Babies delivered at rural hospitals can receive specialized neonatal care through a unique telehealth program

A newborn baby's care team can get live, immediate help
from a neonatologist with TeleICN. (Dartmouth photo)

A pregnancy delivery in a rural hospital far away from specialized care poses significant risks for a baby born with complex needs. In Vermont and New Hampshire, Dartmouth Health created TeleICN, a unique telehealth program that connects rural medical providers to neonatologists who can help manage a baby's health during and after delivery, reports Christopher Cheney for Healthleaders.

As more rural hospitals have cut services to save money, many have shuttered their labor and delivery units. In the case of an emergency delivery, EMS will take a pregnant patient to the nearest emergency department, where a rural care team can "connect to the TeleICN program using an iPad or making a phone call," Cheney explains.

Tapping into TeleICN is similar to using FaceTime. The program allows a neonatologist to "talk with the local teams, look at the baby via video, and work with the mom and their family members to make decisions about the next steps in care for babies," Cheney reports. TeleICN can "connect local care teams to a neonatologist virtually on a 24/7 basis, and it serves 16 rural hospitals in New Hampshire and Vermont."

Katelyn Darling, a director at Dartmouth Health, shared the varying levels of care TeleICN often provides, saying, "Sometimes, they know a mom in labor is on the way to their hospital, and they want us to help them prep the care room. Sometimes, they want us in the background to support them. Sometimes, they want us on the frontline making decisions about care."

Because the TeleICN has been so successful, Dartmouth expanded its virtual obstetrics care with its new TeleMFM program. Cheney explains, "The focus is on high-risk obstetrics care and fetal-maternal medicine services, with the goal of reducing the need for patients to travel long distances. … Patients can go to a clinic associated with a rural hospital and get connected to a TeleMFM provider."

Jessica Clem, TeleICN's medical director, told Healthleaders, "What we are trying to do is provide equitable care in New Hampshire and Vermont, particularly for rural communities."

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.

Rural women in Colorado with 'high-risk' pregnancies often travel long distances or take helicopters for care

Women in rural Colorado who encounter pregnancy complications often face long drives for care, with some having to take helicopters to reach treatment at a larger medical center. "Every year, more than 60 air medical transfers are made for pregnant patients in Colorado’s Eastern Plains, where helicopters regularly fly in to transport them to hospitals," reports Priya Shahi of Rocky Mountain PBS.

Graph by Priya Shahi, from Prowers Medical Center data

As more rural hospitals reduce or end obstetric care, emergency transportation, such as helicopters, has become more common. Emergency air flight can be for the health of the mom, the unborn baby or for after-delivery specialty care.

In Lamar, Colo., pregnant patients can receive routine prenatal care at Prowers Medical Center; however, its obstetric care is limited and expecting moms with more "high-risk" conditions are often transferred or flown to facilities with higher levels of care. 

While some women don't need more expert care or equipment until closer to delivery, some have to travel long distances throughout pregnancy. One patient in Lamar "has to make bimonthly trips to Colorado Springs just for ultrasounds," Shahi writes. 

She told Shahi, "My husband has to take time off just to take me, so we lose income just to go that far. We’re already struggling in the economy that it is. To take me up there for a two-minute appointment, it’s rough." A one-way drive from Lamar to Colorado Springs takes roughly 3 hours.

A simpler assessment tool for newborns exposed to opioids means more mom time and fewer medications

Cailyn Morreale continued using buprenorphine during her pregnancy. Once her baby was born, the two were never separated. (Photo by Taylor Sisk, KFF Health News)

A new approach is helping mothers recovering from opioid addiction and newborns with opioid exposure stay together after birth. Historically, babies born with opioid exposure have been separated from their mothers and received heavy medications in neuro-intensive units, but "research has since indicated that in many, if not most, cases, those extreme measures are unnecessary," reports Taylor Sisk of KFF Health News. "A newer, simpler approach that prioritizes keeping babies with their families called Eat, Sleep, Console is being increasingly embraced."

