SUPPLEMENTARY INFORMATION:

Background

Section 332 of the Public Health Service (PHS) Act (42 U.S.C. 254e) provides that the Secretary of HHS designate Health Professional Shortage ( printed page 24883) Areas (HPSAs) based on criteria established by regulation. HPSAs are defined in statute to include (1) urban and rural geographic areas which the Secretary determines have shortages of health professionals, (2) population groups with such shortages, and (3) public or private medical facilities or other public facilities with such shortages. The required regulations setting forth the criteria for designating HPSAs are codified at 42 CFR part 5. Section 332(k)(1) of the PHS Act provides that the Secretary, acting through the HRSA Administrator, shall identify shortages of maternity care health services “within health professional shortage areas.” Section 332(k)(1) further requires HRSA to identify MCTAs and distribute maternity care health professionals within HPSAs using the MCTAs so identified.

In a September 27, 2021, Federal Register notice (FRN) (86 FR 53324), HRSA requested feedback on six proposed criteria to identify MCTAs: (1) ratio of females ages 15-44 to full time equivalent maternity care health professional; (2) percentage of females 15-44 with income at or below 200 percent of the federal poverty level (FPL); (3) travel time/distance to the nearest provider location with access to comprehensive maternity care services; (4) fertility rate; (5) SVI; and (6) four maternal health indicators (pre-pregnancy obesity, pre-pregnancy diabetes, pre-pregnancy hypertension, and prenatal care initiation in the first trimester). HRSA finalized the MCTA criteria on May 19, 2022 (87 FR 30501).

On February 3, 2026, through an FRN, HRSA announced a 30-day public comment period to solicit input on updated criteria for determining MCTAs (91 FR 4927). In particular, HRSA requested feedback on proposed changes to the criteria and point scales for MCTAs by removing the criterion for SVI and reallocating its two points as follows: one point to population-to-full-time equivalent maternity care health professional ratio, and one point for travel time/distance to the nearest source of accessible care outside of the MCTA. HRSA carefully evaluated and analyzed the comments received and used them to guide the final decision on how to update criteria used in MCTAs.

Comments on the Proposed Criteria for Identifying Maternity Care Target Areas

HRSA received 14 responses to the request for comments. The following is a breakdown of those 14 responses. Of those 14 responses, six comments were from public interest/advocacy organizations, three comments were from state government agencies, two comments were from academic institutions/researchers, two comments were from health care providers/institutions, and one comment was from an individual/private citizen. Of the 14 comments received, one comment fell outside of the scope of this request. The remaining 13 comments and HRSA's responses are summarized below.

Summary of Comments

Social Vulnerability Index

HRSA received three comments that supported the February 3, 2026, FRN proposal to remove the SVI and reallocate points to population-to-full-time-equivalent maternity care health professional ratio and travel time/distance to the nearest source of accessible care outside of the MCTA. Ten comments did not support the proposal detailed in the February 3, 2026, FRN.

The three commenters who supported the removal of SVI as a MCTA criteria all mentioned that reallocation of the points to population-to-full-time-equivalent maternity care health professional ratio and travel time/distance to the nearest source of accessible care outside of the MCTA would better measure access to maternity care providers, and discussed that this will advantage rural communities in regards to MCTA scoring and ultimately recruiting and retaining maternity care providers to serve in those areas. Two specifically mentioned transportation issues and road terrain conditions as additional barriers to health care access facing rural communities. One commenter specifically stated the removal of SVI and reallocation of points to population-to-full-time-equivalent maternity care health professional ratio and travel time/distance to the nearest source of accessible care outside of the MCTA was equitable and will assist in National Health Service Corps Loan Repayment Program recruitment.

The remaining 10 relevant comments were opposed to the HRSA proposal to remove SVI. Nine commenters believe the system should continue to look at multiple factors, including clinical and social challenges, to better understand where care is needed. Five of the 10 commenters recommended retaining SVI or replacing it with a similar metric, however, not all commenters had suggestions on what metric could replace SVI. Two commenters recommended using the Social Deprivation Index as a direct replacement, and one specifically mentioned using the Centers for Disease Control and Prevention National Vital Statistics System. Five commenters requested HRSA monitor how scoring changes affect provider placement and recruitment. Four commenters stated that removal of SVI may adversely affect rural areas via reduced workforce placement, and four also recommended that HRSA should conduct an impact analysis prior to implementation of any policy change.

