Maternal health in rural America

[00:00:16]

ELENA RENKEN: Hello, everyone, and welcome to SciLine’s media briefing on maternal health in rural America. I’m Elena Renken, SciLine’s journalism projects editor, and today we’ll cover what’s causing the health outcomes and risks we’re seeing in rural areas for people who are pregnant and for those who have given birth recently, as well as gaps in access to care and potential solutions.

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Now, a couple of notes before we begin, I’m joined here by three experts who have studied maternal health topics. I’ll let each of them introduce themselves and their topics of research. Dr. Julia Interrante, would you go ahead?

[00:01:42]

JULIA INTERRANTE: Sure, thank you so much. My name is Julia Interrante. I’m a research fellow at the University of Minnesota, and my research really looks at measuring access to maternity care in rural communities and understanding how financial policies impact both access to and the quality of maternity care in rural areas.

[00:02:03]

ELENA RENKEN: Thank you. And Dr. Karen Tabb Dina, would you introduce yourself next?

[00:02:07]

KAREN TABB DINA: Hello. Good afternoon, everyone. My name is Dr. Karen Tabb Dina. I’m a tenured full professor at the University of Illinois Urbana-Champagne. We are the ones surrounded by corn and soy, not in Chicago. I teach in the area of social work, and I conduct research on perinatal mental health disparities and related outcomes in the first thousand days for infants. Thank you.

[00:02:32]

ELENA RENKEN: Thanks. And Dr. Jacquelyn Alvarado?

[00:02:34]

JACQUELYN ALVARADO: Good afternoon. I am the director of rural maternal health at Texas A&M’s Rural and Community Health Institute. There I lead three initiatives to improve maternal health. One is OB emergency simulation training in rural areas that are maternity care deserts. We also have a OB telehealth program for women in these maternity care deserts. And then, we do OB emergency service line evaluations for rural labor and delivery units, and I’m a certified nurse midwife that’s worked rurally and I’ve caught thousands of babies at this point. Happy to be here.

[00:03:12]

ELENA RENKEN: Thank you all. Before we begin taking audience questions, I’m going to ask each of our panelists here a few questions myself. In the meantime, journalists, you can submit your questions at any time during the briefing. Just click that Q&A icon at the bottom of your Zoom screen, and please let us know if you’d like your question directed to a specific panelist. We’ll be posting a recording of this briefing on our website later today, and a transcript will be added in the next couple of days. With that, let’s get started. Dr. Interrante, My first question for you is, how does living in a rural area change someone’s risk during pregnancy and childbirth, compared to in urban areas?

[00:03:51]

JULIA INTERRANTE: So there are a number of barriers to healthcare access in rural community that affects people around the time of birth especially hard. So in rural communities, there are fewer clinicians and hospitals. There are also structural challenges like distance to care, transportation, and having fewer doctors and nurses working in rural areas. And all of these really do contribute to the poor maternal and infant health outcomes that we see for rural residents.

[00:04:22]

ELENA RENKEN: Thank you. And what are the biggest drivers of those poor maternal outcomes in rural communities right now?

[00:04:28]

JULIA INTERRANTE: Yeah, so I mentioned, access to care is, I think, one of the largest challenges that is really facing rural communities right now. And a lot of that is due to the way maternity care is financed. So it’s based on volume, meaning hospitals get paid for the number of patients that give birth in their hospital. So rural hospitals, maintaining obstetric services. There’s very high fixed costs, including keeping doctors and nurses on staff, having the correct training and equipment, and it can be really difficult to cover those fixed costs when you have a smaller volume of births happening at a hospital.

[00:05:14]

ELENA RENKEN: And what’s known about the impact of this lack of services on maternal and infant health, both short-term and long-term? What are those metrics you were speaking about?

[00:05:24]

JULIA INTERRANTE: For maternal and infant health outcomes, yeah, so we know in areas that have lost obstetric services, we see higher risks of pre-term births, out of hospital births, so that can be births on the side of the road as someone’s trying to get to their hospital to give birth and more emergency room births in hospitals that don’t have maternity care services, which we know is a challenge because those emergency department physicians tell us that they don’t have enough training or resources to really handle those situations. We also know that there is greater travel distances to care, and that’s associated with having fewer prenatal visits, also increased interventions, so things like having a planned induction or a c-section, and there’s increased risk of maternal and infant complications as well. We also see that communities that have lost their labor and delivery in their local hospital also have fewer services and supports around the time of birth, including things like childbirth education, breastfeeding support groups, doula care, and other important services like that that really impact the health and quality of life for new moms and babies.

[00:06:39]

ELENA RENKEN: Why are maternity units often the first to close in rural hospitals? What role do Medicaid reimbursement rates play?

[00:06:47]

JULIA INTERRANTE: Yeah, so a lot of rural hospitals are facing really difficult financial situations. This has been true for a long time and is still true now. And obstetric services are often the first ones cut in an attempt to save money for the hospital because they are considered relatively unprofitable because of those things I mentioned earlier. And again, this is especially true among rural hospitals with relatively few bursts. Again, Medicaid pays for obstetric services at a much lower rate than private insurers do, and many rural hospitals have large shares of Medicaid patients, so that can be especially challenging.

[00:07:30]

ELENA RENKEN: And how does Medicaid coverage influence maternal outcomes in rural communities?

