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Hospitals and Maternal Health in Rural America, with John Supplitt, Aisha Syeda, Virginia Uhlenkamp, and Ashleigh Wiederin

Date: August 2, 2022
Duration: 33 minutes

John Supplitt Aisha Syeda Virginia Uhlenkamp Ashleigh Wiederin
An interview with John Supplitt and Aisha Syeda from the American Hospital Association, and Virginia Uhlenkamp and Ashleigh Wiederin from St. Anthony Regional Hospital in Carroll, Iowa, discussing the role of rural hospitals in maternal health.

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Organizations and resources mentioned in this episode:


Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. This is part one of a multi-part series about maternal health in rural America. Today we have four guests. We're going to be talking to John Supplitt, the Senior Director of Field Engagement in Rural Services at AHA, along with Aisha Syeda, who's the Senior Program Manager of Strategic Initiatives at AHA, as well as Virginia Uhlenkamp, the director of The Birth Place at St. Anthony's Regional Hospital in Carroll, Iowa and Ashleigh Wiederin, an Outreach Coordinator at The Birth Place. Thank you all for joining us today.

John Supplitt: Thanks for having me.

Andrew Nelson: And John, I'll start with you. In the last few years, what kind of changes have you seen occur in the availability of rural OB services?

John Supplitt: I have to say, Andrew, that is a loaded question. We've seen quite a difference in the last few years in terms of the availability in access to rural OB. Rural communities in the United States have higher rates of both infant and maternal mortality, as well as serious pregnancy complications. And then this becomes exacerbated by the limited healthcare access, and based on AHA annual survey data between 2015 and 2019, there were at least 89 obstetric unit closures in US rural hospitals and more than 50% of rural counties have no hospital-based obstetrical services. So maternity care deserts have a higher poverty rate and a lower median household income than counties with adequate access to maternity care. And most of these deserts occur in rural areas. So for both women and infants, the risk of death, it's elevated among Black and Indigenous people.

Andrew Nelson: Can you expand a little bit on how these issues affect rural patients in general?

John Supplitt: Well, it affects them in numerous ways. It's one to say that we have a lack of number of services, but that lack of services stems from the lack of clinical capacity in order to provide those services in the community. And in the absence of those services, then patients are required to travel longer distances and there's literature that really shows not only the distances that are being traveled by patients in order to access OB services, but how that travel can, in fact, complicate the delivery of care once they arrive at their destination. So we've seen a lot of changes that have taken place, and unfortunately, most of those are on the negative side.

Andrew Nelson: So, that certainly causes a lot of difficulties on the patient side of things. From a business perspective, what are some challenges for Critical Access Hospitals and other labor and delivery services?

John Supplitt: Well, Andrew, to provide the services, it costs money. And once upon a time, obstetric services was seen as a loss leader. It was a way in which rural hospitals could connect with their community and bring the patients, the moms and the infants into the hospital and keep their loyalty throughout the duration of their lives in the community. Yet the single greatest challenge today is the lack of clinical capacity to perform safe deliveries, followed very closely by the cost of both services. And as I mentioned, there was the time when rural hospitals that had access to clinicians were willing to fund these services as a loss leader to meet that community need and then create those lifelong loyalties, but in the absence of the needed clinical capacity, hospitals are no longer willing to fund obstetrics and therefore, you're seeing them close the service. Today, most, as in of a ratio of more than two to one, babies are being delivered by family physicians and not obstetricians.

And the demand for the service is greater than the supply of the clinicians. How we train rural family docs then and how we supplement the shortage of obstetricians through midwives and doulas is critical then to meet the demand for the service. In addition, there's a need for improved coordination between rural hospitals that don't provide obstetric care and then regional hospitals that have obstetric care capacity, which could be accomplished through regional perinatal quality collaboratives and telemedicine networks. And I think when we talk to the folks from St. Anthony Regional Hospital in Carroll, they'll help us understand how they're doing it within their region of West-central Iowa and how it's working for them.

Andrew Nelson: And Virginia, as I mentioned earlier, you're the director at the birthplace at St. Anthony's. How was St. Anthony's able to improve their birth outcomes after the community health needs assessment they had in 2016?

