Out of Range: Rural Healthcare for Moms

A recent story in a local newspaper illustrated a crisis people in my state are facing – a lack of access to healthcare in rural areas.  The Columbia Missourian ran a well-researched article by Taylor Blatchford that outlined a crisis hurting women in rural counties.  In shows that:

• In 43% of rural counties in Missouri, there is no hospital. In 68% of Missouri counties, there is no access to OB hospital services.
• In the past 4 years, 5 hospitals in rural communities have closed – 3 of which were primarily serving acute needs.  29 hospitals are considered to be “at serious risk” of closing in rural Missouri communities that currently have a hospital.

This rings true for me and members of my husband’s family.  When we attended a family gathering in a county north of our home that had no hospital, my mother-in-law fell, hit her head, and needed stitches.  It took at least 30 minutes for an ambulance worker to reach the house of a family member that was down a long gravel road.  EMS cleared her to go to the hospital with us.  We had no idea how to get to a nearby hospital because we couldn’t use our GPS’s until we got out on the main road.  We finally figured that the closest hospital was over an hour away.   When we got there, my mother-in-law received the treatment she needed along with a staple puller similar to what I had used on a horse.  That was because a common problem that this hospital saw was people not being able to easily make it back to the hospital or see their GP to have them removed.  This allowed her the option of calling an EMT to do the pulling.  We were lucky to have found a hospital but had one of the people in our party been in labor, we would have been out of luck.  The nearest maternity ward was in our town which was about a 90 minute or more drive from where this family gathering was held.

It’s not a surprise that rural healthcare is a problem in Missouri.  Five out of seven of the counties surrounding mine have a hospital with OB services.  Until moving to Missouri, I don’t think I was aware of this issue.  Where I grew up outside Chicago, we had a hospital in walking distance from our house with OB services.  Most of the surrounding towns did, too.  Where I lived in the South East of England did not have an OB ward.  So, when I called EMT’s with extreme endometriosis related pain, they could not take me to the nearest hospital.  However, there was one 20 minutes away.  That alone upset me.  I would have to drive 20 minutes!  Now, though, I wish that was the case for rural American women.

Access to hospitals is not a Missouri-specific problem.  It is a problem throughout America.  And, honestly, it’s hurting moms.  CDC data show that Missouri ranked 42nd in the nation in maternal health outcomes.  This means that only 8 other states have a higher rate of maternal death.  One of the things the piece in the Missourian points out is that a lack of access to healthcare is connected to poorer maternal health outcomes for rural Missourians.

People in rural areas are less likely to practice healthy preventative skills than those in metropolitan or suburban areas, according to Matthews et al. (2017).  We know that maternal health outcomes are deeply affected by risks like heart disease.  If these rural populations are most at risk AND far from hospitals, we have to understand these disparities are important.  As we know that maternal health outcomes are deeply affected by risks like heart disease.  Pre-eclampsia is a leading cause of maternal death.  If these rural populations are most at risk AND far from hospitals, we have to understand these disparities are important.  This doesn’t even begin to cover situations where time is of the essence outside of pre-eclampsia.  If a woman labors at home with a CPM and is far from a hospital, she or her baby are in harm’s way.  If a woman quickly labors or suffers an abruption, this can be disastrous as well.

Rural healthcare for moms is further complicated because access to an OB or, god forbid, a maternal-fetal-medicine specialist for a high-risk pregnancy is also complicated.  The Missourian reports that the University of Missouri and other healthcare organizations in Missouri are trying to make telemedicine a viable option so that moms don’t need to travel for 2 hours each way and take an entire day off of work or to find childcare so that they can see a doctor.  Instead, with telemedicine, routine visits or follow ups can be done without travel.

Another option the literature in this area highlights is empowering local health departments with funding to provide primary care physicians or nurse practitioners and preventative care services.  This would allow rural residents to have better access to care prior to pregnancy and someone to follow up with if they need postpartum support and care beyond a four-week-followup with their OB.  Since women who experienced pre-e can need much more follow up care, this would be an option that could work for them without the barrier of travel.

However, rural health departments are overtaxed and underfunded (Harris et al. 2016).  Funding would certainly assist these centers in better meeting the needs of their populations.  Another approach highlighted in McKenney et al. (2017) is the “health navigator” approach.  In this way, health navigators are trained to best assist those with chronic conditions or health issues.  The article highlights the benefits of this approach for women’s health conditions, where serious barriers have deep impacts on maternal health outcomes.  McKenney et al. argue that, to be effective, patient navigators don’t have to be doctors or nurses.  They just need to be trained on how to spot barriers and overcome them (troubleshoot for patients).  These navigators could be people at WIC offices, social workers, case managers for Medicaid, or health department staff.   A small investment in this approach could have big benefits for rural health departments and the women they serve.

Overall, rural healthcare is an issue that has grave consequences for women.  It is time we begin to address this disparity.  The next blog post is going to cover yet another serious issue facing maternal health – race.

Works cited:

• Harris et al.  2016.  “The Double Disparity Facing Rural Local Health Departments.”  Annual Review of Public Health 37: 167-84.
• Matthews et al.  2017.  “Health-Related Behaviors by Urban-Rural County Classification – United States, 2013.”  U.S.  Department of Health and Human Services 66(5).
• McKenney, Kathryn.  2017.  “Patient navigation across the spectrum of women’s health care in the United States.”  American Journal of Obstetrics and Gynecology.