using inclusive and age-appropriate communication strategies for awareness campaigns and public education—through traditional methods (pamphlets, printed materials, and radio) and modern digital channels (social media, digital health, and telemedicine)—can effectively highlight risks and protective factors. 11 This approach helps women make informed decisions and adopt healthy behaviors with immediate and long-term health benefits. Furthermore, health promotion activities for younger populations should focus on all aspects of women’s health, instead of sexual and reproductive health or framed as pregnancy prevention initiatives, which is often the case for K-12 students and young college women. Thus, patient and community awareness must be designed to connect health behaviors to their future outcomes across reproductive and non-reproductive years. Even more important is the need to include fathers and male partners in chronic disease prevention and management efforts.
Addressing the Social Determinants of Health
As discussed earlier, adverse SDOH, such as food, housing, and transportation insecurity, greatly contribute to chronic diseases and are common in rural counties. Therefore, rural health centers and clinics must systematically collect SDOH data throughout the care process for women’s health, integrating the data into standard clinical practice and for patient referrals to community resources and social services.2,10 Efforts must be centered on the life course perspective and family-centered so that young people’s needs are captured. Additionally, resources to expand social services, build community infrastructure, and community awareness about adopting positive lifestyles, including culturally appropriate interventions within communities, must be heralded. 11
Conclusions
Centering chronic disease prevention and management in the life course perspective offers tremendous benefits for the health of women in rural regions. Stakeholders and partners must understand the plurality of health outcomes that extend beyond the pregnancy and postpartum phases. Concerted collaborative and interdisciplinary efforts between multiple stakeholders, including government agencies, policymakers, researchers, health systems, community-based organizations, and educational institutions, are necessary to implement recommendations for equitable and accessible health services and chronic disease mitigation in rural areas across the life course.
Footnotes
Acknowledgements
Not applicable.
Author Contributions
Kobi Ajayi: Conceptualization and Writing—Original draft preparation. Emesomhi Eboreime: Writing, Reviewing, and Editing. Alva Ferdinand: Writing, Reviewing, and Editing. Ninfa Purcell: Writing, Reviewing, and Editing. Robin Page: Writing, Reviewing, and Editing.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.