Measuring Maternity Care Access in the United States: A Scoping Review of Maternity Care Deserts, Obstetric Service Availability, and Geographic Access

Study Design

This scoping review was conducted to characterize how hospital-based obstetric access, maternity care deserts, labour and delivery unit closures, and geographic access to inpatient obstetric services have been defined and measured in the United States literature. The review was designed to identify methodological approaches, data sources, geographic techniques, and infrastructure measures used to evaluate access to maternity care. The review was guided by the methodological framework for scoping reviews described by Arksey and O’Malley and subsequent refinements to scoping review methodology. The objective was not to evaluate intervention effectiveness, but rather to map the existing evidence base and identify methodological trends and gaps in measurement approaches.

Eligibility Criteria

Studies were eligible for inclusion if they evaluated hospital-based obstetric access, maternity care deserts, labour and delivery unit closures, or geographic and infrastructure-based measures of maternity care access within the United States. Studies focused exclusively on clinical outcomes, outpatient prenatal care, educational interventions, or non-U.S. populations were excluded. Full inclusion and exclusion criteria are presented in Table 1.

Information Sources and Search Strategy

A comprehensive literature search was conducted in PubMed and Scopus to identify studies examining maternity care deserts, hospital-based obstetric access, labour and delivery unit closures, and geographic access to inpatient obstetric services in the United States. Searches were limited to English-language studies published between January 1, 2010, and June 1, 2026. The search strategy was designed around four primary concepts: (1) maternity care deserts and obstetric services, (2) hospital-based labour and delivery care, (3) geographic access and travel burden, and (4) rural obstetric service availability and closures.

The PubMed Search Strategy Utilized Included the Below Search Terms

(“maternity care desert*”[Title/Abstract] OR ((“labour and delivery”[Title/Abstract] OR obstetric*[Title/Abstract]) AND closure*[Title/Abstract]) OR (obstetric*[Title/Abstract] AND hospital*[Title/Abstract] AND access [Title/Abstract])) AND (rural [Title/Abstract] OR geographic [Title/Abstract] OR distance [Title/Abstract] OR travel [Title/Abstract]) AND (“United States”[Title/Abstract] OR US[Title/Abstract]) AND (2010:2026[pdat])

The Scopus Search Strategy Utilized Included the Below Search Terms

TITLE-ABS-KEY (“Maternity Care Desert*” OR ((“Labour and Delivery” OR Obstetric*) AND Closure*) OR (Obstetric* AND Hospital* AND Geographic)) AND TITLE-ABS-KEY (Rural OR Travel OR Distance OR Access) AND TITLE-ABS- KEY (“United States “OR US) AND PUBYEAR > 2009 Search Results from Both Databases Were Imported into Covidence Systematic Review Software for Deduplication, Screening, Full-Text Review, And Data Extraction. The Search Strategy Was Intentionally Designed to Prioritize Studies Focused on Hospital-Based Obstetric Infrastructure and Access Measurement Rather Than Maternal Clinical Outcomes Alone.

Study Selection

All records identified through the database searches were imported into Covidence for screening and review. Duplicate citations were removed before title and abstract screening. Studies judged potentially relevant were advanced to full-text review, where eligibility was assessed according to the predefined inclusion and exclusion criteria. Screening and full-text review were conducted independently by the review team, and any disagreements regarding eligibility were resolved through discussion and Consensus. The Study Selection Process and Reasons for Exclusion at the Full-Text Stage are Presented in The Prisma Flow Diagram.

Data Extraction

A standardized data extraction form was developed before full-text review to ensure consistent collection of information across studies. The extraction form was designed to capture the methodological approaches used to define, measure, and evaluate maternity care access, with particular emphasis on hospital-based obstetric services, maternity care deserts, geographic accessibility, and labour and delivery unit closures.

Information extracted from each study included publication characteristics, study design, geographic scope, and population characteristics. Additional data were collected regarding definitions of maternity care deserts and obstetric access, data sources used to identify obstetric services, geographic and spatial methodologies, infrastructure measures, workforce considerations, approaches to identifying labour and delivery unit closures, outcomes examined, and key study findings. Particular attention was given to the operationalization of access measures, including the use of hospital-based, provider-based, and combined approaches to measuring maternity care availability.

Data Synthesis

Data were synthesized using descriptive and narrative approaches. Studies were first characterized according to their design, geographic scope, and primary focus.

Subsequently, studies were grouped according to the methodological approaches used to measure maternity care access and obstetric service availability.

The synthesis focused on identifying patterns in how maternity care deserts were defined, how hospital-based obstetric access was operationalized, what data sources were used to identify active obstetric services, and how geographic accessibility was measured. Additional attention was given to methods used to identify labour and delivery unit closures, evaluate rural obstetric service erosion, and assess workforce shortages and infrastructure capacity.

