November 2019, Volume XXXIII, No 8

Special Focus: Rural Health

Maternity care

Complexities and critical next steps

ore than half of rural U.S. counties currently lack a qualified childbirth provider. Researchers at the University of Minnesota Rural Health Research Center have published a large body of work on the topic of rural obstetrical care across the country, including a 2017 publication which revealed that between 2004 and 2014, a staggering 9% of rural counties experienced the loss of all hospital obstetric services. This loss was not evenly distributed and differed by county sociodemographic characteristics, with poorer and more remote locations experiencing disproportionate losses.

Sustainable rural obstetrical care is a complex issue that involves local, state, and national resources, as well as health care provider workforce pipelines. Factors that contribute to the loss of rural obstetrical care include financial burdens on small-volume hospitals, patient preference for higher level care options, time burdens for primary care physicians providing obstetrical care coverage, comfort and skill maintenance of nursing staff, and conflicting priorities of policy makers when guiding allocation of available resources.

Prompted by this 9% loss of rural obstetrical care, the question of rural obstetrical care sustainability arises. And how is our own state faring?

Where is Minnesota now?

Concern for declining rural obstetrical services in Minnesota is nothing new. In 1995, Barbara Yawn, MD, and colleagues explored whether Minnesota has a problem with diminishing availability of rural obstetrical services in an article published in the Journal of Rural Health. Their conclusion was that Minnesota did not appear to have a statewide problem, but that a few isolated regions were identified as having limited availability of obstetrical care providers. Nearly 25 years later, as more hospitals have stopped offering labor and delivery care, this same question remains relevant.

More than half of rural U.S. counties currently lack a qualified childbirth provider.

Rural Critical Access Hospitals (CAHs) play an indispensable role in caring for rural and frontier communities. Since 1997, the federal CAH designation may be granted to hospitals who apply and meet specific criteria. CAH designation provides an alternative payment structure that helps to sustain the hospital operation and viability. Roughly 4,500 babies are born in Minnesota’s CAHs each year. However, there is no requirement that CAHs must offer services for planned labor and delivery to pregnant patients.

To create a 2019 snapshot of maternity care at Minnesota’s CAHs, hospital websites were used to ascertain if labor and delivery services were provided. Not all rural Minnesota hospitals are CAHs, but of the state’s 78 CAHs, just over half (53%) support labor and delivery services, while 47% do not. Mapping the distribution of these CAHs across our state, several pockets of potential obstetrical care “deserts” can be found in Minnesota, including areas within the state’s northeast, northwest, and far southeast regions.

The family physician’s role

Nationally, family physicians continue to provide the majority of maternity care services in U.S. rural hospitals. However, recent research has shown a nationwide decline of 50% in all family physicians who provide high-volume obstetrical care from 2003–2016. This comes in addition to the American College of Obstetrics & Gynecologists’ projection that numbers of resident ob-gyn physician graduates are not at pace with population increases.

According to a 2018 article published in the Journal of the American Board of Family Medicine, a significant cohort of family physicians desire a practice that includes obstetrical care, but acknowledge barriers that are unrelated to competency or training experience. These barriers include difficulty finding family medicine jobs that include obstetrics, credentialing, and, to a lesser degree, malpractice insurance costs. In addition, there are also added professional demands on a rural family physician who chooses to include obstetrics in his or her practice. These include maintaining a work-life balance, the necessity for ongoing procedural training to retain and enhance skills, and the requirements to satisfy increasing external regulatory demands.

As generalists, family doctors provide an ideal fit for rural communities whose population may not support the full-time work of a specialty physician with a narrower scope and expertise. In a 2018 survey of Minnesota CAHs, 40 of the 71 responding hospitals reported that they provided labor and delivery services at some point between 2013 and 2017. Of these 40 respondents, 90% reported that family physicians deliver babies at their facility, while 47.5% reported the services of obstetrician/gynecologists. Eighty-seven percent of CAHs reported providing cesarean deliveries. The majority (68.6%) of family physicians performed cesarean deliveries, though the specialties of ob-gyn and general surgery did so as well (48.6% and 31.4%, respectively).

The economic value of a rural family physician providing obstetrical care is significant. An Alabama study published in 2014 by Avery et al. in the Journal of the American Board of Family Medicine estimated that a family physician practicing in rural Alabama resulted in $1 million per year in economic benefit to the rural community. But by adding obstetrical care to the physician’s scope of practice, an additional $488,560 in economic benefit to the community is added, resulting in a total annual economic benefit of $1,488,560.

Other key elements of rural obstetrical care

Patient preferences and perceptions: comparability with urban/suburban offerings. In an era of increasing competition for patient-friendly birthing centers, expectant mothers are increasingly aware of local and regional options available during the delivery experience. Pregnant patients weigh the benefits of delivering at a nearby rural community hospital against the real or perceived advantages of a larger, more urban hospital. For example, pregnant patients may express a desire to deliver their baby at a facility that offers epidural anesthesia to ease the discomfort of labor pain. The 2018 survey revealed that 90% of the CAHs delivering babies have the capacity to provide epidural analgesia to laboring women. CAHs dedicate resources to publicize epidurals and other maternity service offerings to pregnant families in an effort to encourage patients to remain in the community for health care.

Several pockets of potential obstetrical care “deserts” can be found in Minnesota.

