This article is published as part of a collaborative effort by students in the School of Journalism and Strategic Communication at Ball State University and the Ball State Daily News. Produced in a classroom setting under faculty guidance, the initiative aims to provide hands-on experience while informing the public through responsible, student-driven journalism.
Keith J. Mueller, Ph. D., is the Gerhard Hartman Professor of Health Management and Policy at the University of Iowa. However, for almost 45 years, he’s been involved with the Rural Policy Research Institute (RUPRI) and its Center for Rural Health Policy Analysis.
In 1993, Mueller joined the RUPRI health panel and stayed because of its policy analysis work and RUPRI’s facilities. Through its open-door policies, Mueller, who is now the Center's director, has been able to work with different offices and research organizations “with ease.”
RUPRI’s main role is to provide advice to policymakers and comment on proposed rules and requests for information regarding rural healthcare. Additionally, Mueller said the other work being done within the Institute's health initiative directly impacts rural providers.
He said while he is “blessed” and fortunate to have this experience, not everyone he works with or for is so lucky.
In rural America, access to obstetric (OB) and maternal health care has been declining while maternal mortality is rising, according to a 2024 research article on the topic published by the Journal of the American Medical Association (JAMA). The study also found that “maternal and infant morbidity and mortality and care access barriers are elevated for rural residents.”
According to Indiana University’s Public Policy Institute, in 2022, Indiana had the third-highest maternal mortality rate in the country, with the biggest factor contributing to this number of deaths being lack of access.
Mueller said this rate is due to a handful of barriers — not just lack of access.
“The biggest barrier is the inability of rural places to attract and retain adequate workforce. Too often, essential services are not available locally,” he said via email. “Another barrier is [the] inability [of] local healthcare organizations such as hospitals to sustain services because of financial considerations, OB care being a prime example.”
Specialty healthcare, which OB and mental health care falls under, is automatically challenging for rural residents to access, and Mueller said the more “obscure” the care is, the more the challenges magnify.
“When you specify sub-specialty services, access challenges magnify because to receive those [services], rural residents will need to travel to tertiary or quaternary health facilities. Even telehealth access cannot overcome the need to travel to regional centers for the most challenging procedures and treatments,” Mueller said.
Ingrid Jacobson, MPH, Data Analyst at the University of Minnesota (UMN) Rural Health Research Center (RHRC) and Emily Sheffield, MPH, Doctoral Student and Graduate Research Assistant at the UMN RHRC research rural maternity care. Their team focuses on impacting policy-making and building pathways much like RUPRI but specifically focuses on rural maternal health.
“Our maternity care team, led by Dr. Katy Kozhimannil, conducts research on rural-urban differences and within-rural differences in access to and quality of care before, during and after pregnancy. We work to conduct policy-relevant research to build the evidence base on a number of topics impacting birthing people and their infants in rural communities,” Sheffield and Jacobson said in a joint statement via email.
The duo echoed Mueller and said that across the nation, and in Indiana, barriers to rural healthcare do not change, but “become more acute” for people seeking pregnancy, birth and postpartum care.
RHRC is the only academic team in the U.S. working to document OB closures in rural areas. Their work has informed policies such as the 2018 Improving Access to Maternity Care Act and the 2025 Rural Obstetrics Readiness Act, which if passed will support rural hospitals to build their capacity to provide OB care.
“Many areas, including both rural and urban communities, are designated as health professional shortage areas and some have more specific shortages of pregnancy and postpartum-related health care providers, called maternity care target areas,” Sheffield and Jacobson said. “When birthing people need care, workforce shortages of maternity care health professionals mean that individuals may have to travel farther distances to access this.”
While maternity workforce shortages can impact rural and urban communities, the next nearest option for maternity care may be further away for rural residents than it would be for urban residents.
The duo said workforce shortages, related transportation and financial barriers to accessing care are especially important to consider for the periods surrounding pregnancy because increased distances to this care can be associated with negative maternal and infant health outcomes.
“It’s important to know that rural maternity care deserts are growing,” Cara Veale, Chief Executive Officer of the Indiana Rural Health Association (IRHA), said.
Veale and IRHA focus on serving rural Indiana by helping providers in the state in numerous different ways. From securing grants to running programs in different rural communities, the team at IRHA is making an impact in the Hoosier state.
Veale said the team behind IRHA desires to be present and advocate for the rural community against laws that may “hard the survivability and ‘thriveability’” of rural healthcare in Indiana. Regarding maternal or OB care, Veale said the association attempts to tackle the barriers to care in a few different ways.
IRHA manages the “Healthy Start Communities that C.A.R.E” program, which is designed to combat the state's high infant mortality rates by providing support, confidential screenings, treatment and education for expectant mothers. Through grant funding from the Indiana Department of Health, IRHA launched “MommyWise,” a two-year program focusing on improving the infant mortality rate in Grant County, Indiana. With additional grant funding from the Centene Foundation and MHS, the association is preparing to launch a “mobile integrated health program” focusing on maternal and infant health.
Rural Hoosiers are finding “great” alternative solutions to traditional maternal health care — like home-visiting perinatal navigators and collaborative midwifery programs — but Veale said Indiana residents need to continue to note that challenges for these rural communities are still prevalent and do exist.
“We are seeing some very concerning statistics about rapid closure of OB service[s],” she said.
The team at RHRC said the work they do is important and the value of maternity care in rural communities is not always known. Sheffield and Jacobson said it is critical to understand the trends of obstetric unit closures impacting both rural and urban areas in the U.S.
“Rural hospitals tend to encounter further financial challenges with offering labor and delivery care. However, something that is really important to consider about rural maternity care is that it is a vital service line for the health of rural families and communities,” Sheffield and Jacobson said.
Contact the Ball State Daily News via email at editor@bsudailynews.com.
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