Virginia Uhlenkamp: One of the things that was identified was mental health issues. And of course, that affects everyone across the board, whether they're moms, families, it just is a trickle down through the whole community. So one of the things addressed was the depression screening referral on all moms, both prenatally and postpartum, and then referrals made depending on what is shown through those screenings. Another initiative that was brought forth was what they call post-birth warning signs. And this was an initiative by AWHONN, the organization for neonatal and obstetric nurses. It focuses in on warning signs postpartum, related to hemorrhage, related to depression, related to preeclampsia, so it is an education package that every mom gets when they deliver here about those post birth warning signs. And it's very clear about when to call and when to come to the hospital, two categories. Do not pass go. It's a great education program.

The other thing that St. Anthony has done is joined the Iowa maternal quality coalition. And it is a group of hospitals throughout the state that have come together to bring the best practices forward and especially valuable for the rural hospitals like ourselves. And one of their primary focuses this last year was reduction of the primary C-section rate by 10% across the state. Of course, we established that goal for ourselves here at St. Anthony and we're able to accomplish that.

And obviously, if you reduce that primary C-section rate, you are going to reduce the morbidity and mortality for both mom and babe. And some of the strategies were to use best practice algorithms in managing a labor and managing that baby on the monitor that just isn't giving you good information about its wellbeing. Those are always the one that we're like, how long can we stare at this monitor and let this go? When do we need to make our move? What kind of interventions can we do to ensure a healthy outcome? And that has been a huge boon to hospitals across the state. Their next package of quality measures will be related to obstetric hemorrhage.

We've looked at our early elective inductions, induction of labor as certainly on the rise throughout the nation. And lots of studies out there related to elected inductions before 39 weeks, meaning there's no medical indication. And so we've looked closely at those. Those are evaluated on a case by case basis. The other thing we've looked at and this is all through IMQCC, is the family centered experience. And one of the things we've looked at is skin to skin contact after delivery. We do it so well for our vaginal deliveries, but this expanded that to the OR, so it's related to that whole C-section initiative. The IMQCC has just been a wonderful thing because it brings best practices across the board.

Andrew Nelson: Yeah. And Ashleigh, you're the outreach coordinator at St. Anthony. What role does outreach play when it comes to providing maternity services specifically?

Ashleigh Wiederin: It's an important piece of it. In our area, we have three hospitals currently within a 45 to 60 mile radius that deliver. The OB units that have closed, six hospitals within the last, I think it's 17 to 20 years in our area, have closed their obstetrical units. So we're seeing that's just where we're at. So outreach, most of our patients come from the six surrounding counties. However, on any given year, we will have families come from anywhere from 10 to 13 different counties. So having communication with other hospitals and organizations is extremely important. When it comes to serving the patient and meeting their needs, that takes knowledge of services available that they can access. And also allows a better understanding of where gaps in care might be and creates that opportunity to build partnerships and really maximize the efforts in the area.

So providing labor and delivery service isn't just about that two to three day stay in the inpatient unit. It really starts in that prenatal or even preconception period where making sure we have a healthy mom to begin with, supporting her through the pregnancy, does she have access to healthy foods to support the growth of the baby and transportation to her prenatal appointments, all of those things, addressing mental health things and connecting them with services they need there that all still affect the outcome for that mom and that baby.

And so honing in on outreach and being able to build on those connections and know what we can do is really important. We recently received some funding from the Iowa Department of Public Health. Their Center of Excellence Grant Program has allowed us to really expand on that a little bit. It's provided us with the availability for some of that outreach education that we're doing with the EMS crews and the other hospitals, as well as just expand on our general outreach program, making connections, building partnerships with other organizations and just looking at how we can, again, really maximize everyone's efforts for the best interest of the patient and making sure all their needs are met.

Andrew Nelson: What are some steps that rural hospitals can take to ensure patient safety and quality of care, even if they have low volumes?

Ashleigh Wiederin: Some of the things that can be done are just the simple things that might be overlooked for that, but continuing to provide opportunity and to the staff that are there to enhance their skill set and their comfortableness with providing that service. It's also a great way to keep staff engaged, which leads into a workforce issue that we're also facing in the rural area and offering those services, so allowing them to expand on their skills and feel connected to their organization, that they're supported all plays into that. Basic communication with the staff on their comfort level of providing these different skill sets and finding out where they don't feel as comfortable and then identifying ways that they can improve that, so really just the communication. For low volume hospitals, one opportunity to keep up on those skills is through simulation labs, through sim labs.