[00:07:36]

JULIA INTERRANTE: Yeah, so we know that Medicaid coverage is associated with increased use of essential care. This includes care prior to becoming pregnant, which can impact maternal and infant health outcomes as well. And also, Medicaid coverage is associated with increased prenatal and postpartum care use. We also know that Medicaid expansion, so increasing access to more people at slightly higher income levels is associated with reduced hospitalizations, so re-hospitalizations after giving birth, which is a really important time period because that’s actually when the majority of maternal deaths occur. And again, I mentioned Medicaid does underpay for maternity services. It’s still a vital aspect of financing for rural hospitals. And we do know that Medicaid can help reduce the risk of hospital closures as well.

[00:08:36]

ELENA RENKEN: Thank you so much. And let’s move on to you, Dr. Dina. To start off, what is postpartum care and what does postpartum care look like in rural settings compared to urban areas in the U.S.?

[00:08:49]

KAREN TABB DINA: I love it. This is one of the best questions, what is postpartum care? In my field of perinatal social work, we like to refer to this period as the fourth trimester. During the pregnancy, we focus on three trimesters, the first, the second and the third that track the mother’s development over time and also baby’s growth and development through these three distinct period but we drop off after the birth of the infant. We might encourage people to go to their pediatrician for well child visits, and maybe, if we’re lucky, we might have our postpartum visit. It’s often encouraged at two weeks and six weeks per national standards, but we know there’s a large proportion of people that never come back for care. This is critical because in that fourth trimester, the short-term, after delivering a baby, the parent is at the greatest risk for experiencing adverse mental and physical outcomes.

In my sub-specialty within maternal health, I look mostly at maternal mental health. One third of people are going to have a history of a mental health challenge prior to delivering the baby. One third are going to experience something during the pregnancy, and for some, what is of most concern to me is these are people that are experiencing a mental health challenge for the first time. In the postpartum period, especially in rural areas where we have high isolation, we also have the fourth trimester isolation where people might be facing a perinatal mental health challenge by themselves for the first time while caring for a tiny human and they don’t have the resources. I could go on and on because a lot of my work is focused around maternal death and the extreme risk that we have in the postpartum period to care not just for baby, but for mom as well. Thank you.

[00:10:43]

ELENA RENKEN: Thank you. And how many people on average tend to need postpartum care? And how do those numbers differ between urban and rural settings?

[00:10:51]

KAREN TABB DINA: Sure. Well, as you know, births are declining in the US, and this has caught a lot of media attention about the decline in births, but I need to remind you that we still have nearly 4 million births each year. We are hovering somewhere around 3.6 million births. Of those births, people who give birth in rural areas are going to vary by the state. There are many resources like state report cards or the Kaiser Family Foundation that report estimates of birth by rurality.

In some states, like the state of Michigan, one in four people who give birth live in a rural area. In my own state of Illinois, it’s somewhere around 13. And as you move across the country to other places that might be more vast in location or more densely populated, those numbers are going to change. So there is state variation, but just like mental health, being one in five individuals are at risk for a postpartum mental challenge, one in five individuals, upwards, are going to be living in a rural area when they’re delivering.

[00:11:58]

ELENA RENKEN: Thank you. That’s such a good point, how much more there is to the story than just the birth rate. And what are the biggest gaps in maternal mental health services in rural communities?

[00:12:10]

KAREN TABB DINA: Well, I love it, Dr. Interrante mentioned the provider shortages and hospital shortages and the commute times to try and obtain care in rural areas and to obtain high quality obstetric care, full obstetric, care in rural areas remains a concern. In my specific sub area of peroneal, mental health, we have even a greater need of provider shortages, so fewer providers, fewer prescribers as well on this topic, but there are solutions in reach. In recent years, even as recent as last year, we had more perinatal, psychiatric access programs forming at the state level. So 28 states now provide perinatal psychiatric access programs. To assist frontline providers to care for a more encumbncing approach of perinatal health and to support providers on the topic of mental health disorders and even substance use disorders in some places.

[00:13:22]

ELENA RENKEN: How much has telehealth impacted rural health services?

[00:13:26]

KAREN TABB DINA: That’s great. I tuck that away for the final question about what is misunderstood. We learned a lot about telehealth during our most recent pandemic, COVID-19. I’m not sure if those who are joining on this call experienced the pregnancy during that time. I have studied this for 20 years, but also experienced it first time, having many pregnancies myself. I was pregnant during COVID wearing a mask, laboring with a mask. These were strange times. And during that time of COVID, we also had tremendous gains in telehealth, did we not?

We had many questions prior to COVID about how we billed for telehealth services. Who would pay for it? What is the dose response needed? Are our clinical licensure standards appropriate to provide clinical care for people using telehealth. So during COVID, we saw the advancement of telehealth for both physical and mental health problems. There are a number of studies. The Patient-Centered Outcomes Research Institute, PCORI actually supported a rapid review of telehealth strategies in rural areas and which strategies work best. We heard that you could have a physical health visit with your provider, through platforms such as Epic, an electronic health record platform. You could have your visit and you could go through the development of the pregnancy.

