Beyond the Mirage: Confronting Historic Inequities in Maternal Care Deserts

The article “Not-So-Simple Solutions for Improving Maternal Morbidity in Maternity Care Deserts” provides a comprehensive overview of the challenges facing maternal health care in rural communities. ¹ The article’s analysis, however, would be greatly strengthened by incorporating the historical context of medical education in the United States. To effectively address the complex issue of maternal care deserts (MCDs), it is essential to acknowledge how the Flexner Report contributed to their formation.

The closure of labor and delivery units and the subsequent formation of MCDs are deeply intertwined with the legacy of the Flexner Report. This influential document, published in 1910, led to the closure of 77% of medical schools. Due to the report’s stringent and biased standards, many of the medical schools located in rural areas, serving as pipelines for physicians to practice in rural communities, were forced to close. ² The Flexner Report disproportionately impacted underfunded Black medical schools, leading to the closing of five out of seven institutions, which primarily served communities in the rural South. ³ This historical injustice has had lasting consequences, limiting access to medical education for individuals from rural and disadvantaged backgrounds who are more likely to serve MCDs.

The systematic dismantling of medical education by the Flexner Report exacerbated health disparities and created the conditions for the absence of clinicians in MCDs. The report promoted the establishment of medical schools in large urban centers, leading to a concentration of medical education in these areas. This centralization reduced opportunities for minority and rural students to pursue medical education. ² For example, Knoxville Medical College, a predominantly Black medical school, closed directly after the report was published. ⁴ Today, 32.6% of Tennessee counties are MCDs, with the nearest medical school now being more than 3 hours away. ⁵ This example demonstrates the strong correlation between the location of medical training and the location of clinician practice. In general, medical trainees tend to practice where they train. ⁶ As urban medical schools today are far more numerous than rural ones, the shortage of clinicians taking care of pregnant people in rural places persists. The Flexner Report bears responsibility for this uneven distribution of physicians.

Addressing the current crisis of MCDs demands a comprehensive approach considering both historical and contemporary factors. A historical lens reveals root causes and informs equitable solutions, preventing the perpetuation of systemic inequities and worsened health outcomes for marginalized communities. The article outlines potential solutions, including investments from hospital systems, the federal government, and medical schools. ¹ The prioritization should be on supporting rural rotations, residency programs, hospitals, and health care providers. Emphasis should also be placed on medical education programs that value diversity and inclusion and support historically Black medical schools. These changes can lead to a future where physicians are both more diverse and distributed, resulting in all persons having access to the quality maternal health care they deserve.