Building Support for Pregnant Women in Rural and Urban Communities
May 7, 2019
“Just the other day, we got a call,” said Rebecca Bork, a labor and delivery nurse in Greenville, a small South Carolina city of about 68,000.1 A pregnant woman who was in labor was on her way, coming in from the outskirts. Her husband was driving; she was experiencing contractions.
Bork and her team grabbed the “precip bag” and raced to meet the family in the parking lot. The bag — so named for the term precipitous delivery, or childbirth after an especially fast labor — has everything needed for a quick delivery: scissors, core clamps, towels, and a bulb suction.
By the time Bork’s team reached the car, the baby had already been born.
According to Bork, this kind of birth happens at least twice a month — particularly for women who live in rural communities, farther from an obstetrics provider. “Some of these women in the outskirts just can’t get to us in time,” she said. “They deliver at home, in ambulances, in the lobby, or, like this woman, in the parking lot.”
While this mother and child did well, many do not. In the United States, more women die of pregnancy-related complications than in any other developed country, according to an analysis from TheLancet.2
As mediators between pregnant women and care providers, public health professionals are ideally positioned to help individual women access the care they need, wherever they live.
In addition to lack of access to delivery specialists, a factor that adversely affects non-white pregnant women and new infants is race. Black women, for instance, are more than twice as likely as white women to give birth prematurely, according to the Centers for Disease Control and Prevention.3 Field experts attribute this discrepancy to the chronic stress minorities experience accessing healthcare.4
Across categories of race, geography, and socioeconomic status, the national maternal mortality rate is rising.5 As mediators between pregnant women and care providers, public health professionals are ideally positioned to begin addressing these systemic issues and helping individual women access the care they need, wherever they live.
Seeking Prenatal Care in Rural Areas
The classic nightmare scenario for a first-time expectant mother is being unable to reach the hospital in time and giving birth in the back of a car. Many women will not experience this. But for women living in rural areas, this scenario is not an impossibility, particularly as more and more rural hospitals stop providing labor and delivery services.
An analysis conducted by the Chartis Center for Rural Health showed that 152 hospitals in rural communities either stopped providing obstetrics services or closed altogether between 2011 and 2018. For the vast majority of these communities (70%), there is no other hospital in the county that provides maternity care. All in all, only 46% of rural hospitals in America provide labor and delivery services.6
The women who would have given birth in these hospitals now must travel farther for care. In 89 of these communities, pregnant women have to travel an extra half-hour to the closest facility offering obstetrics care. Those in 59 of these communities have an extra hour. For women in the remaining 11 communities, the added drive time is more than an hour.7
These are precious minutes lost for women with full schedules and little time to devote to prenatal care. Diane Calmus, regulatory counsel at the National Rural Health Association, said she believes the extra travel time can be dangerous for pregnant women, particularly once they’ve gone into labor.
“When obstetrics units close, we see an increase of precipitous deliveries in emergency rooms, in ambulances, in cars on the side of the road,” Calmus said. “Emergency personnel in these situations may not be prepared to provide the advanced obstetrics care that some women will need.”
Not all women in rural areas will end up in such a predicament. But many will have to hurdle obstacles that women in better-resourced communities do not, including longer transport times, potential hazards on the road, and the greater risk posed by poor weather conditions.
MATERNITY HEALTHCARE DESERTS
million women in rural America have to cross county lines for obstetrics care
of rural hospitals provide obstetrics care
of all rural hospitals with obstetrics care lost those services between 2011 and 2018
Rural counties that lost hospital-based obstetrics services saw:1
point increase in births outside the hospital, compared to counties with continuous care2
point increase in births in a hospital without obstetrics care2
point increase in preterm births2
1Only includes rural counties that are not adjacent to urban areas.
2Indicates a statistically significant increase.
The Chartis Group. Tracking the decline of OB access, Chartis Center for Rural Health, ivantageindex.com/declining-access-to-ob-in-rural-communities. Accessed April 9, 2019.
Association between loss of hospital-based obstetrics services and birth outcomes in rural counties in the United States, JAMA, doi:10.1001/jama.2018.1830
To regain control of their birth experience, some expectant mothers are taking extra creative measures. Because, as Calmus noted, “Babies come when babies come.”