We could do things like have blood pressure readings at home if somebody had a blood pressure cuff, et cetera. So we had tremendous advancements. With that being said, also in 2020, we hosted the National Rural Perinatal Health Symposium where we gathered individuals across areas, so payers, providers, people with lived experience, and we pulled them together into a virtual room to identify what were the challenges receiving high quality postpartum health in rural settings.

One of the major challenges that we heard at that time was a gap in internet. So what we heard from the people with lived expertise is, telehealth is great and we’re told we’re supposed to have telehealth, but every time I jump on a call, it drops. We don’t have the literal bandwidth or internet speed to be able to have a full visit. So that came across as a limitation that several individuals with lived expertise brought to our group when we were trying to learn models for rural health. And I think I’ll stop there, Elena. I’ve lost track with the question.

[00:16:18]

ELENA RENKEN: Well, I think you addressed it, and that PCORI sounds like a font of great story ideas about solutions that are working in local areas.

[00:16:25]

KAREN TABB DINA: Yes.

[00:16:26]

ELENA RENKEN: One last question for you. What other factors influence postpartum safety and recovery?

[00:16:34]

KAREN TABB DINA: Yes, this is huge. So I mentioned, individuals go home with a little tiny baby during the postpartum period. One thing about rural settings is, like I said, the distance between and the size of communities and greater concerns oftentimes about things with stigma. If communities are smaller and more close knit, there might be greater concerns around stigma when not being able to meet your needs postpartum. This could be physical, mental, financial, like having full economic independence. In the postpartum period, it is a fragile period, I mentioned, for mom and baby, fragile period for dad, something that we’re learning more about, postpartum depression with dads.

So you might have individuals that are in serious need of help, but there might be some isolation and some gaps in care. I mentioned the perinatal psychiatry access programs are a resource for providers, but what do we do to get information into individual’s hands when they go home with a baby? We now have hotlines such as 833-TLC-MAMA, which is the national warm line to provide people, regardless of where they are in the country or their physical distance, access to supports. This could be social support, like attending a dad’s group. It could be peer level counseling support.

And there are programs such as home visiting that are wonderful and can be supported through some level of telehealth, where home visitors can visit with the family regardless of distance and work to meet their needs. One other major factor, and I’m shocked that I did not insert this at all based on my geographic location in the middle of Illinois, is something that we as Americans need to understand right now with postpartum care in this country is the fact that demographics in rural areas across the United States are changing.

I mentioned I’m surrounded by corn and soy. What I didn’t mention is that where I live in the middle of the state of Illinois is a non-metropolitan immigrant destination. In the clinics where we conduct our research, we have large studies that are conducted in both Spanish and English. We take specimens, we meet with families, and we conduct those studies in English and Spanish. We have a large need for French and for Vietnamese. And when I travel to other states, my buddies in Iowa and Indiana, I learn some of those demographic shifts are similar, where we have families who are speaking Kanhobal, the Mayan language, or Spanish or French in the home is their primary language.

Imagine having limited access to health care based on geographic barriers, and then you also do not engage with the language of the clinic. This presents an additional set of challenges in our rural health care settings that are experiencing a demographic shift in the U.S. So we have large groups of non-English speaking recent migrants, something our country has always done, but in rural settings this is new in terms of our contemporary. I will stop there and save my last point for last.

[00:20:28]

ELENA RENKEN: Thank you so much for mentioning those barriers that aren’t always visible to full communities. And over to you, Dr. Alvarado. First, what kinds of maternal care services are lacking in rural communities, and how prevalent of a problem is this across the U.S?

[00:20:45]

JACQUELYN ALVARADO: I’m going to try not to duplicate any answers because it seems to be a consistent theme hence why we’re here, but I’m a little bit in a different situation. Just background, I’ve done the research. We know this is a problem, so I have the opportunity to be more boots on the ground in these communities with these women that are experiencing these challenges. So what I’ve noticed just being in these communities doing the full community assessments is, one of the biggest misconceptions isn’t just the lack of specialists. It’s really just the basic maternity services. So these women are traveling two, three, four hours just to go to a routine prenatal care service.

It’s not even about getting the high risk MFM that we know it’s not even an option for them. So we’ve also noticed that they’re just not getting the basic wraparound services that they have offered through their insurance, things like SNAP, WIC, access to fresh fruits and vegetables. So they may have a WIC opportunity, but they don’t have a grocery store available, so they’re stuck eating very processed foods that’s not ideal for their pregnancy to make it the healthiest as possible. And just like Dr. Dina said, behavioral health services, these women are not getting access to that. Postpartum lactation, that’s another big thing. These women want to breastfeed but they don’t have access to that support. Especially as a first time mom, it’s difficult, and they need those extra hands-on services.

[00:22:16]

ELENA RENKEN: Thank you. And what evidence-based solutions have measurably improved rural maternal health in certain states or counties?

[00:22:27]

JACQUELYN ALVARADO: Sure. The encouraging thing is that we actually know some strategies that are working to improve the maternal health and safety. One is maternal safety bundles, especially through AIM. Being in Texas, that’s a very large quality collaborative that we’ve done. These programs help just standardize how hospitals prepare for emergencies like postpartum hemorrhage or hypertension in pregnancy, and it’s been shown to see a significant reduction in maternal mortality and morbidity. However, we don’t have a branch of that focusing on rural. So that’s one of my initiatives that I’m working on is really customizing it to those communities as well. So one thing that we’ve initiated at our institution is emergency simulation training. We know simulation training is effective. However, going to these communities that have small number of deliveries, like less than 100, making sure they’re getting exposed to those skills in case those women do drop in.