We're fortunate to have a great simulation lab where those real-life scenarios can be practiced. So this is a great way to stay active in treating not only for your low volumes, but just treating those low occurring instances, those low occurring conditions that we see with patients. Obviously, we do everything we can to prevent a compromised situation on the front end so we don't encounter those. So that's another thing that we may not have a lot of experience or exposure to.

So doing simulation drills with those scenarios is a great way to make sure that if we're encountering those situations, that we're equipped to provide that high quality care and expose the new graduate who may not have had the opportunity to experience that during their orientation because we don't see it as often or even a nurse that's been working for a while, but just hasn't had the opportunity to go through that scenario.

So I think that just continuing that education, continuing that communication and then part of what we try to do as well as the drills is just have planned simulation as part of our staff meetings and that kind of thing. So we can talk through the situation with everybody from our team there. And you can pull those experienced nurses that have gone through that situation and said, "When I went through this, this is what I learned, and this is how we can improve upon our practices."

Andrew Nelson: I'll ask Ashleigh this; for rural hospitals that don't provide labor and delivery service, inevitably, they're going to be emergency situations that arise. What are some of the things that hospitals can do to prepare and be ready for those situations?

Ashleigh Wiederin: I think acknowledging that the service is limited and that we are going to start seeing those things happen. We're going to start seeing more out of hospital deliveries or patients presenting to emergency rooms where those services aren't available. So looking at that as your own organization and saying, okay, what are we going to do to help prepare for this situation? And then, again, looking for those opportunities to keep skills sharp, a hospital who may have recently closed their obstetrical unit still has staff who participated in it previously. And so keeping them up-to-date on what to do, have a plan as far as what team members you're going to pull into a situation like that, and looking at how you're going to handle that again, just because you aren't offering a service continuing to keep their education current and know what best practices are. And then looking for the opportunities to participate in things that are available.

We have recently, through our outreach efforts, been offering educational opportunities to our hospitals who aren't delivering and even those who are in the area still delivering, but have lower volumes of neonatal resuscitation and the stable program, the stabilization of that newborn for transfer and looking at ways that we can get that training out to those hospitals that aren't seeing the deliveries, to help them prepare for a situation. And again, another area that we looked at, making sure that they were educated are our EMS crews, making sure that our ambulance crews and those frontline workers are prepared to go and meet that family at the side of the road and help them work through that delivery and that they are equipped to provide that service and really create the best possible scenario for a good outcome.

And so the goal of that outreach education is to collaborate with other hospitals, to collaborate with the EMS services and say “this is a problem in our region and we're going to work together to address that.” Here's what we can offer through that simulation lab, those kind of things, to really help you guys feel supported as well because it affects everyone.

Andrew Nelson: Yeah, definitely. Right now, workforce is definitely a major challenge for healthcare across the country. It certainly affects the provision of maternity services as well. Virginia, what challenges have you seen rural hospitals face when they're trying to recruit healthcare providers?

Virginia Uhlenkamp: Well, obviously recruiting both providers and nursing staff is an issue. We are fortunate enough here at St. Anthony to have the volume of deliveries that allow for a well-built practice for a provider, as well as to allow for those nurses to maintain competency. And there are nurses out there who have a passion for OB and you just have to find them.

The other part of that picture is being in a small community like this, our providers, as well as our nurses, they're part of the community. You take care of your friends, your neighbors, your relatives, people that you're going to see again. As a provider, you establish those relationships throughout the community. You know your patients, you know your patient's families. It just provides a better experience all our way around. And I think that's one of the strong points for recruiting is the small community. These are people you're going to see again. And our volume is enough to keep our skills current, both adding that support to providers and nurses. We have been fortunate to hire two new graduates out of the 2021 class and three new graduates out of the 2022 class, so very fortunate, as well as have experienced nurses on staff. And that's been a huge boon to those new grads to have those mentors.

Andrew Nelson: In your position at St. Anthony's. Do you have any recommendations to address the supply of health professionals that are willing to provide maternal health services in rural areas?