Response

HRSA thanks all commenters for their input on the proposed change to MCTA criteria and recognizes that there are many factors that should be considered when making changes to the way shortage areas are scored. Many commenters indicated that SVI should be maintained; however, HRSA's position is that SVI is used to help public health officials and local planners better prepare for and respond to emergency events, not necessarily to determine access to care. Congress established MCTAs through the Improving Access to Maternity Care Act of 2018 (Pub. L. 115-320) to ensure that shortage areas in need of maternity care health services have access to maternity care. The proposed reallocation of points from SVI to the nearest source of accessible care will work to better quantify the distances some communities must travel to seek maternity care, and reallocation of points from SVI to the population-to-full-time-equivalent maternity care health professional ratio will work to better quantify the availability of maternity care providers versus the population in the area under consideration for designation. These two values closely align with access to maternity care, and therefore, the congressional intent in establishing MCTAs. HRSA understands the sensitivity around workforce recruitment and retention, especially in rural areas. HRSA may continue to evaluate the components of these two values, including the definition of maternity care health professional. HRSA conducted an impact analysis on currently designated MCTAs, including those in rural areas, in the February 3, 2026, FRN, showing that the anticipated effect of these changes will be an overall increase of 6.6 percent to MCTA scores.

Conclusion

HRSA appreciates the comments and recommendations received from the public. HRSA considers many of the comments received to be useful and informative to future discussions on how to strengthen MTCAs moving ( printed page 24884) forward. After consideration of the public comments received, HRSA is implementing the final MCTA criteria as proposed. Details on the final approach are below. If you have any questions, please contact Matthew Patterson at sdb@hrsa.gov.

Final Approach for Determining Maternity Care Health Professional Target Areas

An MCTA score will be generated for each primary care HPSA using the HPSA's service area. The following five scoring criteria will be included in a composite scale that will be used to identify MCTAs with the greatest shortage of maternity care health professionals: (1) ratio of females ages 15-44 to full time equivalent maternity care health professional; (2) percentage of females 15-44 with income at or below 200 percent of the FPL; (3) travel time/distance to the nearest provider trained and licensed to provide the necessary care; (4) fertility rate; and (5) maternal health index which contains the following six indicators: pre-pregnancy obesity, pre-pregnancy diabetes, pre-pregnancy hypertension, prenatal care initiation in the first trimester, cigarette smoking, and the behavioral health factor. Each of these five criteria will be assigned a relative weight based on the significance of that criterion relative to all the others.

The weighted scores will be summed to develop a composite MCTA score ranging from zero to 25, with 25 indicating the greatest need for maternity care health professionals in the MCTA. Accordingly, the higher the composite score, the higher the degree of need for maternity care health services.

Score for Population-to-Full-Time-Equivalent Maternity Care Health Professional Ratio

The population-to-provider ratio will measure the number of women of childbearing age in the service area compared to the number of maternity care health professionals in the service area. Women of childbearing age will be defined as women between the ages of 15-44 years old and maternity care health professionals will be defined as Obstetricians-Gynecologists and Certified Nurse Midwives (CNMs). A population-to-provider ratio of 1,500:1 will be used as a minimum requirement for a population to be considered reasonably served by Obstetricians-Gynecologists and CNMs.

Population-to-provider ratio point values will be distributed as follows:

Score for Percentage of Population With Income at or Below 200 Percent of the Federal Poverty Level

The percentage of women of childbearing age living in the service area at or below 200 percent of the FPL will be used to score MCTAs, based on poverty data from the United States Census Bureau.

Population with income at or below 200 percent of the FPL point values will be distributed as follows:

Score for Travel Time/Distance to the Nearest Source of Accessible Care Outside of the MCTA

The nearest source of accessible care is defined as the nearest provider trained and licensed to provide the necessary care, as determined by the Esri StreetMap Premium road network. Travel time/distance is defined as the average time to travel by road miles or the actual distance in road miles to the nearest source of care.