Over the past decade, how pregnancy pairs with addiction treatment has changed, meaning most women can continue to take addiction-recovery medication throughout pregnancy. For Cailyn Morreale, a West Virginian from rural Mars Hill, the new methods helped her continue her recovery medicine, buprenorphine, and her care team assured her "that her baby would be assessed and monitored using the Eat, Sleep, Console approach," Sisk explains. "Morreale was never separated from her son. She was able to begin breastfeeding immediately. She was told, the trace of buprenorphine in her breast milk would help her son withdraw from it."

The Eat, Sleep, Console method is slowly replacing the older Finnegan Neonatal Abstinence Scoring System, which involved 21 evaluative questions. Sisk writes, "David Baltierra, former director of West Virginia University’s Rural Family Medicine Residency Program, chair of WVU’s Department of Family Medicine, suggests this protocol could simply be called 'parenting.' Baltierra and his colleagues have been training residents to use an Eat, Sleep, Console approach for a decade. . . .The results are persuading more health professionals to adopt the method."

A 2023 study found "babies treated this way were discharged from the hospital in nearly half the time and less likely to receive medication than those receiving Finnegan-based care," Sisk reports. "Matthew Grossman, an associate professor of pediatrics at the Yale School of Medicine, found a non-pharmacological-first approach works best. He said the Finnegan tool is useful but often too rigid. Under its scoring, one sneeze too many could send a baby to the NICU for weeks."

Research by Leila Elder and Madison Humerick, who each did their residency in WVU’s rural program, "found that median stays for newborns in withdrawal dropped from 13 days in 2016 to three in 2020," Sisk adds. "The simpler treatment also means more babies born in rural communities can receive care closer to home and has reduced the likelihood a mother will be released before her baby is cleared to go home."

For the first time in decades, the EPA issued an emergency action to move weedkiller off the market

Farm workers can be unaware of Dactha's
use on fields. (Adobe Stock photo)

The popular weedkiller, Dactha, has been removed from U.S. sales floors by the Environmental Protection Agency, which issued an "emergency suspension of DCPA, citing a serious risk to pregnant women and their unborn babies," reports CNN News. Dactha is mostly used as an herbicide to tame weeds in crops such as broccoli, Brussels sprouts, cabbage, kale and onions.

Exposure to DCPA (Dimethyl Tetrachloroterephthalate) can cause fetal thyroid hormone disruption, which can permanently harm an unborn baby's normal development. The National Archives Federal Register reports, "The downstream effects of such hormone [disruptions] in the fetus may include low birth weight and irreversible and life-long impacts to children exposed in-utero, such as impaired brain development and motor skills."

Dactha's maker, AMVAC Chemical Corporation, worked to address the EPA's concerns; however, the "EPA has determined that there is no combination of practicable mitigations under which DCPA use can continue without presenting an imminent hazard," the Federal Register reports. According to CNN, the EPA noted that DCPA may be considered unsafe for 25 days or more after application.

This is the first time in almost 40 years the EPA has taken this type of emergency action. Michal Freedhoff, the assistant administrator for the Office of Chemical Safety and Pollution Prevention, noted that "pregnant women who may never even know they were exposed could give birth to babies that experience irreversible lifelong health problems."

Oregon is using visiting nurses to help curb infant and new mother mortality rates; visits may have other benefits

Why babies do what they do is often a mystery.
(Photo by Chris Anderson, Unsplash)

Some of the most complicated human beings to deal with are the tiniest: babies. Often referred to as "bundles of joy" or "little miracles," babies can be cranky, impossible to calm and impervious to sleep.

With that backdrop, it's fair to say new parents have it tough, and many lack the resources they need to confidently care for a newborn, which can lead to stress, emergency department visits, and even neglect or abuse. To address these needs and provide a response to high infant and mother fatality rates, the state of Oregon implemented an evidence-based program called "Family Connects" that makes life with a newborn better for everyone, reports Cory Turner of NPR. "The program offers any family with a new baby up to three no-cost visits at home with a trained nurse."

