The U.S. has the highest maternal death rate among high-income countries, according to the Centers for Disease Control and Prevention. And with a surge of labor-and-delivery unit closures across the country, it is getting even harder for women to access high-quality maternity care—particularly in rural areas where these closures are most prevalent.
In Iowa, for instance, there are 3.3 ob-gyns per 10,000 women of reproductive age. This is compared to 4.5 ob-gyns for the same number of women in the U.S. The states with the highest number of ob-gyns per women of reproductive age are the District of Columbia, Connecticut and Minnesota.
“A collision of many trends—including fewer places to give birth, fewer ob-gyns, a rural state and increasing complexity of the birthing population—has created challenges for patients who are already overly burdened with accessing care,” said Stephanie Radke, MD, MPH, an ob-gyn at University of Iowa Health Care and a clinical associate professor of obstetrics and gynecology at the Iowa Carver College of Medicine.
University of Iowa Health Care is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
These trends have resulted in maternity care deserts, which are counties across Iowa that don’t have labor-and-delivery services or doctors who provide prenatal care. In fact, 57% of counties in the state do not have an obstetric facility. And yet, 22.3% of babies are born to women living in rural counties in Iowa. This means a significant population of women in Iowa do not have appropriate access to the care they need for a safe and healthy pregnancy.
To tackle the growing challenge of maternity-care deserts, University of Iowa Health Care’s department of obstetrics and gynecology is taking bold steps to train physicians and other health professionals and support the remaining birthing centers across the state.
Through partnerships and training initiatives, the department’s vision is to build a coordinated regional health care collective focused on one common goal: providing the highest quality maternity care to women in Iowa, when and where they need it.
What happens when facilities close
Over the past 20-plus years, there have been more than 40 birthing-unit closures across Iowa due to low birth volumes, staff shortages and operational and financial challenges facing health systems today.
And when these facilities close, there’s a ripple effect that permeates across the state.
Most notably, pregnant women are now facing unprecedented barriers to accessing quality pregnancy care. Currently, 14% of women in Iowa do not have a hospital where they can give birth within 30 minutes of their home, compared to 9.7% nationwide. In rural areas in particular, women often have to travel up to an hour or more to give birth.
As the only academic health system with an ob-gyn department in the state, University of Iowa Health Care treats many of these women. In fact, 61% of its deliveries and obstetric visits are for patients living outside of Johnson County, where University of Iowa Health Care is located.
By not having specialty services nearby, pregnant patients in Iowa are at risk for missed diagnoses and complications, resulting in poorer outcomes overall. For example, if a patient must drive over an hour to see a specialist, they may ignore a seemingly vague symptom such as a bad headache during pregnancy. However, ob-gyns know that a bad headache during pregnancy can indicate more serious issues, such as high blood pressure, which can put the lives of both the mother and baby at risk.
“When hospitals are farther away or harder to get to, people don't access them as easily. And if patients are not near convenient care, it can be catastrophic in acute care scenarios,” said Christian Pettker, MD, chair and department executive officer of the department of obstetrics and gynecology at University of Iowa Health Care.
Another challenge arises when pregnant patients do seek care for symptoms, but the facility closest to their home is no longer equipped or staffed to care for them appropriately.
“Typically, if you’re over 20 weeks pregnant and have an obstetrical problem, you’re going to be evaluated in the labor-and-delivery unit. But if the facility doesn’t have a labor-and-delivery unit, emergency medicine providers will have to care for obstetrical problems, which may be outside their scope and comfort zone,” said Dr. Radke. “This can pose concerns about the quality of care a patient receives.”
Of course, hospitals are still able to transfer patients who need a higher level of care. But even these transfers require resources that many smaller facilities don’t have. For instance, the facility may not have an ambulance service, or they may not have enough staff to help safely transfer a patient.
“These are very small hospitals and sending two nurses in an ambulance several hours away is a huge drain on the facility’s resources for that day,” said Dr. Pettker.
