Maternal health care in rural areas saves lives, and Dr. Randy Tobler knows that firsthand.
The obstetrician in Memphis, a town of 1,800 in northeast Missouri, remembers a woman who came in for delivery whose uterus had ruptured before she went into labor. She’d had a Cesarean section for a previous pregnancy and was “white as a ghost,” he said — she almost died on the operating table, and her baby didn’t survive.
She lived just 15 minutes from Scotland County Hospital, the only one in a four-county area. If she’d had to travel much farther, she would have died, Tobler said.
It’s emergencies like these that make access to maternal health care so important, he said. But in more than two-thirds of rural Missouri, a pregnant woman can’t go to a hospital with obstetric services to give birth in her county.
Of the state’s 101 rural counties, 43 have no hospitals, according to a Missouri Department of Health and Senior Services document updated in October 2017. Another 26 counties have hospitals, but not dedicated obstetric beds.
In many rural areas, pregnant women must drive long distances to give birth or receive prenatal care. The consequences can be deadly — Missouri women living in rural counties die from pregnancy-related complications more frequently than those in urban counties, according to an analysis of state health department data. Missouri ranks 42nd in the U.S. for maternal mortality, according to the Centers for Disease Control.
“There are several emergencies that can evolve over very short time periods,” Tobler said. “When that happens, if you’re not near a place where you can be stabilized until you can be transported, it can lead to maternal or baby death. If there’s an abruption — the separation of the placenta — and you’re 45 minutes away, it’s an obstetric emergency. You have to get to a hospital, because mom can lose so much blood she can die, and babies will die.”
Access to maternal care is crucial for women in rural areas, obstetricians across the state say. Some hospitals have started using telemedicine to communicate with specialists, and medical schools use pipeline programs to send doctors to rural areas. But they can’t send doctors where there are no hospitals.
Access to maternal care has worsened in recent years, with an increasing number of rural hospitals closing across the country.
From 2004 to 2014, 179 rural counties in the U.S — about 9 percent — lost all hospital-based obstetric services, according to a 2017 University of Minnesota study. Another 45 percent of rural counties never had them in that time period to begin with, leaving 54 percent of rural counties without hospital obstetric services.
Although 19 urban hospitals closed in Missouri from 2000 to 2013, no rural ones did, according to state health department data obtained by a public records request. But since 2014, Missouri has lost five rural hospitals — one rehabilitation hospital, one psychiatric hospital and three general acute care hospitals:
- The Sac-Osage Hospital in Osceola closed in September 2014 due to financial struggles and is now run as an outpatient clinic. St. Clair County now only has one hospital, 27 miles away in Appleton City, which does not have obstetric beds.
- The Parkland Health Center – Weber Road in Farmington closed in August 2015 after regulatory and building safety concerns. St. Francois County still has two general acute care hospitals, one of which is in Farmington and has obstetric beds.
- The SoutheastHEALTH Center of Reynolds County in Ellington closed in March 2016 after financial problems. The county no longer has a hospital.
Since the SoutheastHEALTH Center closed, the nearest specialists are 70 to 90 miles from Reynolds County, Pamela Aiello said. She’s the maternal child health coordinator for the Reynolds County Health Center, a public agency providing education and basic care for the county.
“We’re in a major state of hurt in Reynolds County,” she said. “What do people do? They either put a meal on a table or take that money and put gas in the car and drive 90 miles to get care. Or they don’t go at all and just try to treat what they can with what they have.”
The center offers prenatal case management services for pregnant women, who meet with a nurse each month during pregnancy for basic health checks, health education and referrals to doctors. Aiello estimated 80 percent of the women who delivered in the county used the case management program in 2016, and Aiello said the support system and information have helped women with risk factors.
“It has made an impact on pregnancy outcomes, but you can’t continue to operate and offer services when the funding isn’t there,” she said. “If we continue to be scarce of medical providers, the public will lean more and more on public health, but there’s just so much we can do.”
And more hospitals are still at risk of closing: A February 2016 study by iVantage Health Analytics found that 29 rural hospitals in Missouri, and 673 across the country, were at risk. The study showed the largest factor for closure is financial difficulties, aggravated by federal reimbursement cuts and changes to Medicare and Medicaid policies.
The Missouri House of Representatives voted down a proposal to expand Medicaid coverage under the Affordable Care Act in March 2017. Not expanding Medicaid is expected to cost Missouri hospitals $6.8 billion as federal reimbursement funding is phased out through 2022, according to a study by the nonpartisan Urban Institute.