After the birth of their first child, Matt and Amber Luman from rural Jefferson County, Oregon, chose to participate in Family Connects. Turner writes, "Matt and Amber seem genuinely relieved when [Nurse] Ibrahim arrives for her second home visit with them." After baby Esserley gets a thorough medical check, "comes the beating heart of any Family Connects visit: the chance for new parents to ask a registered nurse whatever they want. . . . Some share their confusion or frustration. Others are eager for advice or comfort in those early weeks of a baby’s life when new parents are most likely to feel exhausted and adrift."

Most new parents need all the help they
can get. (Photo by T. Heftiba, Unsplash)

The Oregon Health Authority based the state's program on a small, successful Family Connects model developed in Durham, N.C. "Research from its smaller rollout there found it was associated with a handful of significant benefits, including a big drop in the number of trips new parents were making to the emergency room," Turner reports. "A study of Family Connects in Durham found mothers in the program were 30% less likely to experience possible postpartum depression or anxiety."

Oregon policymakers used the Durham program model and expanded it to a statewide outreach. "Every nurse acts as a kind of human clearinghouse of local and regional support for caregivers," Turner explains. "If a family is struggling with housing or food insecurity or addiction, the nurse will connect them with local groups and agencies that can help. Mental health counseling, marriage counseling, child care while mom or dad finishes their degree online."

In Durham's smaller rollout, the program "suggested a real return on investment," Turner reports. "Rolling out Family Connects in Oregon has been a costly struggle." From the pandemic to the nursing shortage to trying to cover a state that can be widely rural, Oregon's program has been expensive. It remains to be seen if the "benefits of Family Connects will outweigh the costs."

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."

Prenatal drug exposure is found in thousands of babies each year; rural babies are more likely to have problems

More research is needed on prenatal drug exposure.
(Photo by Jill Sauve, Unsplash)

Amid rural hospitals and clinics ending prenatal care and closing labor and delivery units, unborn children face a quieter threat -- exposure to drugs that limit their in-utero development, can cause lower birth weights and contribute to post-birth disabilities, writes Amna Umer for The Conversation, a journalistic platform for academics. Umer is an associate professor of pediatric epidemiology at West Virginia University. 

Umer writes: "Nearly 1 in 12 newborns in the United States in 2020 – or about 300,000 infants – were exposed to alcohol, opioids, marijuana or cocaine before they were born. . . . These substances can have direct and indirect consequences on fetal development."

When it comes to drug exposure, rural unborn babies are particularly vulnerable. "This includes West Virginia, where I live, a rural Appalachian state struggling with extraordinary rates of substance use and an opioid crisis," Umer explains. "As an epidemiologist, I study the relationship between substance use during pregnancy and infant health outcomes. Our research work showed that between 2020 and 2022, prenatal substance exposure in West Virginia was nearly 50% higher, at 124 per 1,000 births, than the national rate of 80 per 1,000 births."

Poverty and ongoing regional economic stress are part of West Virginia's drug crisis, which extends to pregnant mothers, but there are other factors at play. Umer writes, "Nearly half the population lives in rural areas with limited hospitals and clinics. The geographic isolation limits access to health care and substance use treatment services. Finally, stigma and judgment within close-knit rural communities may discourage these mothers from seeking help."

The body of research on prenatal drug exposure is still growing, and depending on the substance babies were exposed to in the womb, the outcomes vary from low birth weights to withdrawal to developmental delays. Some exposure has a lasting impact on children. Umer explains, "Limited studies have shown an association between neonatal abstinence syndrome and long-term neurodevelopmental consequences that may develop as early as six months old and persist into adolescence. These include delays in learning and language skills, physical growth and motor skills, and difficulty regulating behavior and emotions."

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."

Nutrition programs expanded for women and children during pandemic due to easier access; but changes are temporary

Money for fruits and vegetables is part of the
WIC program. (Photo by Rusty Watson, Unsplash)

Pandemic changes allowed more mothers to access the nutritional benefits of the Special Supplemental Nutrition Program for Women, Infants, and Children. The program's growth was spurred by decreasing participant requirements and in-person interviews. While those changes helped WIC become more popular with mothers, the program faces funding and waiver crunches that may limit access again. "WIC is not an entitlement program — it can only support additional participants if Congress allocates funding for them," reports Caitlin Dewey of Stateline. Temporary federal waivers "made it easier to participate during the pandemic, and Congress would need to change the law to extend them."