And then, we also know telehealth is promising. That’s a great care model which allows those women to receive some point of care throughout their pregnancy, but also getting creative with it. If they don’t have great Internet access at home, let’s bring them to the local rural health clinic where we can do the telehealth in a setting that could be more consistent. And then, the last thing I just want to highlight is just federal investment in rural healthcare infrastructure. So the new program with the Rural Health Transformation Program, this is a great initiative that hopefully is going to provide funding across the United States to really redesign the rural healthcare system and the support for maternal health services, support services and referral pathways between rural and urban facilities, if needed.

[00:24:18]

ELENA RENKEN: And how are community led approaches such as midwives or doulas influencing outcomes for women in rural communities?

[00:24:29]

JACQUELYN ALVARADO: I love this question, being a midwife, obviously. So I feel like one of the most powerful solutions actually comes from the community itself. We’ve heard from the women what they need. So midwives and doulas, that’s their whole structure is really providing something that often gets missed in modern healthcare, that continuity and relationship-based care. Instead of just seeing a different provider or staff member at every visit, being with a midwife in a doula consistency builds that trust with women who will walk alongside them, not just through pregnancy and birth, but across the lifespan, which is a really big benefit in these rural communities. Midwives can do primary care after delivery, so that’s great. And again, as a midwife who’s attended more than 1,000 births, I’ve seen firsthand how powerful that relationship can be.

When a woman feels heard, supported, she’s more likely to ask those questions and talk about maybe her behavioral health concerns. And if something doesn’t feel right, she’s gonna let that midwife know. And research does show that midwifery-led care is associated with lower intervention rates, including c-section births, while still maintaining safe, excellent quality care. And the doula side is great emotional support. We think about doulas and more of the labor aspect, but more postpartum doulas, it’s becoming a thing because they know those first 12 months are very difficult, and even though it’s not a clinical concern, having that extra emotional support has been very beneficial, especially in these isolated, rural communities, I think that that would be an excellent use of resources.

[00:26:09]

ELENA RENKEN: What policy changes would make the biggest difference to maternal mortality right now?

[00:26:17]

JACQUELYN ALVARADO: Definitely, making sure all states have the exact same extension of Medicaid coverage for the first 12 months postpartum. We’re lucky, here in Texas, we have that, but we do know many complications actually occur after the woman leaves the hospital and so we need that additional coverage. Beyond that, we need policies that are really going to strengthen rural maternal health workforce, including things like supporting and training more residency programs for advanced practice providers.

We have a lot focused on physicians, but we also have a large number of advanced practice across the United States that, if we could get the opportunity for them to train in a rural area, they’re likely to stay in a rural area. And then, the next big thing across the United States is scope of practice and policy. In many states, advanced practice providers, such as nurse practitioners, midwives, they’re not full independent practice. So even though they want to go practice in a rural community, where there are no OB services and they want to provide that, they don’t have that ability without a supervising physician. So expanding that full practice authority would allow these clinicians to practice their stay in these communities and train future clinicians that could provide these OB services. So that’s a big thing.

And reimbursement, we all know that that’s a huge issue. Like Dr. Interrante said, in Texas, we did a study with one of our rural hospitals and our urban hospitals, and they get paid 40% of what an urban hospital would get paid for the same exact vaginal delivery. It’s hard to keep those OB units open if we’re not being reimbursed equitably.

[00:27:58]

ELENA RENKEN: And in that same vein of policy, what do you think policymakers, health systems, or the public should understand about the urgency of rural maternal health?

[00:28:10]

JACQUELYN ALVARADO: Well, when a rural hospital loses its maternity services, it’s rarely just about childbirth. It’s really about the financial stability. And so the ability to recruit healthcare providers and whether young families feel comfortable living in that community, it’s just offering that service. And so I think the important thing to remember is majority of maternal deaths in the US are considered preventable. And so it’s our responsibility when we talk about rural maternal health, it’s financial, but geography shouldn’t determine whether you deserve that care or not. And so I feel like in a country with so many resources and expertise, where a woman lives, it really shouldn’t determine whether she survives her pregnancy or not.

[00:29:06]

ELENA RENKEN: Such a good point to remember, how much is preventable. Thank you all so much. We’ll now begin asking questions to all our experts. And I want to remind reporters on the line, please submit your questions using the Q&A box found at the bottom of your Zoom screen. I want to ask all three of you, what is most misunderstood in the public discourse about maternal health and rural communities? Dr. Interrante, would you like to start?

[00:29:33]

JULIA INTERRANTE: Sure, I’m happy to start. So I think I’ll start with the fact that we are more than a decade into the severe maternal health crisis in the US, and policymakers are well aware of the challenges and the lack of access in rural communities, and yet we still see fewer and fewer hospitals offering obstetric care every year. There are financial challenges that rural hospitals face with having a low volume of births, and that really hasn’t been addressed with policy and financial changes. And on top of that, not every community is the same. There are some states and communities that are impacted to a greater extent, so really understanding what local access to care looks like for a community is really important for developing a sustainable solution for that specific community.

[00:30:26]

ELENA RENKEN: Thank you. And Dr. Dina?

