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y the time the pregnant woman arrived at the nearest hospital with a maternity ward—90 minutes after leaving her home in Winfield, Ala.—she was ready to deliver her baby. She made it just in time, recalls Dan Avery, an obstetrician–gynecologist who tended to patients in rural Alabama and elsewhere until his recent retirement. Too often, he says, patients are not so lucky. Some have ended up delivering on the side of the road. Winfield, located in the northwestern part of the state, does have its own hospital—but, like many rural hospitals, it no longer offers obstetrical services, Avery says, so women in labor must travel about 60 miles to Tuscaloosa. When hospital budgets get tight, Avery explains, obstetrical wards are often one of the first things to go.

The problem has metastasized across the state and the nation. In 1980, 45 of Alabama’s 54 rural counties had hospitals providing obstetrical services. Today only 16 of them offer such care, and doctors say that means many, many women need to drive an hour or more to deliver their babies or even get basic prenatal care from an ob–gyn. Too many women cannot make such a long monthly trek, so they simply do without. Others seek care from their family physicians.

Such extreme access problems lead to difficult decisions. Some women in Alabama preemptively choose caesarean section births because they fear they will not make it to the hospital in time, says Dale Quinney, executive director of the Alabama Rural Health Association. Although there have been no studies proving it, Quinney believes the access issue helps explain why his state has one of the country’s highest caesarean rates—35.4 percent of its births in 2015. (The national average was 32 percent that year).

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The disappearing maternal care problem is common across rural America. Only about 6 percent of the nation’s ob–gyns work in rural areas, according to the latest survey numbers from the American Congress of Obstetricians and Gynecologists (ACOG). Yet 15 percent of the country’s population, or 46 million people, live in rural America. As a result, fewer than half of rural women live within a 30-minute drive of the nearest hospital offering obstetric services. Only about 88 percent of women in rural towns live within a 60-minute drive, and in the most isolated areas that number is 79 percent.

Maternal mortality is also significantly higher in rural areas. Scientific American analyzed public mortality data from the U.S. Centers for Disease Control and Prevention, and found that in 2015 the maternal mortality rate in large central metropolitan areas was 18.2 per 100,000 live births—but in the most rural areas it was 29.4. Exactly why this happens is unclear. Underlying health conditions such as hypertension or diabetes could be factors, alongside poor prenatal care and geographic access. But the numbers are troubling, and the same trend holds true for infant mortality rates, according to the analysis of CDC figures.

Credit: Amanda Montañez/Scientific American; Source: CDC

A new analysis from the University of Minnesota Rural Health Research Center puts the situation in dire terms: “More than two thirds of rural counties in Florida, Nevada and South Dakota have no in-county obstetrical services,” says one of the study’s authors, Carrie Henning-Smith, a research associate at the center. The analysis, which has not yet been published, finds that this was true from 2004 through 2014 (the latest year analyzed). That means these counties had absolutely no hospitals providing obstetrical care—forcing women to travel to other counties.

Unfortunately, family physicians are not moving in to fill these care gaps in high enough numbers. And the number of family physicians offering obstetrical services has dropped by half in recent years, although many still offer basic prenatal care: In the year 2000, 23 percent of family physicians offered obstetrics—but when they were surveyed in 2010 it was only about 10 percent.

Some women manage to cobble together a workaround. Maren Webb, who lives just outside Grand Marais, Minn. (population about 1,350) lives two hours from the nearest hospital that does planned deliveries (in Duluth, Minn.). In the five years that she lived and worked in the area before giving birth to her daughter in October, she had heard countless horror stories about women in labor in the back of ambulances on the way to Duluth or those who had to deliver in the emergency room at a local hospital. To avoid those fates she says she decided to “camp out” at her parent’s house—about half an hour from the hospital in Duluth—in the days ahead of her due date. Webb and her husband ended up staying with her parents for a week before she finally went into labor. “We were thankful that we had the option,” she says, but they wished they could have been at home, preparing for their newborn. Still, they were grateful she had not gone into labor early while they were still at home. Her family has a history of fast deliveries—two or three hours—she says, so she might not have made it to the hospital in time.

Searching for more answers

To understand how the U.S. got here is not a simple task. Rural health care in general has taken a hit in the past few decades as hospitals have closed and fewer doctors have sought to practice in rural areas. Eighty rural hospitals have been shuttered nationwide since 2010, and about a third of the country’s remaining rural facilities are vulnerable to closure as they continue to operate under tight margins, according to findings from the latest annual Rural Relevance Study. Half of Mississippi’s rural providers operate at a loss, for example, according to the report, which was presented last week at the annual National Rural Health Association (NRHA) conference in Washington, D.C. Rural communities, however, are in desperate need of care: They tend to be poorer, older and less healthy than their urban counterparts.