Despite the program's history of positive health outcomes and bipartisan support, "House Republicans have signaled a desire to hold WIC funding steady, with no increase to cover new participants. A series of continuing resolutions passed to buy Congress time as it works out a comprehensive budget deal also have maintained prior funding levels," Dewey explains. Without additional funding, some states may face waitlists, which, depending on the wait time, may not be helpful for pregnant women.

Dr. Aditi Vasan is a pediatrician at the Children's Hospital of Philadelphia, where she has researched participation in WIC. Vasan told Dewey, "It's a really important source of nutrition support for low-income pregnant women, children and families, because it provides both nutrition education and the funds to purchase nutritious food." Dewey reports, "[Before the pandemic] participants frequently reported problems scheduling appointments, taking time off work and accessing transportation to WIC offices." To contain Covid-19, WIC offices were allowed to conduct interviews and screenings remotely, which removed a major obstacle for program applicants. Many of WIC's pandemic adaptations were authorized under temporary federal waivers," Dewey writes. "By September 2026, when waivers end, Congress will need to change the statute underlying WIC to make those changes permanent, said Ali Hard of the National WIC Association."

Better known as Roundup, glyphosate is found in pregnant women who live near farms, study finds

Herbicide drift is one possible explanation for the
study's findings. (Photo by Eric Brehm, Unsplash)

Considered the world's most commonly sprayed weedkiller, glyphosate, sometimes sold under the name brand "Roundup," is a suspected cause of  serious health concerns. New research found pregnant women "living near farm fields show 'significantly' increased concentrations of glyphosate weedkiller in their urine during periods when farmers spray their fields with the herbicide," reports Carey Gillam of The Guardian. "The research team said the findings were concerning, given recent studies that have found gestational exposure to glyphosate is associated with reduced fetal growth and other fetal problems."

The study yielded some surprising results, Gilliam writes, "because none of the women studied worked with glyphosate or other herbicides or had a household member who worked with weedkillers, said Cynthia Curl, associate professor at Boise State and lead author on the paper. Curl couldn't account for how the women were exposed and questioned whether herbicide drift, soil particle adhesion, house dust or drinking water were to blame. She told Gilliam: "Until we figure that out, we can't suggest the right interventions."

For the study, researchers from the University of California, the University of Washington, Boise State University and the Centers for Disease Control and Prevention included 40 pregnant women in southern Idaho and took into account their proximity to farms using glyphosate. "In those living near the fields, glyphosate was detected both more frequently and at much higher concentrations during the months when farmers were spraying glyphosate than during the periods when they were not spraying," Gilliam reports. "Those participants living farther away still showed glyphosate in their urine, but the frequency and concentrations stayed relatively unchanged throughout the year."

Philip Landrigan, director of the Program for Global Public Health at Boston College, told Gilliam, “Sadly, I am not surprised that pregnant women who live near fields sprayed with glyphosate have elevated levels of glyphosate in their bodies during the spraying season. This situation is analogous to the elevated exposures to benzene, 1,3-butadiene and other toxic plastics chemicals that have been documented in women who live in ‘fenceline’ communities.”

Gilliam adds, "Though glyphosate has been on the market for more than 50 years, it is only within the last few years that researchers have started to document the extent of human exposure."

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."

'Too many babies are dying in the United States'; infant mortality rates rise for the first time in 20 years

The U.S. infant mortality rate is twice that of other
developed countries. (Photo by Jill Sauve, Unsplash)

Over the past two decades, American medicine has made dramatic advances in cardiac care, obesity medicines and organ transplant success rates, but in a sad marker, "the death rate for babies rose for the first time in 20 years," reports Liz Essley Whyte of The Wall Street Journal. According to the Centers for Disease Control and Prevention, "The rate of babies dying in the U.S. increased 3% from 2021 to 2022. . . . The rate increased from 5.44 infant deaths for every 1,000 births to 5.6 in 2022, a statistically significant uptick."

