Robotics in rural Alabama obstetrics care gets mixed reviews

36 of Alabama's 54 counties lack any obstetrics care.
(Photo by Volodymyr Hryshchenko, Unsplash)

People are conflicted about part of the Alabama Rural Health Transformation Program, which aims to add robotic ultrasound machines in rural areas of the state, reports Liz Carey for The Daily Yonder. Many experts agree that the state's biggest obstacles to ensuring healthy pregnancies, babies and moms is access.

Alabama has the highest maternal mortality rate in the U.S., with 41 of its 54 counties lacking labor and delivery services and 36 counties without any obstetrics care.

While the new robots address a lack of technical support in rural healthcare, the real issue, medical care access, isn't addressed by robot-providing ultrasounds, according to an OB/GYN in Jasper, Alabama.

“There may be a case where a mom may have low fluid, and that patient needs to go to a hospital,”  LoRissa Autery told Fox54 News. “But if you’re in a part of the county that doesn’t have a hospital that has obstetrical services, now you have to drive an hour to an hour and a half to receive those services from a physician that did not do the ultrasound.”

New technology can help provide access to care, but to do so, it requires basic healthcare infrastructure and reliable broadband internet access, Katy Kozhimannil, a professor and co-director of a rural health research center at the University of Minnesota, told the Yonder.

The Alabama's plan also outlines programs to supply emergency labor and delivery carts to rural hospitals, pair patients with specialty providers, and distribute equipment upgrades and minor building renovations, reports Carey.

Some state and federal officials have praised the plan, while others have given it mixed reviews, Carey adds.

After 30 years, this rural hospital reopened its maternity unit

Dana Iglesias, medical director of the UNC Health Chatham Maternity Care Center, left, and Beverly Carpenter, the unit's manager, stand inside a labor and delivery room. (Photo by R. Crumpler, NC Health News)

UNC Health Chatham in North Carolina closed its obstetrical unit in 1991 after years of staffing shortages and poor financial performance. For 30 years, moms and families had to drive farther for care and delivery, while UNC hospital leadership continued to work on how to make maternity care fit in a rural hospital setting. 

After decades of consideration, UNC hospital leadership and medical providers decided to alter their obstetrical unit's staffing structure to make it more versatile and affordable. UNC Health Chatham reopened its mother-baby unit in 2020. Rachel Crumpler of NC Health News reports, "Births at the unit have increased each year since it opened, reflecting demand for local maternity care."

The unit is created to be sustainable and flexible. Crumpler writes, "It serves low-risk mothers and newborns and is staffed by family physicians trained in obstetrics and surgery, along with midwives — a lower-cost model than one centered on OB-GYNs, who cost more to employ and are harder to recruit to rural areas." 

Because family medicine doctors are trained across multiple medical specialties, their versatility helps them meet the two-patients-at-once demands of obstetrical care. Additionally, their salaries are lower than OB-GYNs, "meaning delivery volumes don’t need to be as high for the unit to be financially viable," Crumpler explains.

The unit's unique staffing structure and service model may offer a blueprint for other rural hospitals. Jesus Ruiz, a family physician at the Chatham Maternity Care, told NC Health News, "Chatham is a template, but it’s not a copy-and-paste template. . . .This shows a way that rural maternity care can be built and sustained.”

UNC Health Chatham leaders are working to spread the success of their model. Crumper adds, "Eric Wolak, the chief operating officer at UNC Health Chatham, said he’s fielded calls from other community hospitals — within and outside the UNC Health system — asking about the family medicine-driven model and Chatham’s implementation."

Mobile health clinics are combating maternity care deserts in Florida

An OB/GYN mobile outreach clinic directed by researchers Adetola F. Louis-Jacques, Arielle Ayotte, and Michelle Nall at the University of Florida is helping to address a maternity care desert in north-central Florida, they report for The Conversation.

Nationwide, 2.5 million, or 4%, of American women of childbearing age live in a maternity care desert, they report. A maternity care desert is any county with no hospital, birthing center or obstetric health care professional. “Women in maternity care deserts travel an average of 35 miles to reach a birthing hospital, compared to an average of 9 miles for women in full-access counties.”

Traveling longer distances for obstetric care is directly correlated with poorer infant and maternal health outcomes, studies show.

Florida counties with full, low, or no access to maternity care. 
(Map via The Conversation CC, data from March of Dimes 2023 statistics, Click to enlarge)

In Florida, only three of the 14 north-central counties have full access to obstetric care, the researchers explain, and six have low access. The other five counties are deserts that they estimate to have 3,400 women of childbearing age. They also found in a 2024 report that 18 of Florida’s 21 rural hospitals have no more obstetric care, often because of a lack of funding.