Recognizing the interprofessional rural obstetrical health care team. Interestingly, of the CAHs surveyed in 2018, 90% reported that Certified Registered Nurse Anesthetists, or CRNAs, provided analgesic services (e.g., epidural injections for pain) to laboring women. In contrast, only 5% reported the presence of a physician anesthesiologist. CRNAs are key providers of anesthesia services in small rural hospitals and may represent an under-emphasized element of successful rural obstetrical programs.

In addition, certified nurse-midwives (CNMs) contribute to the maternity workforce at many rural U.S. hospitals. Registered Nurses (RNs) are critical for successful rural labor and delivery programs. Nurses at small rural hospitals often staff multiple units, requiring broad clinical proficiency. Given the comparatively lower birth volumes at rural hospitals, it is essential to provide continuing education and support to hospital nursing staff who care for laboring patients and newborn babies. Challenges in rural recruitment and retention for CRNAs, RNs, and CNMs are widely known. In addition, an organizational commitment to providing holistic maternity care may result in beneficial contributions to patient care from other perinatal health professionals, such as lactation consultants.

Sense of community identity and vitality. An essential aspect to consider is the societal impact of losing rural obstetrical services. A study by Pearson et al. in the Arrowhead region of Minnesota revealed that patient anxiety about getting to the hospital rose 10-fold from 1990–2016 with the loss of local labor and delivery services. In addition, qualitative analysis from this study of women respondents who had received prenatal care in these communities revealed a significant overall negative emotional reaction to this loss. There was also significant concern voiced for the viability of their small northern Minnesota communities in attracting and maintaining young families in the area, as well as preserving a rootedness to a “place” where one could no longer be born. Loss or absence of obstetrical services in a community may exert a negative and significant influence on a rural community’s sense of identity and its optimism for the future.

Challenges and opportunities

Both sides of the political aisle recognize that there is a critical need to sustain and strengthen rural maternity care nationwide to reduce health disparities, maintain access to care, and help support the future health and viability of rural communities. During the 2017–18 Congress, the Rural Maternal and Obstetric Modernization of Services Act, or the Rural MOMS Act, was introduced by Sen. Heidi Heitkamp (D-ND). This Act proposed the creation of regional networks, enhancement in training a rural clinical workforce, and increasing efforts to share maternal health data from rural areas. Sen. Heitkamp was not re-elected, however. Senator Tina Smith (DFL-MN) has supported this legislation moving forward.

To sustain and strengthen rural maternity care, health professionals, community planners, and policy makers must recognize key elements and take a multi-prong, evidence-based approach to addressing them. These essential elements include community engagement, health professional support, financial investment, favorable policies and regulations, and, lastly, research funding to investigate what works best for healthy families, health care workers, and communities. Valuable next steps include:

  • Expanding pipeline training programs to produce family physicians willing and able to do obstetrical care.
  • Recognizing and modifying standards and guidelines (often created for an urban context) for a rural context, so that insurance guidelines and costs do not become prohibitory to rural obstetrical care.
  • Maintaining and enhancing rural obstetrical training and support for RNs and CRNAs.
  • Leveraging resources within larger health systems to support small hospitals (e.g., telehealth and continuing education).
  • Exploring expansion of collaborative practices with midwives, nurse practitioners, and/or physician assistants.
  • Engaging rural communities regarding birth care options, risks/benefits involved, and advocacy for resources supporting the best care for their community members.
  • Encouraging legislation and insurance coverage changes that could aid rural families by reimbursing indirect costs of delivering far from their local community (hotel, meals, lost wages, and day care for other children).
  • Continuing support for the federal Rural MOMS Act

With appropriate programming, funding, legislation, and necessary local support in mind, Minnesotans can work towards ensuring that the needs of rural parturient women are met now and into the future.

Emily Onello, MD, is an assistant professor in the Department of Family Medicine and Biobehavioral Health on the Duluth Campus of the University of Minnesota Medical School. Her career interests include supporting our rural physician workforce. She is part of a team that coordinates medical student placements with practicing rural family doctors, allowing students to experience the richness of rural family medicine first-hand.

Sandra Stover, MD, is an assistant professor in the Department of Family Medicine and Biobehavioral Health on the Duluth Campus of the University of Minnesota Medical School. She joined the Medical School in 2018, after 28 years as a family practitioner in Grand Marais. She provided community-based care to pregnant women, including deliveries at the local hospital. She continues to be a strong advocate of full-range prenatal and obstetrical care in rural communities.

Jennifer Pearson, MD, is an assistant professor in the Department of Family Medicine and Biobehavioral Health on the Duluth Campus of the University of Minnesota Medical School. She is the Course Director for the Healer’s Art and Obstetrical Longitudinal Courses as well as the Clinical Course Director for the Hormone and Reproductive Medicine Course. Her career interests include supporting the Duluth campus’ mission of developing family medicine physicians for rural and Native American communities. 

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Jennifer Pearson, MD, is an assistant professor in the Department of Family Medicine and Biobehavioral Health on the Duluth Campus of the University of Minnesota Medical School. She is the Course Director for the Healer’s Art and Obstetrical Longitudinal Courses as well as the Clinical Course Director for the Hormone and Reproductive Medicine Course. Her career interests include supporting the Duluth campus’ mission of developing family medicine physicians for rural and Native American communities.