[00:30:30]

KAREN TABB DINA: I will go back to the telehealth point. So I think our answers are all coming together so nicely. Telehealth is a wonderful solution, but not the solution to address the known disparities in postpartum health in the United States. I think investing more in our infrastructure and programs, such as home visiting, to make sure that people have access, support, to other programs, such as WICS, it helps with overall enrollment. Home visiting is a model that is proven. It can be from a lay health visitor. It can be volunteer-led. It comes from a number of different places, nurse family partnerships or McVee. But it’s more than that warm touch. It wraps in social support, health, education, health literacy, and then in some states that are rural serving, we’re starting to look at how mental health programs, such as Mothers and Babies: a six-week cognitive behavioral therapy intervention, can be folded into a home visiting program. So I would say too much credit is given to telehealth, which is great, and we need to be able to explore other evidence-based models, such as home visiting.

[00:31:46]

ELENA RENKEN: Thank you, and Dr. Alvarado?

[00:31:48]

JACQUELYN ALVARADO: I think the biggest thing that’s often misunderstood is that maternal health begins only when a woman is pregnant. In reality, maternal health starts way before the pregnancy. So it includes that overall women’s health and access to primary care and mental health services, nutrition, and management of those chronic conditions like hypertension before they get pregnant. So we do not do a great job at preconception health across the United States, let alone in these rural communities. So it’s like we’re almost playing catch-up once they’re pregnant, and if they don’t have any OB services, they don’t know where to go and where to begin. So that’s why I think improving maternal health really requires a multidisciplinary team approach because it’s not just OB providers. It’s the nurses, the family practice, behavioral health, all those workers to make sure that we’re supporting these women before and during their pregnancy, of course, postpartum as well. I think the other misconception that’s not realized with these rural communities is that those teams collaborate in a way smaller, but very mighty and effective way. So if you could present more tools to them, they’re very resourceful in how they’ll utilize them to build this network to make sure the women in the community receive the continuous care that they need. They have a great system that they built. It’s very impressive when you’re in these communities.

[00:33:20]

ELENA RENKEN: Definitely. Thank you. Now I’m going to open things up to questions from the audience, and I have a first question here from the Trinity Journal in Northern California: “I’m interested in whether research has examined how environmental factors such as wildfire smoke, evacuations, or rural infrastructure challenges may affect pregnancy outcomes in remote communities.” Is any of you able to give some context there?

[00:33:47]

JACQUELYN ALVARADO: I’m not familiar with anything specific to environmental exposures. We have done studies on preconception in rural communities and followed them for their nutritional aspects throughout their pregnancy. Because, again, rural communities have a very different nutritional profile than someone in an urban area. And so we do know that that has impacted the pregnancy. If during their preconception stage, they’re not getting the nutrition, but I have not done any studies on actual environmental exposures.

[00:34:25]

KAREN TABB DINA: I’m going to start throwing links in the chat to data sources every time I talk. I’m your professor, okay? We have the ECHO cohort study. We have a cohort here in Illinois, and we are just now studying the effects of chemical exposures in rural areas compared to urban areas. One example is that of glyphosate, which is on one of our recent studies, exposures to pesticides and what that does in utero for baby, the chemicals that are contained in, say, the cord blood,  and then how those exposures result for mom. So here’s the link to the ECHO children study, funded through the National Institute of Environmental Health Sciences. And you can go ahead and explore this portal for more data and information on environmental exposures and certain risks in rural versus urban areas. I will stop.

[00:35:25]

ELENA RENKEN: Thank you. That’s good to know, especially given how glyphosate has been in the news related to the recent executive order.

[00:35:31]

KAREN TABB DINA: And that’s new. So glyphosate, this is new. We shouldn’t even mention newer things. We look at BPAs and parabens and PFAS and a lot of the larger chemical groups, and those mixtures and how they express adverse outcomes for children.

[00:35:50]

ELENA RENKEN: Next question here from the state’s newsroom, Dr. Alvarado touched on this, but could the panelists speak more about their thoughts on the rural health transformation grants? Will those be helpful for maternal care?

[00:36:10]

JULIA INTERRANTE: I can talk to this a little bit. I mean, it’s hard to know until things actually get put into play and the details are ironed out. I think any infusion of resources in rural communities is good, especially those that have a focus on maternity care. I think it’s complicated because there have been, again, financial challenges for rural hospitals, especially in keeping obstetric services open for a long time. So some of these require long-term investments, especially around, like, workforce sustainability. That’s an important thing. So long-term investment is also going to be really impactful and important.

[00:36:58]

ELENA RENKEN: We can move on here to a question from the TCPalm in Florida: Are there any ways for rural hospitals to maintain maternal services to raise money, for example? And what could those be? Is anyone able to give any context around that?

[00:37:11]

JACQUELYN ALVARADO: So I work with a lot of low-volume labor and delivery units where they deliver sometimes 35 babies a year. And so I highly encourage working with an organization that will do an OB service line evaluation, go in there and really break down staffing, billing, and coding, where are we losing money, and where can we have the opportunity to increase funding to support those services to keep the doors open. And finding a team that can help find grants or whatever it may be is finding a champion within an organization that’s willing to support that. But, absolutely, I love that you’re trying to figure out ways to keep those services open because that’s our goal. We can’t afford to close any more labor and delivery units in rural communities.