Their new mobile clinic, started in February last year, offers prenatal and postpartum care, breastfeeding support, family planning, annual gynecological exams and preventive health screenings. They have already cared for 194 women in 616 visits.

Everything is free to the patients, and they offer assistance to help eligible patients apply for Medicaid benefits. “In 2023, about 1 in 7 women of childbearing age in Florida were uninsured,” they report.

A survey of mobile clinic patients across the U.S. found they “reported receiving holistic care, feeling safer than they’d felt in other health care settings and interacting with staff who were mindful of health care costs,” as well as being able to “maintain continuity of care.”

Most mobile clinics don’t offer maternal and infant health services, the researchers explain, and as maternity care deserts grow, more OB/GYN mobile health clinics like this one can directly provide low-income, rural areas with regular prenatal and postpartum care that women wouldn’t have access to otherwise.

The declining availability of maternity healthcare puts moms and babies at risk, but there are solutions

A lack of maternity care can cause issues for mothers and babies.
(Photo by Christian Bowen, Unsplash)

A lack of access to maternity care can cause deaths, preterm births and health risks for mothers.

According to Cynthia Gyamfi-Bannerman in an article for Medpage Today, 2.3 million reproductive-age individuals and more than 150,000 babies are being affected annually by a lack of labor and delivery units in hospitals.

A March of Dimes report found that, “35% of U.S. counties are maternity care deserts, defined as areas with zero ob/gyns, midwives, or family medicine obstetric providers per 10,000 births,” and that about “70% of birth centers are located in just 10 states,” according to Gyamfi-Bannerman.

The article reported that there were about 50,000 ob/gyns in 2018, “with more than 94% practicing in metropolitan areas.” That number is expected to continue dropping due to “high rates of burnout, high liability burdens, and a possible decrease in interest.”

With the vast majority of ob/gyns in highly populated areas, it leaves an even bigger shortage of maternity care providers in rural areas.

Cross-training healthcare providers may be an answer.
(Photo by Bagoes Ilhamy, Unsplash)

Hospitals are also closing many of their birthing and maternity units. Gymafi-Bannerman wrote that beyond declining birth rates, there aren’t high incentives for hospitals to provide maternity services. “Maternity care has often been considered a money-losing necessity, but even moneymaking, for-profit hospitals are discontinuing obstetric services.”

There are solutions to help with this issue, but it’s a matter of implementing them.

Emily Hedegard and Kate Cough at The Maine Monitor wrote that cross-training, offering stipends, training future healthcare providers in rural areas, and paying maternity healthcare providers more may be a start. As maternity care has been considered money-losing for hospitals, some of these solutions may not be as feasible.

However, “One of the most approachable solutions to the rural health care crisis, said several experts, and one that can be implemented immediately, is making better use of providers who are already part of the community,” according to Hedegard and Cough.

Closing rural labor and delivery units poses problems for women, babies and rural population growth

Addie Comegys travels 45 minutes for her prenatal visits. 
(Photo by Tony Leys, KFF Health News)

As rural women have fewer babies, hospitals that once served more remote locations have closed their labor and delivery units, which leaves rural pregnant women facing maternity care deserts, reports Tony Leys of KFF Health News. In many areas, women leaving or not wanting to relocate to smaller towns with limited obstetric care has contributed to rural population loss.

Rural areas surrounding Oskaloosa, Iowa, population 11,558, illustrate how obstetric care has become long-distance care for some pregnant women. "At least 41 Iowa hospitals have shuttered their labor and delivery units since 2000," Leys writes. "Those facilities, representing about a third of Iowa hospitals, are located mostly in rural areas where birth numbers have plummeted."

Addie Comegys, who lives in southern Iowa and is expecting a baby in August, has spent part of her summer driving "45 minutes each way for prenatal checkups at Oskaloosa's hospital," Leys writes. "Oskaloosa's hospital has kept its labor and delivery unit open, partly by pulling in patients from 14 other counties." Not every smaller hospital has that geographical benefit.

For women who don't have reliable transportation or flexible work schedules, longer travel to see an obstetric provider becomes a barrier to care. Declining births have accelerated the problem. "Katy Kozhimannil, a University of Minnesota health policy professor who studies rural issues, said declining birth numbers and obstetric unit closures can create a vicious cycle," Leys reports. "Fewer babies being born in a region can lead a birthing unit to shutter. Then the loss of such a unit can discourage young people from moving to the area, driving birth numbers even lower."

Despite delivering far fewer babies, some rural hospitals have kept their units open, but that choice has posed care challenges. "A study published in JAMA in 2023 found that women were more likely to suffer serious complications if they gave birth in rural hospitals that handled 110 or fewer births a year," Leys writes. "The authors said they didn't support closing low-volume units because that could lead more women to have complications related to traveling for care. Instead, they recommended improving training and coordination among rural health providers."

