How Some Rural Communities Maintain Access To Labor And Delivery

Financial Aids

One suggestion is affiliating with a Health Resources and Services Administration Teaching Health Center Graduate Medical Education program. If working with a Federally Qualified Health Center, then malpractice insurance is covered by the Federal Tort Claims Act Program. Also, hospitals working with an HRSA center gain access to residents in training, who are supervised by faculty.

Some states have a special Medicaid add-on payment per delivery (of $1,500) for rural birthing hospitals. Other places suggest local government ownership of hospitals, funded from taxes.

Bundling care is when reimbursement covers prenatal, delivery, and postpartum care. If two hospitals want to collaborate, an unbundled reimbursement is likely better.

Another proposal, from Harold Miller, the president and chief executive of the Center for Healthcare Quality and Payment Reform, is that hospitals should receive “a standby capacity payment” from insurers to “support the minimum fixed costs of maintaining labor and delivery staffing in that community regardless of how many births there are. “After all,” as Miller told the New York Times, “we don’t fund fire departments based on how many fires there are every year.”

Some programs also focus on reducing the risk of pregnancies. They include advanced education and training for clinicians.

Staffing Aids

Some places use rotating locum tenens (substitute) obstetricians. In Shattuck, Oklahoma, a certified nurse midwife handles low-risk births and OB-GYNs rotate in for a week at a time to attend to high-risk deliveries and gynecological surgeries.

Others provide telemedicine consultations for high-risk pregnant women. Another has a perinatologist who comes to the hospital periodically for high-risk pregnancy consultations.

Texas plans to provide maternal simulation training to emergency room doctors at 11 rural hospitals, most of which don’t provide obstetrics.

Have you heard of destination weddings? Western Wisconsin Health worked to position itself a destination hospital for births by focusing on holistic, natural approaches to maternal and infant health. By marketing itself as “the birth experience you [mothers] deserve,” it has drawn families from the Twin Cities suburbs in Minnesota and from across state lines.

This is the kind of vision that the Miles Delivery Action Coalition has.

Western Wisconsin Health also provided excellent care, with a cesarean section rate of 3.9% among low-risk patients, compared with a national average of 25.7% (2019). They also achieved a 96% vaginal birth after cesarean success rate (vs. the national standard of 60%).

Dr. Stephanie McCullough, a family practice physician who does deliveries, said, “To blame it on a lack of skilled physicians is disingenuous because they just hired two OB/GYNs to take this shared position.” She added, “They’ve never considered growing surgical FPOBs like me.”

One particularly gruesome note is that although general surgeons and Family Practice OBs have experience and training to do C-sections, the MaineHealth administration will no longer let them do so. The one exception is a perimortem C-section, if it is within 4 minutes of the woman dying.

Attendees at protests here in Maine held banners that read, “WHAT HAPPENS TO OUR COMMUNITY IF YOU CAN’T BE BORN HERE, YOU CAN ONLY DIE?”

Proposals From The Miles Delivers Action Coalition

As one MDAC member noted, MaineHealth’s CEO receives a salary of more than $2.2 million/year. Shouldn’t he be able to present some creative solutions?

The Miles Delivers Action Coalition had a vision for turning their maternity center into a referral center and a nationally recognized model for rural maternal and infant healthcare, as Western Wisconsin Health did.

MDAC would be building on a strong foundation.

The Chartis Center for Rural Health named LincolnHealth as one of the Top 100 Critical Access Hospitals in 2023 and the Leapfrog Group named it a Top Rural Hospital. Miles and the Family Birth Center have also received national recognition for adopting World Health Organization baby-friendly practices.

The Coalition’s plan has 8 objectives. Among them is to increase births at Miles through collaboration with midwives, education, regional referrals, and a strong VBAC (vaginal birth after C-section) program. Currently, many women choose to deliver elsewhere. The coalition has no doubt they can turn this around:

—Through telemedicine, advanced ultrasound, simulation training, and specialty partnerships, MDAC believes that more moderate-risk pregnancies could be managed locally.

—Become MaineHealth’s Rural Innovation Laboratory, including telehealth, remote monitoring, a focus on maternal mental health, and emergency preparedness training.

—Increase long-term patient retention. A birth concierge program would likely improve maternal outcomes by providing support for everything from transportation to mental health to lactation support.

—Build on their current reputation for excellence, they believe Miles could become a national demonstration site, using the Rural Health Transformation Fund and one that makes full use of HERSA grants and private foundations.

The Fight Isn’t Over

One of MDAC’s attorneys, State Senator Joe Baldacci, says they intend to file for a permanent injunction because the risks for the mother and pregnancy are significantly higher, given the delays they will have in receiving adequate care.

Stay tuned for what happens next. Locals expect MaineHealth to turn Miles Hospital into an outpatient surgicenter or urgent care center soon, as they did in Boothbay Harbor. While they have agreed not to close more labor and delivery units for 2 years, that is no consolation for the five that they have shuttered just this year, and puts many more women at risk as maternity deserts expand throughout Maine.