Travel time/distance to the nearest source of accessible care point values will be distributed as follows:

Score for Fertility Rate

Fertility rate has been included to reflect the increased need for maternity care services among populations that experience a higher rate of births. Women of childbearing age ( i.e., ages 15-44) will be derived from the American Community Survey and births ( printed page 24885) will be derived from the National Vital Statistics System.

Fertility Rate point values will be distributed as follows:

Score for Maternal Health Indicators

Maternal health indicators are defined as factors associated with poor maternal health outcomes using data from the National Vital Statistics System and the Shortage Designation Management System. Scores will consider pre-pregnancy obesity, pre-pregnancy diabetes, pre-pregnancy hypertension, cigarette smoking before or during pregnancy, whether prenatal care began in the first trimester, and access to behavioral health services. Only women of childbearing age ( i.e., aged 15-44) will be considered for these indicators. HRSA will use the National Vital Statistics System Natality file as the data source to determine the sub-score for pre-pregnancy obesity, pre-pregnancy diabetes, pre-pregnancy hypertension, cigarette smoking before or during pregnancy, and whether prenatal care began in the first trimester. The Shortage Designation Management System Mental HPSA file will be the data source to determine the sub-score for the behavioral health access factor.

Maternal Health Indicator criteria point values will be distributed as follows:

• Pre-Pregnancy Obesity

Pre-pregnancy obesity is defined as having a body mass index of 30 or higher. One point will be awarded if the prevalence of pre-pregnancy obesity in the area is greater than or equal to the 50th percentile among all counties in the United States. If the prevalence of pre-pregnancy obesity in the area is less than the 50th percentile among all counties, zero points will be awarded.

• Pre-Pregnancy Diabetes

One point will be awarded if the prevalence of pre-pregnancy diabetes in the area is greater than or equal to the 50th percentile among all counties in the United States. If the prevalence of pre-pregnancy diabetes in the area is less than the 50th percentile among all counties, zero points will be awarded.

• Pre-Pregnancy Hypertension

One point will be awarded if the prevalence of pre-pregnancy hypertension among women in the area is greater than or equal to the 50th percentile among all counties in the United States. If the prevalence of pre-pregnancy hypertension among women in the area is less than the 50th percentile among all counties, zero points will be awarded.

• Cigarette Smoking

One point will be awarded if the prevalence of cigarette smoking before or during pregnancy among women in the area is greater than or equal to the 50th percentile among all counties in the United States. Smoking before pregnancy will be defined as smoking one or more cigarettes daily for the 3 months prior to pregnancy. Smoking during pregnancy will be defined as smoking one or more cigarettes during any trimester of pregnancy. If the prevalence of cigarette smoking before or during pregnancy among women in the area is less than the 50th percentile among all counties, zero points will be awarded.

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• Prenatal Care Initiation in the 1st Trimester

One point will be awarded if the prevalence of women who did not initiate prenatal care in the first trimester of their pregnancy is greater than or equal to the 50th percentile among all counties in the United States. Zero points will be awarded if the prevalence of women who did not initiate prenatal care in the first trimester of their pregnancy is less than the 50th percentile among all counties.

• Behavioral Health Factor

One point will be awarded if a portion or all of the MCTA service area is designated as a Mental Health HPSA meeting the following population-to-provider median ratio thresholds based on its mental health provider type. Zero points will be awarded if a portion or all of the MCTA service area is not designated as a Mental Health HPSA or if the Mental Health designation does not meet the population-to-provider ratio threshold.

Paperwork Reduction Act

The criteria used to identify MCTAs under section 332(k) of the PHS Act, as described in this announcement, will not involve data collection activities that fall under the purview of the Paperwork Reduction Act of 1995. If the methods for determining MCTAs fall under the purview of the Paperwork Reduction Act, HRSA will seek the Office of Management and Budget clearance for proposed data collection activities.

91 FR 24882