Virginia Uhlenkamp: I think it's so important to provide residencies or preceptorships student experiences. That's been huge across the board in our hospital for anesthesia services, for providers. Both of our clinics here in town host medical students to experience the family practice way of life in the small community. We have radiology students. Obviously, we have several nursing schools in the area that do their experiences, plus we provide preceptorships even from some of the larger universities if those nurses are willing to travel here or are from here.

That would be the biggest thing is to provide those medical residencies in the small communities to get those students familiar with what it's like to practice in a small area and the strengths of that practice. The St. Anthony Foundation does offer scholarships, a number of them, for health-related fields, everything from EMS, nursing, general, anything healthcare related. And I think sometimes when those scholarships are given to local students, it gives them the sense of community support and maybe make them more likely to come back to their community to serve the people that have sent them on their way. And I think that's a great thing that the St Anthony Foundation has started.

Andrew Nelson: Certainly, we've all seen how COVID-19 helped to increase utilization of telehealth in particular. Are there any newer communication technologies or forms of telehealth you've found that have really improved communication between providers?

Ashleigh Wiederin: We continue to look for ways to utilize telehealth more. One thing that we have definitely implemented is the access to mental health services through telehealth and again, outreach, sending our mental health providers to other hospitals and providing that service available closer to the patient. One communication tool, it's new to us so we're still figuring it out, is a platform that we use internally, Telemedic. We know that text messaging is becoming the way to communicate with people and our nursing staff and providers were exchanging messages through that way. And so we were looking, obviously, for a secure way to provide them with patient information. So this platform allows us to do that in a similar way. And then it also has different things built into it where if the provider hasn't looked at a message at a certain amount of time, it kind of re-pings them to know that, hey, you have something about a patient waiting for you.

And then on the other end of it, the nurse can see if the provider has looked at that message or not, so to know if, okay, I really need to follow up. We really don't use it for super urgent situations. Best method is always to just try to call the provider and speak to them in those instances, but we are looking at ways that we do that.

One thing that we use technology or a way to reach patients education-wise is one of our online platforms that we use, our education tool, it's called YoMingo. So again, we find patients will turn to a search engine to look up their question. So we wanted and found it important to offer them an app is what it is that they can put on their phone or their computer that they can access that has reputable information about whatever question they may have related to their pregnancy or even the baby afterwards. So a couple of the technologies that we have looked at using and again, we're always looking at telehealth and how we can utilize that more. It's just something that, especially for the obstetric world, that we just have to think through a little bit.

Andrew Nelson: Yeah. I can see how it could be really helpful to have something like that that might be accessible on a mobile device or something rather than just being tied to a computer in the workplace.

And so turning to Aisha, you're the senior program director of strategic initiatives at AHA. As John mentioned earlier, maternal mortality rates in the United States are high compared with other developed countries. And they're even a higher for rural residents in certain racial and ethnic groups. What are some of the factors that contribute to maternal health disparities?

Aisha Syeda: Yeah, that's absolutely right, Andrew. Rural residents have a 9% greater probability of severe maternal morbidity and mortality. And we also know that American Indian/Native Alaskan and Black women are two to three times more likely to die from pregnancy-related causes than white women, so there are various disparities that contribute to these numbers. In rural communities, we see more people with lower socioeconomic status, higher rates of incidences of hemorrhage. There's limited access to healthcare specialists due to shortages of OB-GYNs practicing rural hospitals. John also mentioned that rural hospitals are closing down more often now. There's lack of insurance coverage and then it even gets more challenging when you have to travel so far out to just get some basic obstetric services, those are just to name a few, but we also want to highlight the role of historic and ongoing racism, discrimination, and implicit bias that contributes to maternal health disparities. Research has shown that women of color have reported not feeling heard or listened to by their providers during their pregnancy.

We've also seen higher rates of stress and anxiety and prenatal depression in Black moms. And additionally, infant mortality rate is also affected by this, so it's higher in Black infants compared to white and other racially diverse groups. So there's a bunch of factors that contribute to these numbers. But as time goes by, we are recognizing that we have to address these factors. So hospitals are working towards addressing these factors and these disparities to provide better and equitable care to women and their babies. So for example, we've seen hospitals adapt the AIM's maternal safety bundle on reduction of peripartum racial and ethnic disparities. We've seen hospitals provide implicit bias training, culturally competent care training to better equip their providers in understanding their patients' needs and wants in their pregnancy or post-pregnancy journey.

