Rural Health Advisory Committee s Rural Obstetric Services Work Group

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Andrea Cobb
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1 Rural Health Advisory Committee s Rural Obstetric Services Work Group March 15 th webinar topic: Rural Obstetric Patient and Community Issues Audio: , conference code

2 Rural Obstetric Patient & Community Issues Today we will cover Patient Issues Costs and travel Access to prenatal care Cesarean deliveries Support for high-risk pregnancies Cultural considerations Community Issues Importance of local OB access Care coordination across systems 2

3 Costs and Travel Fewer OB hospitals = costs, driving & planning Birth plan considerations Birth preferences Contingency plan for complications Rural birth plan considerations Childcare, weather, transportation Drive time (30-60 minutes) Pain management May induce after 39 weeks if distance is a concern 3

4 Access to Prenatal Care Early prenatal care = average 1 st visit at 9 wks No rural and metro difference (2007) Mothers beginning prenatal care in first trimester Minnesota 87% vs. U.S. 83% (2006) Range of prenatal appointments over three trimesters Assessments and screening Counseling and education No shows = skip appointments if no blood test or medications are needed, lack transportation 4

5 Prenatal Care Discussion Topics 91% - safe medications during pregnancy 87% - what to do if labor starts early 85% - tests for birth defects or diseases 85% - breastfeeding 76% - birth control following pregnancy 76% - testing for HIV 74% - how drinking affects fetal development 74% - how smoking affects fetal development 63% - how illegal drugs affect fetal development 55% - using a seatbelt during pregnancy 55% - physical abuse by husbands or partners 5

6 Barriers to Prenatal Care in Greater Minnesota 8.2% - could not get an appointment 5.4% - no money/insurance 4.4% - no MA/MNCare card 4.2% - MD/clinic would not start earlier 4.1% - wanted to keep pregnancy secret 4.0% - no child care 3.8% - too many other things going on 3.2% - no leave from work 2.1% - no transportation 6

7 Prenatal Care & Uninsurance Rural women are less likely to have insurance coverage. Statewide uninsurance rate (2009) = 9% Northwest = 14%, Central = 11% Southwest and Metro = 8% Statewide pregnant women uninsurance rate = 16.4% Rural = 17% vs. Metro = 15.9% Lack of insurance has been associated with lack of access to medical care, especially early prenatal care. 7

8 Cesarean Deliveries Rural women are more likely to have a cesarean delivery. Rural shortages of medical staff = medical interventions (induction or cesarean surgery) less likely to be offered vaginal birth after cesarean (VBAC). VBAC is safe and appropriate choice for most women with one prior cesarean, sometimes two Twins, +40 wks gestation, big baby or low vertical scar should not prevent women from VBAC 8

9 Cesarean Deliveries (2009) U.S. cesarean rate = 33% Fetal distress (most common) Position of baby (breech) Placenta previa (1 in 200 pregnant women) Uterine rupture (1 in 1500 births) Placental abruption (1% pregnant women) Birth defects, diabetes, active herpes Minnesota c-section rate = 27% 39% c-sections in rural hospitals were performed by family practice physicians (2007) 9

10 C-Section Rate by County of Residence 10

11 Support for High-Risk Pregnancies Rural women are more likely to have a low birth weight infant. Low Birthweight as a Percent of All Births = Minnesota 6.5% vs. U.S. 8.2% Rural vs. metro? more likely to have a preterm birth. Preterm Births as a Percent of All Births = Minnesota 10% vs. U.S. 12% Rural vs. metro? 11

12 Support for High-Risk Pregnancies Rural women are more likely to experience neonatal and postneonatal mortality. Currently about 70,000 babies are born in Minnesota every year, and about 380 babies die. 12