Findings were summarized through narrative synthesis and descriptive tables to highlight methodological similarities, differences, and gaps across the literature. The primary goal of the synthesis was to characterize the range of approaches currently used to measure hospital- based obstetric access in the United States and to identify opportunities for greater standardization in future research.

Study Selection

The database search identified 211 records, including 99 records from PubMed and 112 records from Scopus. After removal of 52 duplicate citations, 159 records remained for title and abstract screening. Following screening, 82 records were excluded and 77 articles underwent full-text review. Twenty-two studies were subsequently excluded because of incorrect study focus (n = 5), evaluation of outcomes without access measurement (n = 2), lack of maternity care access measurement (n = 4), incorrect patient population (n = 1), or non-empirical publication type (n = 10). A total of 55 studies met all eligibility criteria and were included in the final synthesis. The study selection process is presented in Figure 1.

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Study Characteristics

The characteristics of the 55 included studies are summarized in Table 2. Cross-sectional studies represented the most common study design (25.5%), followed by GIS or spatial analyses (21.8%) and retrospective cohort studies (16.4%). Nearly one-half of all studies were national in scope (47.3%), while state-level studies accounted for an additional 18.2% of the literature. Collectively, these findings demonstrate the strong emphasis on population-level and geographically oriented approaches to evaluating maternity care access.

The predominance of national and state-level analyses suggests that investigators frequently examine maternity care access as a systems-level phenomenon rather than focusing on individual facilities or local service areas [11, 12, 14, 16, 18, 19]. However, substantial variation existed in how studies defined and measured access, prompting further examination of the specific access measures employed across the literature.

Access Measurement Approaches

The methodological approaches used to operationalize maternity care access are presented in Table 3. Hospital- based measures were the dominant approach, appearing in 94.5% of studies, while provider-based measures were incorporated in approximately half of the literature (52.7%). Although maternity care deserts have become increasingly prominent in policy and research discussions, fewer than half of the studies (41.8%) provided an explicit definition of the concept. Labor and delivery unit closures were discussed in nearly nine out of ten studies (87.3%), highlighting the extent to which declining obstetric infrastructure and rural service erosion have become central themes within contemporary maternity care access research [6, 7, 8, 17, 20].

These findings suggest that hospital availability remains the primary lens through which maternity care access is evaluated [6, 18, 19]. Nevertheless, considerable variation exists regarding whether access is conceptualized through facilities, providers, geographic proximity, or combinations of these measures [10, 11, 12, 14, 15]. This variability becomes particularly apparent when examining the geographic methodologies used across studies [1, 3, 4]. To provide a broader overview of how maternity care access has been operationalized across the literature, Figure 2 summarizes the frequency of major measurement approaches identified in the included studies. Hospital-based measures were the most commonly used approaches, followed by workforce and provider-based measures. In contrast, direct measures of geographic accessibility, such as travel-time analyses and spatial clustering methods, were comparatively uncommon [1, 3, 4, 8].

Studies frequently incorporated multiple approaches to measuring maternity care access; therefore, categories are not mutually exclusive and the percentages exceed 100%. Hospital-based measures were the most used approaches, whereas travel-time and advanced spatial analytic methods were used infrequently.

As shown in Figure 2, the literature is heavily oriented toward hospital infrastructure and service availability measures [6, 10, 18, 19]. Nearly all studies incorporated hospital-based indicators [21], and a large proportion examined labour and delivery unit closures, active obstetric services, or workforce shortages [6, 14, 15, 17, 20]. Although geographic barriers to care were frequently discussed, relatively few studies incorporated direct travel-time measures. This pattern suggests that maternity care access research has focused primarily on the availability of services rather than the practical accessibility of those services from the patients’ perspective. The substantial difference between the frequency of hospital-based measures and travel-time methodologies suggests that much of the literature evaluates service availability rather than directly measuring patient accessibility [1, 3, 4].

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Geographic Methodologies

Geographic approaches to measuring maternity care access varied substantially across the included studies (Table 4). Rurality classifications were the most employed geographic measure (89.1%), followed by GIS mapping techniques (50.9%). Travel distance measures appeared in 38.2% of studies; however, only 10.9% incorporated travel-time analyses despite widespread discussion of transportation barriers and travel burden within the literature. Similarly, spatial clustering techniques were used infrequently.

The relatively limited use of travel-time and advanced spatial analytic methods suggests that many studies rely on administrative or geographic classifications rather than direct measures of accessibility. Consequently, studies may identify underserved populations differently depending on the methodological approach selected. The infrastructure measures used to characterize obstetric service availability also varied considerably.

