Just a few months ago, Celia Geel of Calais would have had to drive less than a mile to give birth in a hospital. But Calais Regional Hospital shuttered its maternity wing in late August, and Geel recently told the Maine Sunday Telegram that she’s trying not to think about the chance that her second child, who’s due in the next few weeks, will enter the world somewhere along the 95-mile route between her family’s home and Eastern Maine Medical Center in Bangor.
Declining access to maternity services in rural areas is a nationwide crisis that’s making both mothers and babies more likely to get sick or even die, and reversing this alarming trend demands dramatic shifts in thinking about how we deliver and fund maternity care.
PROBLEM IN MAINE, NATIONWIDE
Calais is just the latest hospital in Maine to cease offering maternity services: Penobscot Valley Hospital in Lincoln stopped delivering babies in 2015, and Millinocket Regional Hospital and Charles A. Dean Hospital in Greenville shut their labor and delivery services in the 1990s.
The same scenario is playing out across the country, according to a recently released study in the journal Health Affairs. Scholars from the University of Minnesota Rural Health Research Center found that about 9 percent of rural counties in the U.S. lost maternity services in the past decade, and about 54 percent of rural counties now have no hospitals with obstetric services at all. As a result, fewer than half of rural women are now within a 30-minute drive of the nearest hospital that offers maternity care.
Cost pressures are a crucial factor in the loss of obstetric services. Most deliveries are low-tech, putting obstetrics at a disadvantage in a reimbursement system that favors technology-intensive procedures, explains study co-author Katy Kozhimannil. Meanwhile, the low rates and the low volume of births at many rural hospitals add up to low obstetric revenues — certainly not enough to maintain labor-and-delivery units and employ skilled professionals, she points out.
As the nation’s small hospitals struggle to stay afloat (81 have shut their doors since 2010), they look to cut corners wherever they can: Calais, which has lost an average of $1.8 million a year in the last seven years, anticipates annual savings of $500,000 from closing obstetrics.
INNOVATIONS AND CHALLENGES
But what keeps the hospitals alive isn’t so good for the patients. A 2011 study of 50,000 births in rural British Columbia concluded that infant mortality rates are as much as three times higher among women who have to travel a long distance to give birth. Longer travel is also associated with higher preterm birth rates and longer stays in neonatal intensive care units, both of which can have negative implications for a child’s future physical and behavioral well-being.
And it’s not just babies who are affected: Their moms are, too. The rate at which women died of pregnancy-related complications was 64 percent higher in rural areas than in large U.S. cities in 2015, according to a Wall Street Journal analysis of U.S. Centers for Disease Control and Prevention data. Risk factors for complications — including diabetes and high blood pressure — are on the rise at the same time that fewer clinicians are choosing to practice in small towns, so women aren’t getting the level of prenatal and delivery care they need.
Improving this dire situation demands that policymakers and health care professionals take both a short-term and a long-term approach.
In the immediate future, emergency medical services and law enforcement in places that have lost maternity care need to plan for the rise in emergency births to mothers who can’t reach the hospital in time, Kozhimannil, the University of Minnesota researcher, told Vox earlier the month.
To effect more lasting change, it’s worth looking at Alaska, where shortages of medical care providers are nothing new.
The nation’s most sparsely populated state has slashed its once-high infant mortality rate by focusing on logistical barriers to prenatal and labor and delivery services. Midwives are sent by plane or ferry to conduct monthly checkups in remote villages. Two to four weeks before their due date, pregnant rural residents are required to travel to the nearest community with a hospital that has an obstetric unit. (Medicaid covers housing costs; prematernal homes are a popular option for women coming into town from the Alaskan bush.)
Another pioneering initiative was recently launched by the University of Wisconsin School of Medicine and Public Health, which has developed the nation’s first obstetrics-gynecology residency program for “very rural” areas: that is, those with a population of less than 20,000. The program’s first resident was selected in March; she began her training in July, and she’ll graduate in 2021.
FUNDING, EMPATHY LACKING
For these health care efforts and others like them to succeed, though, they need reliable funding – which they won’t be getting from Washington any time soon.
Medicaid covers over half of all births in rural areas; if funding is strengthened and reimbursements are raised, fewer providers will leave remote areas and more patients will be able to afford services, thus providing rural hospitals with a stable source of payment.
Instead, the program faces an ongoing threat from congressional Republicans: In their relentless attempts to get rid of the Affordable Care Act, they’ve called for not only gutting Medicaid spending but also rolling back Medicaid expansion. The most recent repeal bill, Graham-Cassidy, also would have allowed insurers to drop maternity and newborn care coverage, requiring women to buy supplemental insurance or pay out of pocket.
There’s one bright spot. The Improving Access to Maternity Care Act would identify areas that have shortages of maternity care professionals and provide student loan forgiveness for obstetrician-gynecologists and certified nurse-midwives who work there — a benefit currently offered to dentists and family doctors in some underserved areas. (The proposal has passed the House but hasn’t made it to the Senate floor.)
In an ideal world, this bill would be a priority. In an ideal world, we’d all be working to make access to maternal care even better. In an ideal world, more of our policymakers would have empathy with all the rural women and families affected by their decisions. In this world, unfortunately, we have to work hard just to maintain the bleak status quo. And nothing less than the future health of our country is at stake.
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