But obstetrics–gynecology care is particularly vulnerable because delivering a baby is such a pricey business, accounting for more than 5 percent of hospital costs. Why is it so expensive? Unlike a hip replacement, it is hard to anticipate exactly how long it will take to deliver a baby, so the number of nurses, doctors, surgeons and anesthesiologists that must be available throughout delivery adds up. Rural Americans are also less likely to be insured, and more likely to pay for their care using Medicaid—which reimburses doctors at lower rates than private insurance, making it difficult for doctors and hospitals to recover costs and make profits. Low birth volumes make the economics of obstetrical units harder still: Rural communities are generally graying, a demographic fact that reduces the number of births and makes it difficult for hospitals to financially justify having maternity wards at all. And when those wards cannot make adequate money, it leads to their shutdown.

The problem also has a multiplier effect. “It’s a quality of life issue. You don’t want to be the only ob–gyn in a 150-mile radius. You’d never sleep!” Michael Kennedy, associate dean for rural health education at the University of Kansas Medical Center said at the NRHA conference.

The blueprint for addressing the situation remains obtuse at best. Some medical schools think part of the solution is to train more doctors for rural work. The University of Wisconsin School of Medicine and Public Health is launching the nation’s first official obstetrics–gynecology residency program for “very rural” areas, with the first resident slated to be selected next month. “Increasing the physician workforce is important,” says Ellen Hartenbach, residency program director for the school’s Department of Obstetrics and Gynecology. “A large percentage of people practice in the same area after residency, so the theory behind our new training track is to get people training in the smaller communities and increase their exposure,” she says. (ACOG says about half of all residents practice in the state where they trained.)

There are already other ob–gyn residency programs in rural areas, Hartenbach says, and there are rural tracks in family medicine for doctors in other specialties. But official definitions of rural often just mean “not urban,” she says, and the Wisconsin residency program will make sure that communities considered “very rural”—those serving fewer than 20,000 people—will be the focus. “You would be hard-pressed to find that elsewhere,” she says.

Yet this is only one program, with only one resident expected for 2017. Rural health care advocates are also pushing for policy action to help fuel further changes and to incentivize work in rural America. The Improving Access to Maternity Care Act, which has already passed the House but has not yet been introduced in the Senate, would require further data collection by the Department of Health and Human Services about which geographical areas need these maternity care professionals and provide student loan forgiveness for OB-GYN work there—a benefit that is currently offered for dentists and primary care physicians in some underserved communities.

Telemedicine—offering online video call access to patients—for prenatal care could also be part of the solution, rural health experts say. But a lack of broadband internet access continues to keep that from becoming a reality in many rural areas in Alabama, says Hillary Beard, a legislative assistant for Rep. Terri Sewell (D–Ala.). “I don’t think this is unique to Alabama,” she says. “This is a problem for many rural areas.” And too often, she says, people in Sewell’s district report that they had to deliver on the side of the road because they could not make it to the hospital in time, she says.

Changing state laws to let certified nurse–midwives and nurse practitioners perform more clinical tasks might help, too, Henning-Smith says. But other cultural changes may be needed to really lure more clinicians to move to rural areas, she adds. One analysis she conducted found that rural areas—at least in the state she studied, Wisconsin—were less likely to offer child care services than their urban counterparts. That matters, of course, for working parents and their quality of life.

Yet, despite these widespread ob–gyn shortages, there is still little hard data on the long-term effects of these health access gaps. “We know a lot about the closures and about the workforce challenges, but we don’t really know how these things impact women and the health of their infants,” says Britta Anderson, a senior research scientist at NORC’s Walsh Center for Rural Health Analysis at the University of Chicago. “We need more data on if women who travel longer distances to get care suffer more negative outcomes—emotionally and physically.”

Webb, the new mother from Minnesota, says knowing about this potential harm—and reducing the burden of these distances—is essential. “No one has done this research about if these distances are increasing bad outcomes,” she says. The emotional burden, however, is apparent. “If the roads aren’t clear and there’s a blizzard, it could take a lot longer than two hours from my house—and that, too, adds to the stress,” she says. “You don’t want to have this extra stress when you are in labor! You want things to flow.”

This article was originally published by Scientific American.

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  • A major component of the problem is the embedded in Critical Access Hospital reimbursement methodology. Small rural hospitals cannot survive but for CAH cost based reimbursement, and the smaller CAHs struggle even with the cost based reimbursement program. Labor and Delivery patients are almost never Medicare patients, and tend to be poorly reimbursed. This is a double financial whammy. The Labor and Delivery unit dilutes the ability to receive cost based reimbursement across all the hospital’s support departments (it’s complicated, but trust me), and this dilution is compounded by being done for a typically expensive service which is poorly reimbursed. It becomes a matter of killing OB to save the ED and the rest of the hospital.

    Now add demographics…most rural areas have at best stable, and probably declining populations of child bearing age, and rapidly growing elderly populations. With these demographics, the only hope for survival is to drop OB and all the costs associated with it, and focus investment in services for the elderly and the older middle-aged.

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