Infrastructure Measures and Closure Methodologies

Infrastructure measures used across the literature are summarized in Table 5. Most studies evaluated active labour and delivery units (89.1%), while workforce shortages were discussed in more than three-quarters of studies (76.4%). Hospital closures or labour and delivery unit closures were formally evaluated in 54.5% of studies. Notably, only 60.0% of studies reported facility-level verification of obstetric service availability. NICU access was incorporated less frequently, appearing in approximately one-third of studies.

The incomplete use of facility-level verification highlights an important methodological limitation within the literature. Researchers frequently rely on administrative datasets, workforce databases, or secondary classifications of access, yet comparatively few studies verify the ongoing availability of obstetric services directly at the facility level.

This variation contributes to broader inconsistencies in how maternity care deserts and obstetric access are defined and measured.

Definitions Of Maternity Care Deserts and Obstetric Access

To better characterize the conceptual frameworks underlying maternity care access measurement, studies were grouped according to their primary operational approach (Table 6). Definitions of maternity care deserts and obstetric access varied substantially across studies and are summarized in Table 6. Although the March of Dimes framework emerged as the most cited maternity care desert definition, alternative approaches relied on hospital availability, provider availability, travel burden, workforce density, or combinations of these measures. Some studies defined access primarily through hospital-based indicators, whereas others emphasized provider availability or geographic proximity to services.

Considerable variation was observed in how maternity care access was defined and operationalized across studies (Table 6). The most common approaches relied on hospital- based measures of labour and delivery service availability or maternity care desert classifications [10, 18, 19]. More recent studies increasingly adopted multidimensional frameworks that combined hospital infrastructure, provider availability, and geographic accessibility measures [11, 12, 22]. Travel distance and travel time measures were used to quantify geographic barriers to care, although travel-time analyses were comparatively uncommon [1, 3, 4]. Studies evaluating labour and delivery unit closures frequently conceptualized access as the loss of local obstetric infrastructure [6, 8, 20], whereas workforce-focused investigations emphasized provider availability and distribution [14, 15, 23]. Collectively, these findings demonstrate that maternity care access is measured using multiple distinct but overlapping conceptual frameworks, with no single standardized approach dominating the literature.

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The findings suggest that contemporary maternity care access research can be broadly organized into three overlapping methodological domains: hospital-based measures, provider-based measures, and geographic access measures (Figure 3). While many studies incorporated elements from multiple domains, substantial variation existed in how these components were combined to define and operationalize access [10, 11, 12, 22]. This conceptual framework illustrates the principal approaches identified across the literature and highlights the multidimensional nature of maternity care access measurement.

As illustrated in Figure 3, the literature conceptualizes maternity care access through three primary methodological domains: hospital-based measures, provider-based measures, and geographic access measures [1, 14, 19]. While individual studies frequently incorporated elements from more than one domain, substantial variation existed in the relative emphasis placed on infrastructure, workforce, and geographic accessibility [10, 12, 22]. The lack of a standardized framework integrating these dimensions contributes to the methodological heterogeneity observed across the literature and highlights an important opportunity for future standardization efforts.

Methodological Gaps in Maternity Care Access Measurement

Several methodological gaps emerged across the included studies. Fewer than half of the studies provided an explicit definition of a maternity care desert, and substantial variation existed in the criteria used to classify underserved communities [10, 11, 12, 13]. Although hospital-based measures dominated the literature, provider-based approaches and multidimensional access frameworks were applied inconsistently [14, 15, 19, 22]. Direct measures of geographic accessibility were relatively uncommon, with only a small proportion of studies incorporating travel-time analyses despite widespread discussion of travel burden as a barrier to care [1, 3, 4, 8]. In addition, only 60% of studies reported facility-level verification of obstetric service availability [6, 18, 19]. Together, these findings highlight substantial heterogeneity in how maternity care access is measured and operationalized across the United States literature.

Policy Implications

The absence of standardized approaches to measuring maternity care access may have important policy implications. Access measures are increasingly used to inform workforce planning, maternity care shortage designations, rural hospital funding initiatives, and maternal health resource allocation [28]. Differences in how access is measured may therefore lead to different conclusions regarding which communities are underserved. Greater consistency in access measurement could improve comparability across studies and support more evidence-informed decision-making. As maternity care access measures increasingly inform maternal health policy, workforce planning, and designation of underserved communities, greater methodological consistency may improve the precision and effectiveness of interventions designed to address geographic inequities in maternity care [16, 23].

Collectively, this review suggests that maternity care access should no longer be conceptualized as a single construct measured solely through hospital availability or provider supply. Rather, access is a multidimensional phenomenon that reflects the interaction of healthcare infrastructure, workforce capacity, and geographic accessibility. Future measurement frameworks that integrate these dimensions may provide a more comprehensive understanding of obstetric service availability and better support maternal health research, policy, and planning.