Greater travel distances created by losing hospital obstetric services have potential negative effects on maternal and infant health, according to the Minnesota study. A University of British Columbia study also found that having to travel to access maternity services in rural areas was associated with adverse outcomes for mothers and infants.
John Bennett, an obstetrician in Hannibal, said he’s seen an increase of patients from hospitals that haven’t closed but have started to reduce their services. When patients no longer have access to preventative care close to home, they delay getting care for simple ailments.
“An infection becomes something that has to be admitted and surgically treated when it could have easily been treated in an outpatient setting, but that place had closed,” he said.
A lack of maternal health care affects women in all stages of pregnancy, Bennett said. Preconceptual counseling helps women address any medical issues they have before pregnancy; prenatal care tracks progress and finds any problems during pregnancy; and access to specialists and emergency care is crucial during delivery.
“If women have to take a full day off work to go see the doctor because they’re an hour or two away, that doesn’t bode well for their families or for them from a socioeconomic standpoint,” he said, “especially if they have children they have to care for and arrange for childcare and other things.”
Some women travel voluntarily to have access to more specialists and care. Erica Parmley lives in St. Robert and works as a nurse at a hospital in Lebanon, but she chose to travel an hour-and-a-half to Mercy Hospital Springfield for prenatal care and to give birth. She’d worked at the NICU in Columbia and seen everything that could go wrong, she said.
“I wanted my baby to be able to have what he needed should something arise, just to have more resources,” Parmley said. “We just decided to go to Springfield and hope for the best, and hope we could make it there in time.”
She traveled to prenatal appointments once per month until the third trimester, when she went every two weeks and then every week in the last month. She had to schedule doctors appointments on her one day off each week, and her husband, a teacher, couldn’t go with her.
Ultimately, though, Parmley said it was worth it to be at a larger hospital. She made it to the hospital in time after her water broke, even though she and her husband had been worried about knowing when to travel to the hospital during labor.
“It was a good experience and really comforting to know the care was there when we needed it,” she said.
In areas where no hospitals offer obstetric care, there also tend to be no licensed obstetricians.
Missouri has 535 licensed obstetricians and gynecologists, according to a directory of licensed specialist physicians from the Missouri Division of Professional Registration updated in November 2017.
Of those, 470 are registered in urban counties, leaving 65 spread across the state’s 101 rural counties. As a result, 76 rural counties are left with no licensed obstetricians or gynecologists. Rural family physicians also frequently deliver babies in rural areas, but they can only assess and stabilize complicated pregnancies before referring them to high-risk obstetricians, Tobler said.
Sarah Buchanan has practiced in Osage Beach since 2010, when she was one of the first obstetricians hired by the Central Ozarks Medical Center. Because her clinic is a Federally Qualified Health Center, she treats patients that don’t have insurance but can get any service for as little as $20 out of pocket.
But even though she said she has closer relationships with her patients, there are significant challenges, like transporting high-risk patients to specialists in Columbia. One woman pregnant with twins went into labor at 25 weeks and came to the hospital in Osage Beach. They needed to transfer her to Columbia, but the transfer was delayed, so she delivered in Osage Beach and the staff had to keep the babies alive until they could be transported.
Buchanan said she hasn’t been affected by the closure of hospitals, but many are losing services, especially when they’re taken over by larger entities. After Mercy took over the hospital in Carthage in 2012, it stopped delivering babies, she said; now, patients have to drive half an hour to Mercy Hospital Joplin to deliver.
And before they give birth, women aren’t going to drive two hours to get prenatal care if they don’t have the resources, Buchanan said. Eighteen percent of babies born in Missouri in 2013 had no or inadequate prenatal care, according to state health department data, with a higher rate of inadequate care in rural than urban areas.
“When you’re in labor, do you want to be driving two hours to your hospital while you’re in a lot of pain?” Hannibal obstetrician John Bennett asked. “Then you end up delivering in the middle of the countryside somewhere because you didn’t have time to get to the hospital. If something emergent did happen, if you had bleeding and had no access to emergent care, obviously that would pose risks to the mom and the baby.”
Living in a rural area without obstetric services or obstetricians comes with deadly risks. Maternal mortality rates rose in the U.S. from 2000 to 2015 as they declined in every other developed country, according to an analysis from ProPublica and NPR.
In 2015, a woman was more likely to die from pregnancy complications in the U.S. than in Libya, Turkey, Chile or Uruguay, according to a Global Burden of Disease study.