[00:38:05]

JULIA INTERRANTE: I’m putting a resource in the chat as well, where we’ve synthesized the research on maintaining services in rural communities with low birth volumes. We’ve also done a series of case studies where we talk to hospitals that, again, really bucked this trend and were able to maintain and sometimes even grow their obstetric practice in the rural communities. Sometimes it’s things like being creative with the services that are offered, like having vaginal birth after cesarean available. (mw) births are really getting at the types of birth experiences that people want. We have a hospital in rural Wisconsin that was able to do that and actually drew in urban patients to their hospital from that. Again, that requires access to resources and staff and a bunch of other things that are important too. But sometimes, again, it is also having a CEO at your hospital who is really passionate and creative with fundraising to keep that service line open. So there’s not always a one-size-fits-all, but there are things that hospitals are trying and doing, and some that have been successful.

[00:39:31]

ELENA RENKEN: We have a follow-up question here from the TCPalm: What’s the optimal travel time to a hospital to give birth, and what’s too long? Is anyone able to take that one?

[00:39:39]

JACQUELYN ALVARADO: I mean, that’s not a set answer. It’s not really timing, either. It’s, you know, within 20-30 miles, but think about the terrain. I do a lot of grant projects in southern West Virginia. A 10-mile drive could take an hour because of the Appalachian environment. So really, 20-30 minutes is obviously, five minutes is better. But when we talk about true maternity care deserts, these women are often traveling two plus hours, which is just not realistic to deliver their baby. And again, that doesn’t even factor in the potential for complications. That’s just, oh, I think I’m in labor. I’m gonna head to the hospital.

[00:40:25]

JULIA INTERRANTE: I don’t know of a specific safe distance. I will say, again, the research does show increased time as increased risks. And I will say, again, I think the point about rural terrain is so important. This is also something that’s a challenge for some urban communities, too. Again, I know our focus is rural here, but there are some urban communities that don’t have access to care, and it could take them like two hours on public transit to get there, and that’s also problematic.

[00:41:01]

ELENA RENKEN: A lot of aspects to that journey that’s important to cover. We have a couple more questions here related to those closures of labor and delivery units that I want to ask. One is from a freelance reporter based in Maine: Is there research about the ways in which rural delivery and labor unit closures are affecting emergency medical responders like EMTs and paramedics?

[00:41:27]

JULIA INTERRANTE: That’s a good question. I mentioned some of our research looking at emergency departments and emergency department clinicians, and in our survey of those hospitals that didn’t have maternity services but had emergency departments, 80 percent said that they didn’t have the training or resources to handle emergency obstetric situations. So obviously, EMS is part of that. There are a lot of rural communities that rely on volunteer services for that, or don’t have that at all. And I think that’s also another area that’s sometimes overlooked and also may need some additional training and resources around obstetrics.

[00:42:08]

JACQUELYN ALVARADO: I’m going to add to that. So, with rural L&D closures and the paramedics, it really just depends on county by county. Because some of the EMS and paramedics are employed by the county or the local hospital. So they kind of have different policies and procedures on how to handle women and labor. But what we are seeing is that they’re bringing them to the emergency department. They’re not trying to make it 2-3 hours to the local labor and delivery. They’re going to go to the ED first, stabilize them, and then what I’ve often seen is one of the rural nurses will get on the EMS transport and continue traveling with them as an option if they don’t think delivery is imminent. But I also have seen an increase where the EMTs don’t have those emergency medications on their trucks. And so if you do have a patient that’s hemorrhaging, they have no solution for those women. So again, I think that’s why going back to training, simulation training, going over these emergency skills with the EMS and the ED is so important because these women are presenting. It’s not a matter of if, it’s when.

[00:43:18]

ELENA RENKEN: And a question here from the Milwaukee Journal Sentinel: In Wisconsin, we’ve covered hospitals losing their labor and delivery units, but are now thinking about the aftermath. What are the most important stories to be told in a community after obstetric services leave to show the effects of those closures? Any ideas to add there?

[00:43:47]

JULIA INTERRANTE: I can go. Sorry, I don’t want to take over all the talking here, but yes, I think we’ve touched on this a bit. It’s not just labor and delivery often that’s lost. It’s all these other important wraparound services, in terms of access to care. Again, that ties into perinatal mental health and breastfeeding support groups and all these other aspects. When you lose the hospital workers that were doing labor and delivery, often those are the same people who were doing prenatal and postpartum care and all those other services. And when places lose their obstetric services, sometimes it’s just the unit that closes and the hospitals still open, but sometimes it’s the hospital that closes as well. And we know that that has economic impacts in that community that extend beyond just services that are happening there.

[00:44:48]

ELENA RENKEN: Moving on then. We have a question here from CNN for Dr. Dina: Are you seeing more migrant families skipping or delaying care due to fears of deportation? And, are you seeing more maternal morbidities or complications in immigrant communities because of this?

