Shrinking Maternity Care in Rural America

[J.Adderton, BSN, MSN]

Each year, half a million babies are born in rural hospitals. For the 18 million reproductive-age women living in rural communities, accessing maternal care in rural communities is a challenge. According to The Minnesota Rural Health Research Center (MRHRC), more than half of all rural counties in the U.S. do not have a hospital offering obstetrics care. More than 200 hospitals stopped providing obstetrics care from 2004 to 2014 and the shortage grew from 2010 to 2018 as 83 rural hospitals closed. As a result, less than half of rural women live within a 30-minute drive to a hospital offering maternity care.

Community Impact

Adding to the challenges facing rural communities, lack of access to obstetric care directly impacts infant mortality rates. The infant mortality rate in rural counties is 6.69 deaths per 1,000 live births compared to 5.4 infant deaths per 1,000 live births in rural counties. Maternal mortality is also higher in rural counties 29.4 per 100,000 live births compared to 18.2 in larger urban areas (Scientific America, 2015). Women in rural communities already have poorer health outcomes. The most vulnerable (low income, remote and minority) groups experience the greater consequences of having fewer health services. A study conducted by the University of Minnesota School of Public Health found rural communities with lower income thresholds for Medicaid and high percentages of black women were less likely to have access to obstetric services.

Underlying Factors

How the U.S. got to this point is multifactorial and complicated. Over the past ten years, rural healthcare has experienced hospital closures and fewer doctors. Obstetric and gynecology services account for more than 5% of hospital costs. The high price of delivering babies make these services an easy target for cuts. There are a few reasons why it is so expensive:

• How long it will take to deliver any baby is unknown. However, the delivery team (nurses, doctor, surgeon etc) has to be available and ready when the moment arrives.
• Rural Americans are less likely to have insurance and more likely to pay for services through Medicaid. Medicaid reimbursement is less private insurances- decreasing the hospital’s ability to cover costs and make a profit.
• Demographics in rural communities is changing and the population is shrinking. The aging of rural America naturally decreases the number of births. Low birth volumes present another financial challenge for hospitals.
• According to the American Congress of Obstetricians and Gynecologists, only 6% of Obstetricians and gynecologists work in rural areas.

Addressing the Problem

There is no one silver bullet solution for the lack of obstetric care in rural areas. However, progress is being made through policy and innovative approaches. The University of Wisconsin School of Medicine and Public Health implemented the nation’s first obstetrics and gynecology residency program for remote rural areas (population less than 20,000). The program’s aim is to increase the number of physicians working in rural areas. Other approaches to bridging the care gap include:

• The Improving Access to Maternity Care Act, if passed, would require additional data collection from the Department of Health and Human Services in rural communities lacking sufficient maternity services. The act also includes a loan forgiveness program for obstetricians and gynecologist working in rural areas.
• Implementing telemedicine programs with online video for patients to access prenatal care. One challenge to this solution is the lack of internet service to support telemedicine in some rural areas.
• State laws that would allow nurse practitioners and midwives to help fill access gaps.
• Training police and emergency response on the delivery of baby if no other access available.
• Transportation programs to improve access to care

• Community and patient education focused on proactive prevention of complications

Additional research is needed to determine the long term effect rural health gaps have in the outcomes of mothers and infants. Research data is needed to determine if traveling longer to access care leads to negative outcomes.

What initiatives are being implemented to improve access in your community?

Additional Resources:

National Rural Health Association Policy- Access to Rural Maternity Care

Rural Health Research Organization- Diminishing Access to Rural Maternity Care

[ruby_jane, BSN, RN]

This is excellent. When I worked in public health, the only hospital in one county stopped doing routine deliveries. The effect was absolutely chilling on that community. The biggest problem (and this was the view of the ID nurse): the number of "drive-by" deliveries, where mom had little to no prenatal care. If we want to grow that 6% figure, someone needs to help the docs who are willing to deliver higher-risk pregnancies with their malpractice premiums.

[UrbanHealthRN, BSN, RN]

Maybe it's just because this is a nursing site, but I couldn't help but notice that your article only mentions OB/GYNs and not midwives. In my neck of the woods, nurse midwives have been an excellent source of women's healthcare. I'm just wondering if your research pulled up any information about midwives, birthing centers, and similar strategies for addressing rural maternity care.