U.S. infant mortality rate is strikingly high at "double that of many developed countries," Whyte notes. "Globally, baby death rates have fallen for decades, though five countries that have reported their rates this year recorded increases for last year. . . . The death rate for women who give birth has also been rising in the U.S. Researchers who study the issues said the pair of trends indicate more women giving birth are facing challenges getting proper care."

Arjumand Siddiqi, a University of Toronto professor who studies population health, told Whyte, "The U.S. is falling behind on a basic indicator of how well societies treat people. In a country as well-resourced as the U.S., with as much medical technology and so on, we shouldn't have babies dying in the first year of life. That should be super rare, and it's not."

American medicine needs to do the basics
better. (Photo by Filip Mroz, Unspash)

The maternal-infant relationship has complex layers, but it begins with how healthy the mother is. "Complications during pregnancy was one of the fastest-rising causes of infant death, the CDC said, along with dangerous bacterial infections called sepsis," Whyte explains. Researchers cited premature births as one likely contributor to the increase, along with poor nutrition throughout pregnancy.

The CDC reports infant-mortality rates every three months. "Its latest report compared birth and death certificate data from 2021 to provisional data from 2022," Whyte adds. "The report didn't give reasons why the rate was increasing, and researchers said they would have to do more studies to determine the root causes." Dr. Elizabeth Cherot, chief executive of the infant and maternal health nonprofit March of Dimes, told Whyte: "We, as a developed country, should be doing some of the basics better. Too many babies are dying in the United States."

New study reviews eight centers that are working to improve rural postpartum care through innovation and collaboration

A new case study highlights eight community-focused postpartum care centers working to address the unique challenges of postpartum health for rural women. The review from the University of Minnesota looked at programs serving rural communities in Colorado, Maine, Minnesota, Montana, Oregon, South Carolina and Washington.

The goal of each center is to reduce maternal mortality rates, which are disproportionally high in rural areas. Each organization reviewed provides support to rural women and their families through access to obstetric care, mental health services, logistical support and social services during pregnancy and after childbirth.

Researchers cite one of their key findings: "Despite challenges related to transportation, stigma, isolation, and affordability, the organizations profiled here innovate, including in their program offerings and finance models, and collaborate with local and national partners to provide a variety of critical resources to postpartum families in their rural communities. . . . Each organization expressed the importance of stable, secure funding for their work."

In the study, each center is reviewed for rural community context. The Postpartum Resource Group in Whitefish, Montana, is an example. The area "is a mountainous community located near Glacier National Park in northwest Montana. The town is one of only three in the [Flathead] county, which occupies 5,098 square miles and is home to about 108,000 people. . . . ."

Each center in the study is reviewed by discussing its services. In Whitefish, researchers spoke with Brooke Jaszczak, the Network Director of Postpartum Resource Group who gave a program overview: "The Postpartum Resource Group is a non-hospital-affiliated, community-based postpartum mental health support group that was founded in 2016 by a midwife who created a support group with her patients. She recognized the need for such support based on both professional and personal experience, as she was also experiencing postpartum mental health challenges at the time."

The researchers write, "Their mission is two-fold: to provide support, education, and resources for mothers and their families who are experiencing postpartum mood disorders, and to educate and inform the community and providers about postpartum mood disorders."

A discussion of each center's challenges is also shared. "In the Flathead Valley, many local residents struggle to afford basics like housing, food, childcare, and health care due to rising costs. Located near Glacier National Park, the region experienced a population increase during the Covid-19 pandemic, as people moved there to work remotely. The service industry workers were priced out of housing and health care, and a rationing of care and preventive services resulted due to their limited resources. Furthermore, the population is very spread out. Between winter weather and poor driving conditions through the mountain passes, it can be difficult to access areas of the community, its resources, and clinicians."