Meanwhile, the remaining 54 birthing centers in Iowa have absorbed more patients—despite frequently lacking the resources and staff needed to handle the spike in volume.
“When a facility is overwhelmed with volume and can't safely take care of patients because they don't have enough rooms or nurses for the volume that they're now seeing, that poses a new set of challenges,” said Dr. Radke.
As part of its advocacy to improve maternal health, the AMA has outlined concrete actions that should be taken to reduce and prevent rising rates of maternal mortality and serious or near-fatal maternal morbidity in the U.S.
Focus on training
University of Iowa Health Care has stepped up to address this ripple effect that is challenging, physicians and health systems. The academic health system is focused on training physicians and other health professionals, advising small health systems on capacity management and providing support to patients and doctors.
“We take our role as being the academic health system for Iowa very seriously,” said Dr. Pettker. “A lot of the work we are doing right now is to help Iowa take care of Iowans.”
Through a federal grant and a partnership with the Iowa Department of Health and Human Services, the health system has launched projects and programs that leverage their physicians’ expertise in clinical care and program development to support maternal health care.
This starts with playing a proactive role in addressing gaps with education programs and opportunities that allow physicians and other health professionals to expand their clinical skills to include obstetric care. The goal for these programs is to grow the pool for delivering high-quality maternity services.
These education and training programs include:
- Family medicine obstetric fellowship: After completing their three-year family medicine training, family medicine residents can match into a one-year obstetrics fellowship to learn how to do cesarean sections and care for more complex pregnancies.
- Ob-gyn residency program for rural physicians: The university’s ob-gyn residency program offers a rural track for two residents each year. The rural track includes modified training that gives residents hands-on experience working in smaller communities. The hope is that these ob-gyns will choose to practice in these smaller Iowa communities after finishing residency.
- Midwifery training: A two-year midwifery training program to train more certified nurse midwives.
Subscribe to learn how innovative health systems reduce physician burnout.
Collaboration to build community
Another effective approach for addressing maternity care deserts is by playing a leadership role in the Iowa Maternal Quality Care Collaborative, which was launched about five years ago. The goal of the collaborative is to identify opportunities and implement programs to help all birthing facilities in Iowa to ensure they are providing the highest quality of care to their patients.
“We want to help them be able to do their jobs better, more efficiently and more effectively, [which] will hopefully help improve the quality and safety of their care,” said Dr. Radke, who directs the collaborative.
The collaborative is focused on helping birth centers in rural areas in the state gain more experience in treating the leading causes of maternal morbidity and mortality. These include hemorrhage, hypertension and preeclampsia, as well as reducing the inappropriate use of cesarean section.
“When you work in a really high-volume center, you manage complications all the time because they happen more frequently with more births,” said Dr. Radke. “But facilities that are only delivering 200 babies a year often only see a handful of these emergencies like hemorrhages or preeclampsia.”
To give lower-volume centers more exposure to obstetric emergencies and complications, the collaborative launched a simulation program that guides smaller facilities through simulated emergencies.
For example, a simulation team recently worked with a rural facility on a simulated obstetric hemorrhage. The simulation team expertly guided the facility staff through clinical care and communication best practices to successfully treat a patient in such an emergency.
This training exercise ultimately led to a real-life success story. Shortly after the simulation training, a patient at the facility experienced a major obstetric hemorrhage.
“When the team [at this facility] discussed and debriefed afterward, they all felt like the simulation and best practices review made a very big difference in the outcome,” said Dr. Radke, noting that the patient’s life and baby were saved. “While there's no way to know what the outcome would've been had they not had this training, they were not certain the patient would have lived had they not had the training.”
Overall, Dr. Radke has heard this type of positive feedback time and again: “Staff feel more confident in what to do in these rare situations,” she said. “This can have a trickle-down effect on staff retention and recruitment because we're really offering them professional development.”
“I’m hopeful that this work will create a level of trust and coordination that helps us [build] a regionalized care system in Iowa,” says Dr. Pettker. “These programs have really set the groundwork for that.”