Without help, the rural maternal care crisis will only get worse, and 'more women and babies will die unnecessarily'

Over the past decade, many rural hospitals have struggled to stay afloat, but even among the surviving hospitals, labor and delivery services have been cut, which forces mothers to travel and increases pregnancy dangers. Dave Muoio of Fierce Healthcare reports, "Over half of the country's rural hospitals aren't offering labor and delivery services, according to a new report from the Center for Healthcare Quality. The center wrote that over 200 rural hospitals across the U.S. stopped delivering babies in the past decade. As of this month, 55% of rural hospitals don't offer these services, and in 10 states, more than two-thirds don't."

Why obstetrical care is getting axed in rural areas comes down to costs. "CHQPR noted that it can be financially difficult for hospitals to staff for 24/7 maternity care and that private and Medicare payments often fail to break even," Muoio writes. "Per hospital cost reports for 2022, over a third of rural hospitals that still provide maternity care logged an overall loss on patient care services. . . . Within 12 states, more than half of rural maternity care hospitals posted patient care losses."

CHQPR graph

The lack of care can prove deadly for mothers and babies. Muoio writes, "The sparse availability of maternity care hospitals forces pregnant women to travel further for a delivery and incur a higher risk of complications and death for the mother and baby alike, the center wrote. Whereas travel time to a hospital with labor and delivery services is often under 20 minutes for those in urban areas, in rural areas, 'the travel time is likely to be at least 30 minutes, and it is often 40 minutes or more,' according to the report."

Stemming the tide of closures will require approaches that work for more remote health care systems. "Any strategy to bolster the rural maternity workforce will also require targeted clinician training," Muoio reports. "To address the financial roadblock, CHQPR urged employers to put pressure on their health insurance plans' to demonstrate that they are paying adequate amounts to cover the cost of maternity care services. Similarly, states should require Medicaid plans to pay adequate amounts for maternity care services.'"

"It is not an exaggeration to say that rural maternity care is in a state of crisis, and a crisis demands immediate action," the CHQPR report said. "Every day that steps are not taken to implement the changes in workforce recruitment and payments described above increases the likelihood that more women and babies will die unnecessarily."

Expectant moms face OB-GYN deserts; one state is an example of the national problem

A mother holds a newborn baby.
(Photo by Katie Klingsporn, WyoFile)

Wyoming is one of many states where women and families are finding obstetric care harder to find. "More than 15% of Wyoming women had no birthing hospital within 30 minutes of home in 2022, compared to 9.7% of women nationally, a report by the March of Dimes shows," Katie Klingsporn of WyoFile reports. "Such distance from care comes with real risks. Women who live farther from delivery hospitals are more likely to experience adverse medical outcomes. . . . In rural areas of Wyoming, 22.4% of women live over 30 minutes from a birthing hospital compared to 5.2% of women living in urban areas, according to the March of Dimes."

Nestled in west central Wyoming, Fremont County is "not unique, but with one obstetric practice, one midwife and one birthing hospital serving the general population of Fremont County — a New Hampshire-sized area that's home to nearly 40,000 people — the situation here offers a window into the challenges, and consequences, of limited maternal health services," Klingsporn writes. And while Fremont County has a 24/7 delivery center in SageWest Hospital in Lander, women who labor and deliver there will most likely be treated by a traveling doctor, who is also a stranger. 

Map of towns Fremont County women travel to for
obstetric care. (Map by Eda Uzunlar,WyoFile)

Traveling in Wyoming can be both risky and expensive. It "requires money, childcare, work flexibility and other resources that not everyone has. And then there's the issue of winter travel in Wyoming, where icy storms regularly close roads and ground air ambulances," Klingsporn reports. "The OB shortage is not isolated to Fremont County. Hospitals in Rawlins and Kemmerer stopped offering delivery services in recent years. Other counties like Sublette and Weston don't have birthing facilities at all."

Jen Davis, Gov. Mark Gordon's senior policy advisor on health and human services, "said of the dearth of maternal health care, 'It's a huge problem,'" Klingsporn writes. 

While traveling longer distances to see obstetric providers can lead to poor outcomes, more pregnant women in Wyoming are having to take that risk. "The farther a woman travels for maternity care, the greater the risk of maternal morbidity and adverse infant outcomes," Klingsporn reports. 

The loss of labor and delivery care is a national problem. "In 2022, the March of Dimes reported on the problem of 'maternity care deserts' across the United States," reports Stacey Kelleher for Health eCareers. "These communities do not have birthing centers or hospitals offering obstetric care. Outside these maternity care deserts, which affect more than two million women of childbearing age, nearly seven million other women and 500,000 births are also impacted by low or no access to Ob-Gyn care in this country."