Researchers hope their analysis will inform and encourage other communities looking to bridge the gaps in rural postpartum health. 

Health investigation finds startling gap in funding to prevent maternal deaths, new grant award aims for change

USA Facts map, from CDC data

National maternal mortality rates have been on a steady incline, with far more minority women dying while pregnant or within 42 days of the end of pregnancy than white women, reports Sarah Jane Tribble of KFF Health News. Despite the rate difference, a federal program designed to "combat the alarming rates of rural women dying from pregnancy complications. . . . hadn't sent a grant to serve mothers in majority-Black rural communities."

A KFF Health News investigation discovered the possible funding-bias and criticized the program for neglecting some of the most marginalized women. The program has addressed that problem by "supporting an organization that serves predominantly Black counties in the Deep South," Tribble writes.

The Institute for the Advancement of Minority Health in Madison, Mississippi, was "one of two winners in the latest round of an initiative administered by Health Resource and Services Administration," Tribble writes. Mississippi has the highest rate of maternal mortality in the U.S. and the highest proportion of Black births in the U.S. "In June, KFF Health News found that HRSA's Rural Maternity and Obstetrics Management Strategies Program had failed to fund any sites in the Southeast . . . . despite a White House declaration to make Black maternal health a priority, and despite statistics showing America's maternal mortality rate rising sharply in recent years."

Peiyin Hung, deputy director of the University of South Carolina's Rural and Minority Health Research Center, is a member of the health equity advisory group for the maternal grant program. Hung said "the Mississippi nonprofit is an unusual awardee because it is not part of a larger health system." Tribble reports: "The grant application process skewed toward large health systems because they 'have much higher capacity to form a statewide network', Hung said. That's, in part, because grant winners were required to create a network of specific health care clinics, hospitals, and the state Medicaid office. In recent years, the agency has 'become much more flexible,' Hung said."

Tribble adds: "The success of the Mississippi application is a 'promising signal' for states that don't have large rural health systems focusing on maternal care, said Hung, who hopes a South Carolina applicant receives a grant in the future."

Rural help for expecting and postpartum moms is coming from someone new with a 'baby phone'

Paramedic Darren Forman sees a Project Swaddle
patient in her home. (Photo via RHI Hub)

Rural women, infants and toddlers often need special supports that are difficult to get in more remote areas. The fire department in an Indiana town of 16,000 is filling that need with a "baby phone," reports Gretel Kauffman of the Rural Health Information Hub. "Through Project Swaddle, a home visitation program in which a community paramedic brings wrap-around care to pregnant and postpartum patients, the Crawfordsville Fire Department has provided education, support, and medical care to more than 200 women. . . . Bringing resources and support to women experiencing at-risk pregnancies or other social or environmental challenges, the program aims to keep vulnerable patients from falling through the cracks in a maternity-care desert."

Darren Forman is a Project Swaddle paramedic and Kauffman's object example: "When Darren Forman's baby phone rings, he answers." Callers have been "a young mother calling for help on a Friday evening after a domestic dispute. A pregnant 17-year-old girl stopped by law enforcement after a methamphetamine relapse. A woman in need of a listening ear following a miscarriage. Through the baby phone, expectant and new mothers can reach Forman at all hours of the day and night with questions, crises, medical needs, or just to talk."

The need for Project Swaddle arose in 2011, when Crawfordsville's main hospital, Franciscan Health, closed its birthing unit. Five years later, "a community needs assessment revealed a gap in care and resources for mothers and babies in Montgomery County. But the severity of the issue came as a wake-up call for many community members and leaders, including first responders," Kauffman reports. The Crawfordsville city and county leaders moved to find a way to bridge the gap. "They turned to the Crawfordsville Fire Department, which had already begun to launch a home visitation program focused on chronic disease management. With that foundation laid, the department decided to pivot to try something new: shifting the focus of the home visitation program to moms and babies instead."

