Sunday, March 5, 2017

Maternal mortality and rural access to services

This blog has recently touched on many topics concerning rural children; including newborns and opiate addictions, children and guns, education issues, child abuse, children with disabilities, and rural brain drain. But even before rural children begin facing these issues, pregnant women in rural areas must overcome multiple obstacles to give birth to these children.

Access to maternal health care in rural America is on the decline. Only 6.4% of ob-gyns practiced in rural communities in 2008, and by 2010 49% of the counties in the US did not have a single ob-gyn. These counties were predominately rural and less populated. As a result, "fewer than half of rural women live within a 30-minute drive of the nearest hospital offering obstetric services," and around 88% of women live an hour drive of such services.  

With the lack of access to maternal health care, both maternal and infant mortality are significantly higher in rural areas. In 2015, maternal mortality was 29.4 per 100,000 live births in rural areas, compared to just 18.2 in more metropolitan areas. 

Credit: Amanda MontaƱez; Source: CDC
Researchers posit that there a number of reasons for this disparity: geographic access, poor prenatal care, and/or underlying health conditions like diabetes or hypertension. However, one theory may be found by looking closely at what has happened in Texas.

While the worldwide rate of pregnancy related deaths is declining, Save the Children's 2015 report "State of the World's Mothers" showed that the United States performs worse than any other developed nation in maternal death. For example, a woman in the US is 10 times more likely to die from a pregnancy related cause during her reproductive years than a woman living in Austria, Poland, or Belarus.

One of the most shocking statistics I've seen recently is that the rate of pregnancy related deaths in Texas has more than doubled over the last few years. Between 2006 and 2010, there was relatively little change in the number of maternal deaths in Texas, with the lowest number being 69 in 2009 and the highest being 82 in 2008. However, the numbers rapidly increased to 148 in 2012, 140 in 2013, and 135 in 2014.

For those who have been following the blog for a while, you are probably very familiar with Lisa Pruitt's coverage of HB2 and it's effect on closing women's health clinics throughout Texas (see here, hereherehere, here, herehere, and here). As Pruitt points out, these closures are especially harmful in rural areas, where women were forced to travel over 200 miles to reach the nearest clinic. It's not difficult to link these clinic closures to the rise in maternal deaths. Yet, the Texas Department of State Health Services believes drawing a correlation between HB2 and the rise of maternal morality "isn't fair" and that there is "no evidence" and the clinic closures "wouldn't have taken effect till September 2011 and it would have taken months to be reflected" in data.

Despite this data, in 2017 the Texas Legislature has only "sparingly mentioned" the issue of maternal deaths in the most recent legislative session and it was not listed as a top priority. (Meanwhile, two of the "top priority" issues that the legislature does have time for are: SB 8- "Fetal Tissue/Partial Birth Abortion" and SB 20- Prohibiting Abortion Insurance Coverage.")

While none of the data on the rate of maternal deaths in Texas has specifically investigated the rurality of the descendants, if we draw a connection between the closure of clinics and the increase in deaths, then it would seem logical to infer that this may be disproportionately affecting rural women.

With this information, we can then zoom back out to the general issues of rural maternal healthcare throughout the US. There have been a number of proposed solutions to his problem: allow telemedicine for prenatal care (though many rural areas struggle with access to internet), change laws so certified nurse midwives can take on more clinical responsibilities, launch OBGYN residency programs in rural areas, and adopt the Improving Access to Maternity Care Act. The Act would provide student loan forgiveness for ob-gyn work in rural areas. (Interestingly, the Act was sponsored by a Texas representative who has strongly promoted the defunding of Planned Parenthood clinics.)

However, the problem still remains that ob-gyn care is difficult for rural hospitals and we are in a time where rural hospitals are floundering. 80% of rural hospitals have closed since 2010, and the ones that remain open are underfunded and vulnerable to closure. In rural areas the typical hospital patient tends to be older, poorer, and less healthy than people who live in more metropolitan areas.
When rural hospitals need to cut their budget, ob-gyn units can be enticing. Ob-gyn units are one of the pricier programs for a hospital and can account for more than 5% of the total hospital costs. Because of the older population in rural areas, there are fewer births at rural hospitals and it "makes it difficult for hospitals to financially justify having maternity wards at all."

7 comments:

Anne Badasci said...