[00:45:08]

KAREN TABB DINA: I am searching for a study out of Iowa. This is now historic. We have heard many reports from our clinicians about who is willing to enroll in research studies. So it’s slightly different than obtaining care, but we’re recruiting consenting participants in clinics to enroll in our research studies, and we’re hearing about barriers and hesitation around being in the wrong place at the wrong time and being profiled with our current push against migration. I am going to find a reference for a study in Iowa that looked at ICE presence in farming communities in Iowa, in association with adverse birth outcomes, and found an association within communities that were fearing some sort of negative experience and impact on their birth outcomes where the babies either came smaller or came sooner than we would expect normally, based on their experience. I will put that citation in the chat. I’m only leaving that to the historical framework and saying we do not have the data to rely upon for 2026, but historically, we are aware of some patterns.

[00:46:40]

ELENA RENKEN: Unless anyone else wants to weigh in, I’ll ask another question here from a freelancer based in Kansas: I live in southwest Kansas in a community with a mostly Hispanic Catholic population and a high teen pregnancy rate. What is being done to link or encourage faith organizations to support maternal care solutions? Does anyone have any contexts they can contribute there?

[00:47:14]

KAREN TABB DINA: Can you repeat? I was so busy throwing the link in the chat.

[00:47:19]

ELENA RENKEN: Absolutely. This is a question from a reporter in southwest Kansas in a community that has a mostly Hispanic Catholic population and a high teen pregnancy rate. And they’re wondering about any efforts to link or encourage faith organizations to support maternal care solutions.

[00:47:40]

KAREN TABB DINA: I don’t have any other efforts that I know of for research other than our own. Right now, there’s a decline in services broadly. I’m speaking as a social worker, and we try and understand where the babies go. We’ve seen a decline in WIC enrollment. It’s a Women Infant and Children Supplemental Nutrition Assistance program, and it’s not for less babies; it’s just in some places, people are choosing not to enroll. So there’s much discussion about where the babies are. So if you partner with religious organizations, it’s usually a great place to encourage health promotion and health literacy. It’s a standard public health approach to support communities. So in terms of teen births, our teen birth numbers have plummeted. That’s what I can tell you from the population health perspective. We’re now seeing complications with older births, and older births are on the rise. So hopefully, that’s where we’re addressing our energies. Thanks for the question and hi, Kansas.

[00:48:45]

ELENA RENKEN: I have a question here from Charlottesville Tomorrow: I came across in my reporting on rural maternal health that women can be unwilling to look for help, even if they know that they’re struggling. In your experience, what kind of mental health concerns or conditions actually drive women to look for or accept professional help?

[00:49:07]

KAREN TABB DINA: No, there’s not one condition. I see more head nods. I want to hear from you. We’ve been working on non-pharmacological treatments. So I mentioned the stigma in smaller knit communities, maybe it’s the people. There are many conflicts, right? They don’t want to disclose to the one therapist in town about what’s going on, or that they are taking medication for a problem that they should be addressing on their own if they feel that way. But there are many non-pharmacological treatments that are available and work. There are apps. I’m not trying to lean too much into the telehealth side, but there are apps that anyone can use. There are apps that can be prescribed, like Daylight and Sleepio, for sleep conditions. We forget sleep, we forget rage, and we forget anxiety. In all of our research right now, with millions of people from their charts, with millions of people, we are learning that anxiety is now one of our greatest risk factors. And we know from this younger generation, this Gen Z generation, anxiety is something that they talk about. We know that anxiety emerged out of the COVID pandemic. No surprise. We’re more anxious about our interactions and our social experiences. So I don’t think there’s any one condition that’s in a race for which one is the worst and which gets treated first. But there are many other factors in play. What were you going to say?

[00:50:39]

JACQUELYN ALVARADO: I also think what I’ve seen just speaking to these women, if they are previously diagnosed with a mental health disorder, when they become pregnant, their primary care won’t see them anymore because they’re like, “Oh, you’re pregnant,” and they don’t know that it’s safe to continue their medication. So most of the time, these women will stop, not knowing, or “Hey, can you switch me to something until I can get in with an OB provider a couple of hours away?” So I’ve seen that, and then postpartum, we don’t educate enough on what postpartum depression is, so they don’t know what signs to look out for.

[00:51:24]

ELENA RENKEN: We have a question here from KFCF Public Radio in California: How will the defunding of Medicaid affect rural maternal health? There’s a lot of concern about this issue in Central California. Anyone able to jump in on that one?

[00:51:45]

JULIA INTERRANTE: I’ll repeat some of what I said before because again, we don’t have data yet on something that’s coming up, and we’ll have to see how that plays out, along with the rural health transformation funds. But as I mentioned before, we know that Medicaid is a really important source of funds for rural hospitals, and they need those funds to operate. Again, as I mentioned, Medicaid was already reimbursing below what is needed to maintain obstetric services for areas that have a low number of births. And so that was already a challenge and concern. Again, as I mentioned before, on average, Medicaid covers 40 percent of births across the US. In rural areas, that’s closer to 50 percent. And in some states, that’s above 50 percent, even as high as 70 percent of rural births covered by Medicaid. So you can imagine that’s a lot of people and a lot of births. We now have 2.6 million reproductive-age women living in rural communities without labor and delivery services available locally. So it’s a lot of people who need access and need coverage for that care.

[00:53:14]

ELENA RENKEN: A question here from a freelancer who’s based in Houston: How urgent is the need for policies to get implemented? And what could happen if we do nothing to address this maternal health crisis?

[00:53:34]

KAREN TABB DINA: Will you read the first part?