Wikipedia map, adapted

Kauffman reports, "Since then, Project Swaddle has expanded into a mobile integrated healthcare program offering wrap-around services to pregnant and postpartum women, with a holistic approach that requires coordination between paramedics, physicians, nurses, social workers, and other service providers in the community. Patients can enroll in Project Swaddle as early as the first trimester of their pregnancy and receive care up to 90 days postpartum; the program is in the process of expanding to serve mothers up to one year postpartum." Samantha Swearingen, Project Manager for the Crawfordsville Fire Department, told Kauffman: "We like to say the program is physician-led but patient-centered."

Project Swaddle developers put together a how-to guide with best practices for communities that want to start a similar program. "Swearingen notes that the Crawfordsville Fire Department was fortunate to have already had a relationship with the Franciscan Health Network after partnering with the local hospital for previous programs, making it easier to establish a partnership for Project Swaddle," Kauffman adds. "Having 'passionate, dedicated practitioners' has also 'been huge for us,' Swearingen said. Still, funding has been an ongoing challenge for the program, organizers say. After initial funding through a one-year grant from the Montgomery County Community Foundation and the Indiana Department of Health, the program is primarily funded today by the Franciscan Health Network and the city of Crawfordsville."

Opinion: The loss of rural labor and delivery departments means lower-quality health care for mothers and babies

Photo by Jill Sauve, Unsplash

When fewer than half of rural hospitals offer labor and delivery services, what does that mean for rural pregnancies and deliveries? It means less prenatal, postnatal, and postpartum care – and more risk – for moms and babies, Anna Thompson Hajdik writes in an opinion piece for The Daily Yonder. The reasons we got here are complex, but there are solutions to consider. Here's a gently edited version:

"The accelerated closure of rural hospitals has touched every part of the country, and even if the hospitals themselves stay open because of a Critical Access designation, their labor and delivery units are disappearing. Multiple media outlets have reported on the dire situation. Families driving over four hours in blizzard conditions in the middle of the night because their local hospital ceased delivering babies 18 months earlier. A mom in rural Illinois was forced to deliver a baby on an Interstate 55 off-ramp a month after the labor and delivery unit in the small town of Lincoln, Illinois, closed. A soon-to-be mom in labor who navigated an isolated mountain pass in rural Washington on her way to the hospital with barely enough gas to get there.

At the same time, maternal mortality rates across the United States have increased significantly. In 2021, the rate of maternal deaths that occurred while pregnant or within 42 days of being pregnant was 32.9 per 100,000 live births, 10 times the rate for countries of comparable high income. The proliferation of "maternity care deserts" in rural America is an adjacent issue to overall maternal mortality; the March of Dimes defines maternity deserts as counties where there are no hospitals providing obstetric care, no birth centers, no ob/gyn and no certified nurse midwives.

Three major factors seem to drive closurs of maternity units: Labor and delivery departments are expensive to operate, risk and liability to doctors and medical staff have become untenable in a much more litigious environment, and it is challenging to recruit new obstetricians and other reproductive professionals like certified nurse midwives to rural areas.

If policymakers care about fostering a vibrant and resilient future for rural America, they would safeguard rural hospitals by creatively and sustainably funding labor and delivery departments in rural places. And while many rural health-care stakeholders advocate increased reliance on technology like telehealth and mobile health clinics, expectant mothers shouldn't have to deliver their babies over Zoom or drive more than two hours to receive care. A recent study demonstrates that the closure of labor and delivery units in rural areas is linked to the reduced quality of prenatal care, even if health-care institutions are providing it.

States like Texas (where rural hospitals more broadly are in especially dire circumstances) that have opted not to expand Medicaid should reconsider that decision as the rate of rural hospitals at risk of closure steadily increases each year. But a simple federal solution exists as well – significantly increasing Medicare and Medicaid reimbursement rates that actually reflect the skyrocketing costs of healthcare and maternity care in particular in a post-pandemic America. The American Hospital Association supports this action, among many other initiatives, in their call for Congress to pass the Rural Hospital Support Act, which is a piece of legislation that has broad bipartisan backing.