These statistics completely floored and devastated me. My grandmother was a nurse-midwife for several years before eventually becoming a full OB-GYN, and from hearing her talk oftentimes her duties as a midwife felt more closely tied to the wellbeing of the mother and infant, and she developed a closer and more well-informed relationship with the patients and their particular medical needs. I had never thought about the limitations a midwife might face in giving certain types of care in certain geographic regions, and this post really opened my eyes to that. I will absolutely be keeping up with this issue as news and political choices develop, and hope to see Texas (and other ruralities) progress in providing increased quality obstetric care, rather than regress.

Kyle Kate Dudley said...

Courtney,

This is an incredibly important post. I can't believe that the US lags so far behind on pregnancy-related deaths --something that I mistakenly thought was mostly a medical-problem of the past. I also find the tension between the maternal mortality rate and push against rural clinics in Texas and elsewhere very disheartening, because it reads to me as if the politics and polarization in our nation are trumping (eek, forgive that) our care for women's lives. It seems to me that some legislators are more comfortable with certain (dare I say "undesirable") women dying, than with relinquishing their agendas. I know this is harsh, but the topic gets me heated! Another (more academic) thought, which you likely have already considered, is how ACA repeal might have a devastating impact on these issues. More reading here: https://theintercept.com/2017/03/06/repealing-the-affordable-care-act-would-jeopardize-womens-health/

Thanks for writing this!

dnlauber said...
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dnlauber said...

Thank you for such an informative post! I, like Kyle Kate, mistakenly assumed that such high rates of pregnancy-related deaths were a thing of the past. It blows my mind that only about 6 percent of the nation’s ob–gyns work in rural areas when approximately 15 percent of the country’s population, or 46 million people, live in rural America (https://www.scientificamerican.com/article/maternal-health-care-is-disappearing-in-rural-america/).

Your blog post touches on an interesting question: how do we bring better ob-gyn care to rural women? An increasing proportion of women are entering obstetrics and family practice; but, substantially fewer females compared with males in both specialties choose to practice in rural areas (http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Disparities-in-Rural-Women). How can we encourage more women in the health-care field to choose to practice in rural areas? As your post mentioned, rural hospitals are floundering and a significant number have closed. I really like your idea of launching ob-gyn residency programs in rural areas. However, it seems as though the lack of funding and available hospitals, coupled with the low birth rates in rural areas, makes this solution somewhat unfeasible. I do not have any better solutions myself. Perhaps, as you mentioned, federal legislation, such as the Improving Access to Maternity Care Act, is the only practical solution.

K. Harrington said...
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K. Harrington said...

Great post! After reading your comments about Texas, I was curious to see how California compares to the national statistics on maternal mortality. Interestingly, until 2008, California was tracking the national average for maternal mortality rates. But since 2008, California's maternal mortality rate has steadily decreased (7.3 deaths per 100,000 live births in 2013) and now it is far below the national average. I would be interested to know if there are particular reasons for this and what steps California took to address this issue.

I think providing OB/GYN residency programs in rural areas are a good idea, but I also think that increasing the use of certified nurse midwives should seriously be considered. CNMs have the necessary training to deliver babies and provide prenatal care for most women and hiring CNMs would be a more cost efficient option for rural hospitals and clinics. Although some states require that CNMs have physician supervision, the level of supervision is often low and physicians aren't required to be present to oversee the care.

EAG said...

Maternal mortality in rural areas is not often brought up in the current healthcare debate, so thank you for bringing this up! However, I think Medicaid, or lack thereof, is another important factor contributing to rural maternal mortality. As you mentioned rural hospital closures are negatively affecting access to maternal health care. Rural women are more likely to be poor, lack health insurance, or rely substantially on Medicare and Medicaid. (http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Disparities-in-Rural-Women). These rural hospitas serve greater numbers of low-income people who were not previously covered by health insurance, so they often operated at a loss unlike their urban counterparts. Poor funding makes it difficult for these hospitals to attract or pay for more skilled doctors, including OBGYNs, or to simply stay open. Medicaid expansion in some states has helped this problem by covering more people, but many states with large rural populations have not expanded Medicaid. Furthermore, Medicaid reimburses at a much lower rate than private insurers making it more difficult for rural doctors to make ends meet. (http://khn.org/news/lack-of-medicaid-expansion-hurts-rural-hospitals-more-than-urban-facilities/) For instance in Georgia, a state that did not expand Medicaid, they have an OBGYN shortage that is attributed to low Medicaid reimbursement rates, large numbers of uninsured patients, hospital closures, and the high cost of malpractice inusrance. (https://gacommissiononwomen.org/2015/11/09/obgyn-shortage-in-rural-georgia-hampers-access-to-care/)