Instead of waiting for labor to begin naturally, some women opt for a scheduled cesarean section. Others will get a hotel room near the hospital where they will give birth and stay for the week before the due date.
But not all women have the luxuries of reliable transportation, time off work, and the ability to afford child care and a hotel room.
“For those women, they’re just really hoping for a good outcome,” said Calmus, “because there’s not a lot that they can do to ensure one.”
Finding Prenatal Care in Cities
Although urban areas often have more resources for maternity care, women in cities face a different kind of challenge: decision fatigue, which experts say happens when the number of decisions a person must make in a day impairs their ability to make them well.
A pregnant woman, particularly in a well-resourced city, faces an overwhelming number of choices related to pregnancy and childbirth. Where should she deliver her baby? Should she choose an obstetrician or a nurse-midwife? Does she want a doula?
The mental work of making these decisions can be draining. Once a woman has depleted her store of mental energy, experts say she is at greater risk of making poor healthcare decisions out of exhaustion.8 She may feel unable to make any choices at all and miss out on the opportunities available to her.
Particularly visible in highly concentrated urban areas are the health disparities that exist between pregnant women of different communities, races and ethnicities, and socioeconomic statuses. In 2018, The Atlantic documented the lack of maternity care in southeast Washington, D.C., where the population is 93% black, 32% of people live below the poverty line, and the maternal mortality rate is twice the national average.9 Even though the maternity care infrastructure in the district exists, not all women can access that care easily and affordably. For those who cannot, often the health outcomes are worse.
Community health centers can help bridge the gaps, connecting women with providers, translators, and even legal advisors.
Accessing maternity care can be especially difficult for expectant mothers who are uninsured; who are living in the country illegally and may not understand their rights to care and safe work environments; or who have lower incomes, fewer resources, and a smaller support network — no matter where they live.
Community health centers can help bridge these gaps, connecting women with providers, translators, and even legal advisors. Mary’s Center, a community health center in Washington, D.C., offers women the option of group prenatal care called CenteringPregnancy. Each session lasts 90 minutes to two hours and gives the women 10 times more time with their provider and allows women in the group to build relationships with each other.10 In the most recently provided estimates, only 7% of CenteringPregnancy participants at Mary’s Center gave birth prematurely. By contrast, the preterm birth rate in the district in 2014 was 9.6 percent.11
But not every community has a well-resourced health center. Even in those that do, not every woman can access the care she needs. How can community health improve the healthcare system for expectant mothers?
How Can Communities Better Serve Pregnant Women?
The reason women struggle to access maternity care varies from community to community. Some don’t have enough providers. Many struggle to recruit and retain providers who will invest in their communities. Hospital closures, poorly designed transportation systems, and inflexible working arrangements all affect women seeking care.
Public health professionals can strive toward improving maternal health in their communities by identifying the particular pain points in accessing care and addressing them accordingly.
Emergency room providers need specialized training. With training, providers can be better prepared to manage emergencies, which is especially critical in rural areas where a specialist may be far away. Refer to organizations like American Academy of Family Physicians (AAFP), which offer courses for pre-hospital care providers, first responders and emergency personnel, and students in training.
Family physicians and certified nurse-midwives can help meet shortages of maternity care. For routine pregnancies and births, these providers offer the full scope of obstetrics care. Many family physicians specializing in childbirth have been further trained to perform cesarean sections.
Telemedicine can bring specialized care to rural communities. Rural providers and their patients can connect with specialists through telehealth services such as videoconferencing and store-and-forward imaging, where a provider can send X-rays and MRIs to a specialist for further evaluation.
Health departments offer home visiting programs to improve access to care. Home visitors meet pregnant women in their own homes to answer questions, provide screenings, make referrals, and help prepare women for childbirth and motherhood.
Cindy Phillips, acting director of Home Visiting and Early Childhood Systems of Health Resources & Services Administration
Diane Calmus, regulatory counsel at National Rural Health Care Association
Improving maternal health outcomes is imperative. But equally as important is helping a woman feel safe and supported in pregnancy and childbirth. With time, effort, and careful planning, public health professionals can start to mend the brokenness in the maternal health system and make all communities a safer place for giving birth.