August 18th 2024.
Cheianne Pogline, a mother of four, shared her experience of getting prenatal care for her first child. She described it as a relatively easy process since the hospital where she planned to give birth was only a short seven-minute drive from her home. However, things became significantly more challenging with her next three pregnancies. In 2019, Cheianne and her husband relocated from Craig to Parachute, leaving them with limited options for obstetrical care. The closest options were an hour away in either Glenwood Springs or Grand Junction. When they moved back to Craig in 2022, they were disappointed to find out that Memorial Regional Health no longer offered maternity care. This meant that the closest option for them was now in Steamboat Springs.
Unfortunately, Cheianne's situation is not unique. In fact, two out of five counties in Colorado face the same challenge due to the lack of birthing facilities and specialized pregnancy care providers in their communities. As a result, women in these areas are more likely to skip prenatal care, leading to less healthy babies than those who have easier access to care. The solution of reopening hospital birthing units is not feasible in many places, so communities have to get creative.
To continue receiving care during her pregnancies, Cheianne was fortunate enough to be able to participate in a UCHealth outreach program. This program brings obstetricians from Steamboat Springs to Craig for appointments. However, she still had to make a long hour-long trip for her 20-week ultrasound and to meet with the doctor who would perform her cesarean delivery. While they were able to schedule the birth, Cheianne and her husband were constantly worried that she would go into labor early.
Cheianne's story is not an isolated case. According to March of Dimes, twenty-five out of Colorado's sixty-four counties are considered "maternity care deserts." This means that they lack a hospital or birthing center and do not have an obstetrician or midwife available. This is a higher percentage than the national average of about one-third. Rebecca Alderfer, CEO of the Colorado Perinatal Care Quality Collaborative, stated that the group has not studied the health outcomes in these counties. However, the state's most recent maternal mortality report revealed that mothers in the least populated areas, which often are care deserts, have a significantly higher risk of dying in pregnancy or the postpartum period compared to urban-dwelling mothers.
While the long drive to the hospital is often the most dramatic aspect, the lack of access to routine care is the more significant problem. Conditions go untreated, and this can have severe consequences. The collaborative, along with other organizations, are working together to find solutions. This includes increasing remote monitoring of patients, bringing midwives into rural areas, and training local doctors to handle the physical and mental health of pregnant and postpartum patients. This is critical as suicide and overdoses are the top causes of maternal mortality in Colorado.
A study from Colorado State University's Regional Economic Development Institute found that pregnant women living in maternity care deserts were more likely to report starting prenatal care five months into their pregnancy or later. They also generally have higher rates of premature birth and infant mortality. While not all communities can support a hospital labor and delivery unit or a birthing center, Dr. Laurie LeBleu, an obstetrician-gynecologist with UCHealth, believes that they need at least one provider offering prenatal care on a weekly basis and access to transportation to help families reach care that is not available locally.
In a typical, uncomplicated pregnancy, the birthing parent sees a doctor every four weeks for the first 28 weeks, then every two weeks until week 36, and finally once a week until week 40. However, women who go past their due dates may need more frequent monitoring. Unfortunately, Memorial Regional Health in Craig stopped delivering babies about four years ago. When the hospital still had an obstetrics department, UCHealth had a provider from its Steamboat Springs location visit Craig once or twice a week to meet the high demand in the area. Since then, they have increased their "outreach" presence to four times a week.
However, pregnant patients still need to travel to Steamboat Springs at least twice, which can be a significant burden. Dr. LeBleu explains that women with complicated pregnancies may have to make the trip more often for additional monitoring. However, UCHealth is currently working on installing a machine that would allow more monitoring to happen in Moffat County.
Caring for rural patients requires a proactive approach, sometimes involving steps that providers in urban areas may not typically take. This includes scheduling inductions before the due date if a patient may not make it to the hospital in time. However, even with these measures, roadside births are still a reality. Dr. LeBleu recalls a recent incident where she talked a father through the basics while the family waited for an ambulance.
Fortunately, some rural hospitals are interested in bringing labor and delivery, or at least prenatal care, back to their communities. Denise Smith, project director for the Colorado Rural Midwifery Workforce Expansion program, shares that the University of Colorado's College of Nursing received a $2 million grant to fund scholarships for aspiring nurse-midwives who agree to work in rural areas. In Colorado, certified nurse-midwives can prescribe medications and practice without a doctor's supervision. They can attend births in hospitals or elsewhere, but they are not allowed to perform cesarean deliveries.
Smith's goal is to have a midwife available in every community. However, the odds of recruiting obstetricians to rural areas are slim. To restart birthing programs, hospitals could consider a combination of midwives, general practitioners with obstetrics training, and an on-call general surgeon to perform cesarean births. Ultimately, the most crucial factor is that hospitals are financially stable and receive enough reimbursement for births to avoid losing money. Currently, commercial insurers pay an average of $9,700 for an uncomplicated vaginal birth, while Medicaid, which covers 40% of births in the state, pays only $3,200.
Unfortunately, Colorado's limits on state spending prevent significant increases in Medicaid rates for births, resulting in cost savings for taxpayers. However, when services are not available locally, families bear the costs of paying for gas, lost work time, and possibly missed care. As Smith puts it, "With the cost savings, it costs somebody something."
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