August 18th 2024.
According to Cheianne Pogline, her experience with receiving prenatal care for her first child was relatively easy. The hospital where she planned to deliver was conveniently located just seven minutes away from her house. However, things became significantly more challenging with her next three pregnancies. In 2019, Cheianne and her husband moved from Craig to Parachute, which left them with limited options for obstetrical care. The closest options were now an hour away in either Glenwood Springs or Grand Junction. But, when they moved back to Craig in 2022, they were faced with another hurdle - Memorial Regional Health had stopped offering maternity care. This meant that the closest option for Cheianne was now in Steamboat Springs.
Unfortunately, Cheianne's situation is not unique. In fact, two out of five counties in Colorado face a similar challenge due to the lack of facilities and providers specializing in pregnancy care. As a result, women in these areas are more likely to forgo prenatal care, which can lead to less healthy outcomes for both the mother and the baby. However, simply reopening hospital birthing units is not a feasible solution for many communities, so they must find alternative solutions.
For Cheianne, this meant being able 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. Although they were able to schedule the birth, Cheianne and her husband still had concerns about the possibility of labor starting early.
Currently, 25 out of Colorado's 64 counties are considered "maternity care deserts," meaning 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 of one-third, according to Rebecca Alderfer, CEO of the Colorado Perinatal Care Quality Collaborative. Although the collaborative has not yet studied the health outcomes in these counties, the state's most recent maternal mortality report found that mothers in the least-populated areas are at four times the risk of dying during pregnancy or the postpartum period compared to those in urban areas. This is a concerning statistic, as it highlights the urgent need for better access to care in these areas.
While the drive to the hospital may be the most dramatic aspect, the lack of access to routine care is the bigger issue. Alderfer explains that conditions can go untreated without proper care and monitoring. Therefore, the collaborative and other organizations are working together to implement solutions such as increasing remote monitoring of patients, bringing midwives into rural areas, and training local doctors to handle the physical and mental health needs of pregnant and postpartum patients. This is crucial, as suicide and overdoses are the leading causes of maternal mortality in Colorado.
The study by Colorado State University's Regional Economic Development Institute found that pregnant women living in maternity care deserts were more likely to delay starting prenatal care until five months into their pregnancy or later. They also had higher rates of premature birth and infant mortality. However, not all communities can support a hospital labor and delivery unit or a birthing center. But, at the very least, they need a provider who can offer prenatal care at least once a week and transportation options for families to access care that is not available locally.
Dr. Laurie LeBleu, an obstetrician-gynecologist with UCHealth, regularly sees patients in Craig, despite being based in Steamboat Springs. She explains that in a typical, uncomplicated pregnancy, the birthing parent would see a doctor every four weeks for the first 28 weeks, every two weeks until week 36, and then once a week until week 40. Those who go past their due date may need more frequent monitoring. However, for those in remote areas, this means traveling long distances, which can be a burden.
The Memorial Regional Health in Craig stopped delivering babies four years ago, and since then, UCHealth has increased its "outreach" presence to four times a week. However, pregnant patients still need to travel to Steamboat Springs at least twice, and those with more complicated pregnancies may need to make the drive more often for additional monitoring. The system is currently working on installing a machine in Moffat County that would allow for more monitoring to happen locally. Dr. LeBleu also explains that caring for rural patients means being proactive and sometimes taking steps that providers in urban areas may not, such as scheduling an induction before the due date if the patient is at risk of not making it to the hospital in time. Unfortunately, roadside births are not uncommon in rural areas, and Dr. LeBleu recalls a recent experience where she talked a father through the basics while they waited for an ambulance.
Denise Smith, project director for the Colorado Rural Midwifery Workforce Expansion program, says that some rural hospitals have expressed interest in bringing back labor and delivery, or at least prenatal care, to their communities. The University of Colorado's College of Nursing has received a $2 million grant to fund scholarships for aspiring nurse-midwives who agree to work in rural areas. Although it may be challenging to recruit obstetricians to remote areas, Smith suggests that hospitals could restart their birthing programs by utilizing a combination of midwives, general practitioners with obstetrics training, and an on-call general surgeon to perform cesarean births. However, the most crucial factor is that hospitals are financially stable and receive enough reimbursement for births, as commercial insurers only pay an average of $9,700 for an uncomplicated vaginal birth, and Medicaid pays $3,200. Unfortunately, Colorado's limits on state spending prevent significant increases in Medicaid rates, but when services are no longer available, families bear the costs in other ways, such as paying for gas, losing work time, and possibly missing out on necessary care.
In conclusion, the lack of access to proper prenatal care in rural areas has serious consequences for both mothers and babies. It is essential for communities to get creative and find alternative solutions to combat this issue, such as increasing remote monitoring, bringing in midwives, and training local doctors. While not all communities may be able to support a hospital labor and delivery unit, it is crucial to have a provider offering prenatal care at least once a week and transportation options to access care elsewhere. The goal is to have a midwife in every community and to ensure that hospitals are financially stable enough to provide necessary care for families in remote areas.
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