August 18th 2024.
Cheianne Pogline, a mother of four, shared that her experience receiving prenatal care for her first child was relatively easy. The hospital where she planned to deliver was conveniently located just seven minutes from her house. However, things became significantly more difficult with her next three pregnancies. In 2019, Cheianne and her husband moved from Craig to Parachute, which meant that the closest options for obstetrical care were now an hour away in either Glenwood Springs or Grand Junction. Then, in 2022, they moved back to Craig and discovered that Memorial Regional Health had stopped offering maternity care. This meant that the closest option was now in Steamboat Springs.
Unfortunately, Cheianne is not alone in facing this challenge. In fact, two out of every five counties in Colorado do not have a place for women to give birth, nor do they have providers who specialize in pregnancy care. As a result, these women are more likely to miss out on prenatal care and have less healthy babies compared to those who live closer to these services. Reopening hospital birthing units is not a feasible solution for many of these communities, so they must find alternative ways to address this issue.
Cheianne was fortunate enough to receive some care through a UCHealth outreach program where obstetricians from Steamboat Springs would visit Craig. However, she still had to make an 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 couldn't help but worry about the possibility of going into labor early.
According to March of Dimes, a non-profit organization, 25 out of Colorado's 64 counties are considered "maternity care deserts." This means that they lack a hospital or birthing center that offers deliveries, as well as an obstetrician or midwife. This is a higher percentage compared to the national average, which is about one-third of counties.
Rebecca Alderfer, CEO of the Colorado Perinatal Care Quality Collaborative, stated that they have not yet studied the health outcomes in these counties. However, the state's most recent maternal mortality report revealed that mothers in the least-populous parts of Colorado, where access to care is limited, have a significantly higher risk of dying during pregnancy or the postpartum period compared to urban-dwelling mothers. In fact, the risk is four times greater. This means that for every 10,000 births, there are 8.2 deaths in the most remote counties, compared to 2.2 deaths in urban areas.
While the long drive to the hospital may seem like the most daunting aspect of this issue, the lack of access to routine care is actually the bigger problem. Conditions can go untreated, leading to potentially negative outcomes. To address this, the Colorado Perinatal Care Quality Collaborative is working with other organizations to increase remote monitoring of patients, bring midwives into rural areas, and train local doctors to handle pregnant and postpartum patients' physical and mental health. This is critical, as suicide and overdoses are the top causes of maternal mortality in Colorado.
The study conducted by Colorado State University's Regional Economic Development Institute also showed that pregnant women living in maternity care deserts were more likely to start prenatal care later in their pregnancy compared to those who live closer to care facilities. They also have higher rates of premature birth and infant mortality.
Dr. Laurie LeBleu, an obstetrician-gynecologist with UCHealth, who regularly sees patients in Craig, stated that not all communities can support a hospital labor and delivery unit or a birthing center. However, they do need a provider who can offer prenatal care at least once a week, as well as transportation options for families to access care that is not available locally. In an uncomplicated pregnancy, a birthing parent would see a doctor every four weeks in the first 28 weeks, every two weeks until week 36, and then once a week until week 40. If the pregnancy goes past the due date, more frequent monitoring may be necessary.
Unfortunately, Memorial Regional Health in Craig stopped delivering babies four years ago. When they still had an obstetrics department, UCHealth would send a provider from their Steamboat Springs location once or twice a week to meet the extra 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, according to Ryan Larson, director of clinic operations at UCHealth Yampa Valley Medical Center. For women with complicated pregnancies, the drive may be more frequent, as additional monitoring may be needed. The system is currently working on installing a machine that would allow for more monitoring to be done in Moffat County.
Dr. LeBleu also shared that caring for rural patients requires being proactive and sometimes taking steps that providers wouldn't normally take in urban areas. This may include scheduling an induction before the due date if a patient may not make it to the hospital in time. However, roadside births do happen occasionally. In fact, Dr. LeBleu recently talked a father through the basics while the family waited for an ambulance.
Denise Smith, project director for the Colorado Rural Midwifery Workforce Expansion program, shared that some rural hospitals have expressed interest in bringing labor and delivery, or at least prenatal care, back to their communities. 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 other locations, but they are not able to perform cesarean deliveries.
Smith's goal is to have a midwife available in every community, but she acknowledges that the odds of recruiting obstetricians to rural areas are slim. However, hospitals could potentially restart their birthing programs with 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 so that they don't lose money. On average, commercial insurers pay $9,700 for an uncomplicated vaginal birth, while Medicaid, which covers 40% of births in the state, pays $3,200.
Unfortunately, Colorado's limits on the growth of state spending prevent them from significantly increasing Medicaid rates for births. This may save taxpayers money, but when services are unavailable, families are left to bear the costs, including gas, lost work time, and potentially missed care. As Smith stated, "With the cost savings, it costs somebody something."
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