Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Arts and Sciences



First Advisor

Dr. Erin Koch


Obstetric and maternity health services are being rapidly eliminated in the rural United States, making maternal care more difficult to access and causing negative birth outcomes. Service closures have a magnified impact in Appalachia due to histories of systemic regional and state policy practices which devalue the lives of people living rural areas, local economic marginalization, geographic barriers, and insufficient health infrastructures. This research investigates how women living in rural Appalachia navigate pregnancy and birth amidst constant care closures. The Sunflower Mountain Region is a seven-county area in rural Southern Appalachia. The region has experienced ongoing obstetric closures over the course of the past decade. The findings presented in this dissertation are based upon 15 months of a combination of remote and in-person ethnographic research with pregnant women, mothers, and health professionals in the Sunflower Mountain Region between 2019-2022. I conducted formal interviews, informal conversations, participant observation in local health and educational settings, and an online survey.

This dissertation questions the impacts of obstetric service closures on communities and individual women. The elimination of maternity services in the Sunflower Mountain Region has wide-reaching effects because the area is so interconnected with livelihoods, resources, and healthcare. Therefore, one obstetric closure impacts how other maternity care providers structure their care due to the changes in patient flow. I argue that the elimination of rural birthing services creates a ‘sacrifice zone’ where rural lives and health are sacrificed in the name of saving hospital systems money. When obstetric services are eliminated, risks to the health and wellbeing of pregnant women living in rural Appalachia increase and birth choices decrease. Fewer birth choices create disempowerment in pregnancy experiences. Pregnant women, mothers, and health professionals exhibit resilience in the face of health inequalities, but resilience can be exhausting and frustrating. This sheds light on cultural and political aspects of policymaking and implementation. I also explore the various marginalizing processes in the region and how intersectionality shapes birthing experiences. Additionally, because this research was conducted during the COVID-19 Pandemic, I document the novel challenges of pregnancy, birth, and postpartum during an unprecedented global crisis. I explore the intersections of rurality and pandemic, which creates a precarious healthcare and social environment. Ultimately, this research shows that eliminating birth choices is an act of disempowerment and highlights the way local professionals and women fill the gaps that the state creates in removing maternal healthcare.

Digital Object Identifier (DOI)

Funding Information

This study was supported by the University of Kentucky Department of Anthropology in 2019 and 2020.

This study was supported by the National Science Foundation Doctoral Dissertation Research Improvement Grants (no.: 2048988) in 2021.

Available for download on Monday, June 17, 2024