13 Support for High-Risk Pregnancies Early term complications Mid- to late term complications NICU facilities mothers referred before birth Level 1: No NICU (small rural) Level 2: Intermediate, NICU for mildly ill (large rural) Level 3a: Ventilation w/restrictions (metro only) Level 3b: Minor surgeries (St. Cloud, Fargo-ND, Grand Forks-MN/ND, LaCroix-WI Level 3c: Major surgeries (St. Mary s-duluth, Sioux Falls-SD) Level 3d: Pulminary Bipass, ECMO (metro only) 13

14 Capabilities of Providers in Hospitals Delivering Basic, Specialty and Subspecialty Care Level 1 (BASIC) Providers: Family physicians, obstetricians, pediatricians Level 2 (specialty) Providers: Obstetricians, pediatricians - Surveillance and care of all patients - Transfer of high-risk patients - Capability to begin emergency cesarean delivery within 30 minutes of decision - Anesthesia, radiology, ultrasound, lab & blood bank services on 24-hour basis - Resuscitation and stabilization of all neonates - Care of women at high-risk and fetuses, both admitted and transferred - Stabilization of severely ill newborns before transfer - Treatment of moderately ill, larger pre-term and term newborns 14

15 Capabilities of Providers in Hospitals Delivering Basic, Specialty and Subspecialty Care Level 3 (subspecialty) Providers: Maternal-fetal medicine specialists, neonatologists Regional subspeciality perinatal health care center - Comprehensive perinatal health care services for both directly admitted and transferred women and neonates of all risk categories, including basic and speciality care services - Evaluation of new technologies and therapies - Maternal and neonatal transport - Regional outreach support and education - Development and initial evaluation of new technologies and therapies - Training of health care providers with specialty and subspecialty qualification and capabilities - Analysis and evaluation of regional data, including those on perinatal complications and outcomes 15

16 Tribal Doula Perspectives Some Ojibwe people are connected to traditional ways; others do not know traditions Traditional ways Berry Ceremony (women coming of age) Follow moon for birth control Birth ceremonies and naming Sacred ability to give life; babies, children = good Traditional birth settings Surrounded by extended family; home, birth lodge Squatting position, smudge with cedar Retain piece of umbilical cord, placenta 16

17 Cultural Sensitivity in Rural Hospitals Doctor knows everything = passive patients Number of people in birthing room Medical interventions (induction, epidural) vs. natural progression (breathing, walking) C-section limits # babies = forced sterilization Baby connection w/mother after birth Open discrimination against young AI women Education needed for rural hospital staff UMN Center for Spirituality & Health (general) Ontario community project (traditional birth) 17

18 Discussion: Patient Issues 18

19 Access to Local Obstetric Services U.S. 18% of U.S. births take place in small or remote rural areas HOWEVER About 33% rural women live in counties with no OB/GYN 19

20 Access to Local Obstetric Services In Minnesota, 43% of births take place in nonmetro areas Rural hospital survey (n=101) Of the 101 rural hospitals in Minnesota, 76% offered obstetrical services Of the 79 hospitals in towns under 10K people, 71% offered obstetrical services 91.7% hospitals with obstetric services have family medicine physician providing services 20

21 Access to Local Obstetric Services Elimination of OB services Low patient volume Difficult to maintain staffing High proportions of Medicaid patients Many rural facilities replace the delivery ward with a shared-care model Local family medicine MD = pre-natal care Distant OB/GYN = delivery 21

22 Access to Local Obstetric Services Community awareness of OB services Local competition Recruitment Modern birthing facilities Local collaboration Call coverage Surgical coverage Training 22

23 Care Coordination Across Systems Regionalized perinatal care Transportation Electronic Medical Records Pregnancy and perinatal tracking Ultrasound imaging integration Risk management Patient education Telemedicine Diagnosis and continuous management 23

24 Discussion: Community Issues 24

25 Review of draft recommendations 25

26 Work Group Staff Contact Information Paul Jansen Mark Schoenbaum Kristen Tharaldson Office of Rural Health and Primary Care: 26

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