[00:53:39]

ELENA RENKEN: How urgent is the need for policies to get implemented? And what could happen if we do nothing to address this maternal health crisis?

[00:53:48]

KAREN TABB DINA: Can I take this?

[00:53:48]

ELENA RENKEN: Yes. Yes. Jump in.

[00:53:51]

KAREN TABB DINA: We all have a mother. Let me not cry. Our country is facing a maternal health crisis like no other country in the world. I had to step away from our maternal mortality review committee because in our state of Illinois, we are experiencing 120 women who die every year after giving birth. Almost all of them are preventable. That’s one woman in every county. These are people we work with. These are American children who are growing up without a mother. They’re preventable. I don’t know. I don’t understand how we, as a society, are letting this happen. And the solutions are straightforward. We have this huge gap. We’re so great at so many things, America. We’re so great. But then, on some topics, we are so dumb. About our bodies and how they function, and how to talk to one another, and how to ask, “Are you okay?” The majority of women in my state who show up in the emergency department asking for help are sent home because nothing’s wrong. That may be nothing’s visibly wrong. And they are found dead hours later from a drug overdose or from suicide. So in the great United States of America, we have people dying from preventable causes. So the time is now.

I don’t know, like how we can sit back and watch. I started documenting this 15 years ago with my colleagues, an international group. We’re called the Global Burden of Disease study. And when it came to my country, the United States, the mortality rate was 13. I was like, this isn’t right. This can’t be right. Thirteen? We were at seven. I don’t understand. That doesn’t sound like a big number, right? 13 out of 100,000. But it shouldn’t be going up. When we followed up in a Jama article, it was at 17 and then 26. I mentioned in my state, there’s more than one person for every county. In rural areas, the impact is greater on people who are losing their lives after giving birth. I have so many things to say about it. I could go down the military readiness rabbit hole. Like, we’re not taking care of ourselves at birth and after we give birth and not looking out for our babies, how are we going to be a strong country that has people who are fit and ready to be good citizens? I don’t know. There are so many paths to it.

So, yes, we do something today. We published an article earlier this week, last week, I don’t know. In health affairs about maternal mortality review committees. Every state doesn’t have one. Every state needs one. Well, we review all the deaths. We identify preventable factors. We identify things that can make our country greater with small interventions. Small intervention, small awareness. How about we work better with pediatricians and OBs? It’s a paradigm shift. It’s a culture shift, but it’s a family-centered shift. How about we train our emergency medical techs, our EMTs, the people on ambulances what to look out for? The perinatal continuum of care? So there are small intervention points that we can do today as a society, and they often require policy leaders. I’ve talked too much. I will stop. Yes, we need to do something. Yes. This is urgent. Yes, and there are solutions in reach.

[00:57:47]

ELENA RENKEN: Thank you so much for sharing that. That’s important to know from someone who tracks this day in and day out.

[00:57:56]

JULIA INTERRANTE: That’s hard to follow that one, but I agree. I will also say that from research and using evidence and data to understand the problem and improve it, maintaining data sources is so important for being able to even understand what’s happening. So we’re talking about trying to maintain. We need to improve data sources, not just be worried about maintaining data. So I think that’s really important. And then also when we do have quality improvement metrics that come out, making sure that those make sense in rural communities is so important and often overlooked. And then ensuring that any new quality standards that do come out, there are resources for rural communities to help reach those standards. Not just saying, “Okay, this is a smaller community that has fewer births, and so there could be increased risks. So then it’s just not safe to give birth there.” Because that’s not necessarily true. In the current policy environment, it may be, but there are policies that you can change to make birth safer and more accessible in rural communities that need it.

[00:59:07]

ELENA RENKEN: Thank you both. Now we have one last question, which we’ll give our experts here a chance to offer some brief takeaway messages. First, I want to flag for reporters on the line that you’re going to get a quick email survey when you sign off from this briefing, and if you have even 30 seconds, your feedback would really help us plan our services so that they’re more helpful to you. Now, for our last question, for all three of you in about 30 seconds, what is one take-home message for the reporters here? Dr. Interrante, do you want to start?

[00:59:39]

JULIA INTERRANTE: Sure. I kind of hit my take-home message already. But I would add again, just going back to, we really do need to address the challenges of low-volume facilities and ensuring that there is some kind of payment or support for keeping those services open even when there’s a low number of births.

[01:00:05]

ELENA RENKEN: Thank you. Dr. Dina?

[01:00:08]

KAREN TABB DINA: Just recognizing the importance of mental health. We now have data and dashboards that I shared to identify the severity of the problem, but awareness is key, and treatments are in reach, and we can fulfill our greatest potential.

[01:00:21]

ELENA RENKEN: Thanks. Dr. Alvarado?

[01:00:28]

JACQUELYN ALVARADO: I would just say I would recommend everyone spend time in a maternity care desert. Spend some time at the hospital, visit with these women, and see really what the challenges they’re facing. And that’s really the only way that we’re going to move forward, is that everyone’s on the same page about supporting all of these women and really seeing the dedication of the teams who are doing the work every day.

[01:00:50]

ELENA RENKEN: That’s a wonderful point about seeing on the ground how it’s occurring. Thank you all so much for lending your expertise here on an ongoing story that reveals such acute and long-term effects on people’s health. I hope to see you all at SciLine’s next briefing. Thanks so much.