Missouri ranks 42nd in the U.S. for maternal mortality, according to the Centers for Disease Control. In 2016, 28.5 women died from pregnancy-related complications for every 100,000 live births — the same mortality rate as central Asia.
From 2000 to 2015, 245 women died in Missouri from pregnancy-related complications, according to state health department data; 106 of those were in rural counties. The frequency of maternal deaths has risen significantly — from 2000 to 2001, 18 women in Missouri died from pregnancy complications. From 2014 to 2015, it was 65. Part of the increase could be due to changes in the way those deaths are reported.
The death rates have consistently been higher in Missouri’s rural counties than in urban ones. From 2000 to 2015, 24.2 women in rural areas died for every 100,000 live births; in urban areas, it was 17.4.
Missouri created the Pregnancy Associated Mortality Review in 2011 to track maternal deaths across the state. The board analyzes the cause of death and contributing factors to give the health department recommendations for actions.
Facility closures and lack of primary care providers contribute to a lack of health care services in rural areas, which can be associated with higher rates of maternal mortality, health department spokeswoman Sara O’Connor said.
Other contributing causes include sociodemographic factors such as poverty, inadequate health insurance and lack of transportation or education. Chronic disease conditions and risk factors like obesity, hypertension, diabetes and smoking also increase the risk of maternal mortality, she said.
The Pregnancy Associated Mortality Review has made the following recommendations to reduce maternal mortality rates, O’Connor said:
- Early access to quality prenatal care
- Comprehensive prenatal care, including care coordination
- Extending MO HealthNet (Medicaid) coverage of postpartum care (to at least 12 months after delivery)
- Medicaid expansion/preconception health care coverage
- Substance use/mental health treatment services for pregnant/postpartum women
- Increased access to and attendance of postpartum follow up appointments.
The most common causes of maternal death across the state were embolisms, cardiovascular diseases, hemorrhage and hypertension, accounting for a combined two-thirds of pregnancy-related deaths, a 2015 report found.
Women who were older than 40, black or overweight were all more likely to die from pregnancy-related causes in Missouri. Women who gave birth via C-section or smoked during pregnancy also had higher mortality rates.
About the same percentage of women — 30 percent — gave birth via C-section in rural and urban areas, but the 10 counties with the highest C-section rates were all rural.
One-quarter of women who gave birth in rural Missouri from 2000 to 2014 smoked during pregnancy, compared to 14 percent in urban counties, according to state health department data. In some rural counties, the rate was as high as 37 percent.
It’s hard for medical schools to open more hospitals, but they can make sure the existing ones have a flow of incoming doctors.
That’s the goal of the MU School of Medicine’s rural track pipeline program. The school runs a pre-admission program for students from rural Missouri, and once students are in the medical school, they spend time working in rural practices in the summer before their second year and during their third-year clerkships and fourth-year electives.
Even if students come from a rural community, they’re not always aware of what it’s like to practice as a rural physician, said Kathleen Quinn, the school’s associate dean for rural health. Students working in rural areas get a comparable education to those in urban settings, but more one-on-one training and hands-on practice.
“If I want to be an OB, do I want to be in an academic health center and observe a couple births, or do I want to deliver 15 babies?” she asked. “It gives them a little better idea of what that specialty is going to be like.”
About 55 percent of students in the rural pipeline program practice in rural areas after graduation, she said, and 80 percent of the students pre-admitted from rural areas stay in Missouri.
“There are 37 (rural pipeline) programs like ours in the nation, and we’re all working toward the same thing,” Quinn said. “If a student has a rural background and they are trained in a rural area, they’re more likely to practice there.”
None of the hospitals the school works with have closed, but others have had to stop partnering with MU for the summer program because they can’t afford to pay students a stipend anymore.
“Our program can’t keep hospitals from closing, but we definitely advocate on a national level for rural health and rural health care as part of our program,” Quinn said.
Telemedicine can also provide additional resources to rural areas. The Hannibal Regional Hospital started a program five years ago, in collaboration with MU Health, where specialists in Columbia read ultrasounds for high-risk pregnancies. Maternal-fetal doctors can consult with patients via teleconference; that way, they don’t have to take a day off work and travel hours to visit specialists.
“Having a relationship with the bigger university and subspecialists is crucial to maintaining the rural access hospital,” Bennett said. “If you don’t have that relationship, then you’re going to be floundering.”
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