[Destin293]

I work in a rural hospital. I had my baby in August of 2018 at the hospital where I work. I had to receive all my prenatal care in network due to insurance. Thankfully I wasn’t high risk because when I was supposed to be going every 2 weeks for my appointments, I was fortunate enough to get one monthly. When I was supposed to be going weekly, I was fortunate to get an appointment every 3 weeks. And just to schedule the appointment required me to put my name on a waitlist and have them call when/if an appointment time opened. I had to beg for an appointment for my GBS swab because it was going on a month since my last appointment and I still hadn’t been contacted for another one. I couldn’t imagine having complications and having to stress about the next time I may see a provider.

[J.Adderton, BSN, MSN]

15 hours ago, ruby_jane said:

This is excellent. When I worked in public health, the only hospital in one county stopped doing routine deliveries. The effect was absolutely chilling on that community. The biggest problem (and this was the view of the ID nurse): the number of "drive-by" deliveries, where mom had little to no prenatal care. If we want to grow that 6% figure, someone needs to help the docs who are willing to deliver higher-risk pregnancies with their malpractice premiums.

In researching for this article, I was shocked at the number of births with no prenatal care.

[J.Adderton, BSN, MSN]

14 hours ago, UrbanHealthRN said:

Maybe it's just because this is a nursing site, but I couldn't help but notice that your article only mentions OB/GYNs and not midwives. In my neck of the woods, nurse midwives have been an excellent source of women's healthcare. I'm just wondering if your research pulled up any information about midwives, birthing centers, and similar strategies for addressing rural maternity care.

Great question. Yes, the use of midwives and birthing centers is a promising strategy. The hurdle will be changing laws (in many states) that will allow the practice.

[lindahartford]

One of the major reasons for this is our Congress has been pushing to get rid of Planned Parenthood for decades now, Whether you are for or against abortions, the care they have given to poor and uninsured women for over 50 years is sorely missed in the areas that have forced them out.

In Texas, the Maternal death rate, about 30 deaths/100,000 births (terrible when compared to European and other civilized nations with rates from 4 - 11) has increased to almost 40 since they got rid of all but one PP in the whole state.

Now Trump is pushing to take away all Federal funding for the entire organization. This policy is killing mothers and leaving families without a parent.

I have no idea how many babies have died because of these laws.

Please register to vote and vote for Medicare for all.

[Kooky Korky, BSN, RN]

Midwives?

Legislators standing against Trump's wishes?

[Jory, MSN, APRN, CNM]

As long as the practice of midwifery is restricted in this country in over half the states, these numbers will not improve. At all.

Physicians right now, are in charge of over 90% of all births in the US and they have made a complete mess of the process. Pregnancy is part of the life cycle..it is not a disease, but it is treated like one. Mothers are made to feel they can't manage labor, cannot give birth without a host of interventions and nurses that have only worked labor and delivery with physicians think all of the interventions is necessary.

Well, they aren't. One unnecessary intervention leads to another and that is why maternity care sucks in this country.

[Jory, MSN, APRN, CNM]

On 2/27/2019 at 12:18 AM, J.Adderton said:

Great question. Yes, the use of midwives and birthing centers is a promising strategy. The hurdle will be changing laws (in many states) that will allow the practice.

CNMs are permitted to work in all 50 states, but the problem in over half the states, CNMS are required to work with an OB/GYN and their practice can be very restricted and no better than the OB/GYN they are working with.

On my first CNM job I got into what shouldn't have been, a huge debate because the OB wanted to know why I was ordering a CBC in the AM after lady partsl births. He didn't think it was necessary for anything but a c-section.

So I said, "What is going to be my defense if I don't order it and this mother has internal bleeding, DIC, etc....or the nurse hasn't been properly monitoring her bleeding? You can have a slow postpartum hemorrhage."

He said, "That's rare, it's an unnecessary lab".

I said, "I agree it's rare..but what is going to be my defense? Without a lab, how am I going to know?" Because we do it for any patient in the hospital for any other condition, associated with blood loss.

I held my ground...he went on and on how "ridiculous" I was being but he could not come up with ONE answer I would give should my patient be compromised. This same OB freaked out when he found out I let my patients have clears during labor (anesthesia was OK with clears but not food).

Patients that come to me...don't get the "I want to be induced by 39 weeks". I just don't do those...unless you are 41 weeks, no induction without an indication. I don't do AROM at all unless I have a strong indication to use a FSE or IUPC. Nobody pushes at 10 cms without pressure, I'm a huge fan of laboring down, I let the placenta come on it's own, etc....but you would be surprised...how these little things that help so much, are a battle to do in a hospital environment.

I still remember the look at the nurse's face when she ran to me on my first patient with her, "I'll get the table! She's complete" and I said, "Is she having an urge to push"...Response: "Uh..no...but she's complete"...Me: "We'll wait". <crickets>