Ultimately, a national reckoning is playing out across the country when it comes to rural healthcare, exposing so much that is broken. . . . Unless policymakers (regardless of their political affiliations) and civic leaders take action to solve this crisis, rural people are left with limited options, while the future of the nation's rural communities more broadly is one of precarity and accelerated population loss.

Anna Thompson Hajdik is a senior lecturer at the University of Wisconsin-Whitewater in the Languages and Literatures department. Her rural background and continued interest in agriculture inform her research and writing, as well as her "extracurriculars," including serving as vice president of the Wisconsin Dairy Goat Association.

Deliveries in rural hospitals with lower numbers of birth have poorer outcomes; 'tailored' support needed, study says

In an obstetric suite (MedPage Today photo)

Rural hospitals that have lower numbers of births had "a higher risk for severe maternal morbidity compared with rural hospitals delivering more babies," Rachael Robertson reports for MedPage Today on a study published in the American Medical Association's Health Forum Network. The study "used data from more than 11 million urban births and more than half a million rural births in California, Michigan, Pennsylvania, and South Carolina.” Severe cases were defined by Centers for Disease Control and Prevention parameters “and generally included unexpected outcomes of labor and delivery that result in significant short-term or long-term health consequences, excluding blood transfusion."

Women with low-risk pregnancies, "defined as having none of 27 comorbidities such as advanced maternal age or placenta accreta spectrum, were actually at particularly high risk in rural hospitals with relatively few deliveries," Robertson reports. Co-author Stephanie Leonard, an epidemiologist at Stanford University, told her: "If they gave birth at a low-volume rural hospital, they were at over twice the risk of having severe maternal morbidity as a similar person who delivered at a high-volume rural hospital."

Dr. Shon Rowan of West Virginia University told Robertson, "This study was done on larger states, which shows that this is a nationwide issue. . . . I think it lets us know that we need to maybe divert even more resources to these small hospitals. . . . It's not unheard of for a patient [from an obstetric care desert] to drive two to three hours to a delivering facility. And that's leading to more patients showing up in emergency rooms that don't have the resources."

The study recommended "'a need for tailored quality improvement strategies for lower-volume hospitals in rural communities,'" Robertson reports. Leonard said research should examine differences in prenatal and postpartum care," and the role of people's trace and ethnicity. She said, "It's already been well shown that in rural communities that have substantial populations of Black and Indigenous people, you see the highest rates of severe maternal morbidity. . . [that] certainly is a big area that needs attention."

When rural hospitals stop delivering babies, fewer expectant mothers receive prenatal care, Iowa study finds

University of Missouri Health Care photo

When rural counties lose their last labor-and-delivery unit, fewer expectant mothers in those counties get adequate prenatal care, even though that care is still available, according to a University of Iowa study.

 “Our study reflects continuing problems in our maternal health system in general, and in rural areas in particular,” Tom Gruca, co-author and professor of marketing, said in a news release. “It suggests a breakdown of maternal health care in rural areas.”

The study, published in the Journal of Rural Health, looked at the impact of the closure of seven labor and delivery units in 2018 and 2019 in rural Iowa, where prenatal care continued after the closure of those units. 

The researchers found that 18 percent of expectant mothers were making an inadequate number of prenatal care visits to a doctor in those hospitals before the closings. Following the closing, that number increased to 22%. “And 18% is not a great number, to begin with,” Gruca said.

Research shows that prenatal care reduces preterm birth and low birth weight babies. 

"All women in rural counties where the only labor-and-delivery unit closed have a 24% higher likelihood of having inadequate prenatal care compared to those in counties that still have a unit. For women enrolled in Medicaid, the difference is even more pronounced, with a 38% higher likelihood of receiving inadequate prenatal care," says the release. 

The researchers said the drop in prenatal-care rates might be attributed to expectant mothers' thinking that the hospital did away with all maternity services when the labor-and-delivery unit closed. They said poor mothers' access to prenatal care is complicated because not all health care providers accept Medicaid. 

Gruca said one solution could be creation of a central source of information that expectant mothers can use to find health-care professionals who provide the care they need and accept the insurance they have.