Hospitals are also starting to work with nursing schools and medical schools to integrate these concepts of social determinants of health, social needs, societal factors that influence health, implicit bias, culturally competent care, all of that into their curriculum to better educate the future generation of providers and nurses. So we're better suited to address these challenges as they come forward. And that our providers and our nurses are equipped with the training and the knowledge to serve different types of women and people that are coming into their hospitals.

Andrew Nelson: Those are some ways in which rural hospitals can work to improve health equity for mothers and their babies. Can you give us some examples of external services that rural hospitals can direct families to in order to provide further support before, during, and after pregnancy?

Aisha Syeda: Yeah. So a couple things come to mind. I think what hospitals definitely are doing now are looking into screening for social determinants of health and social needs that are impacting women. So we've seen rural hospitals partner with community based organizations outside, obviously outside of clinical walls and then social service organizations to refer patients to when a positive screen comes along. So having that support and having those resources in place and having those partnerships in place have been really helpful for rural hospitals to build a connection and just have a repository of resources that they can direct moms to. We've also seen an example of a hospital called Brookings Health System from South Dakota that had their first free doula program. It's staffed by volunteers who went to a doula training, are supported by the regular medical staff. And they're really there to just provide additional support to moms during their pregnancy and delivery and postpartum journey.

Sometimes doulas being members of the community has helped patients be more open to them about what they really want. And then having doulas communicate that to the provider has been helpful because it builds a connection with the patient and the doula. Patients might not be comfortable with sharing some of their challenges with the providers. And that's where the doula comes in. They are from the community, most likely from the same ethnic or cultural background where patients might feel more comfortable sharing their needs and wants with the doulas rather than providers. So they become that medium to build a better way of providing coordinated care. So Brookings is one of those hospitals that have that doula program and that they've seen great outcomes from it. And then another example is St. Peter's Health in Montana. They have a program called Taking Care of You, which is really focused on screening for perinatal mood and anxiety disorders and then referring families and moms to community resources to better support when a need has been identified. So those are some external services that hospitals are providing.

And lastly, I know we've talked about tech-based solutions or tech-based approaches and some hospitals are leveraging those tech-based solutions and digital solutions to reach more people in their served rural communities. And they're doing that by making sure that these solutions are running on local cellular network or they are text-based services because every phone now you can text, rather than having high speed internet, rather than way of broadband.

So some hospitals are being mindful of making sure that there's that digital health equity aspect to their solution that they're providing for their rural residents and communities. As the American Hospital Association, we're always trying to gather feedback and input from all the different work hospitals are doing to better improve maternal health outcomes. So just learning from St. Anthony's work and learning from other hospitals and being that medium to share what's working and what the best practices are, has been really rewarding. So I just want to say thank you to St. Anthony Regional Hospital for all the work that they're doing to improve outcomes from moms.

John Supplitt: Andrew, after listening to our friends from St. Anthony's and Aisha, I think there are some policy solutions and actions that are needed and we can take. First and foremost, we need to eliminate maternity care deserts by implementing perinatal regionalization and addressing the social determinants of health like transportation and the Rural Maternity and Obstetrics Management Strategies Program, or RMOMS, which was established by the Federal Office of Rural Health Policy has been very effective in this way.

I think another policy solution is we need to expand Medicaid or keep the Medicaid expansions that are there in place and to extend Medicaid postpartum coverage and create a family leave system. We talked about telehealth, but we need to improve broadband in rural areas in order increase access to clinicians and specialists. And we must improve access to care by funding emergency training. We talked about that, but family docs need that extra training in order to provide quality care and be more comfortable in their role in delivering babies and then expanding access to certified midwifery, reimbursement for doula care, and then the effective use of community health workers. I think all of these policy solutions are things on which we can act, which will make a huge difference in terms of the accessibility for obstetrical services for rural communities.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today, we spoke to John Supplitt and Aisha Syeda from the American Hospital Association, as well as Virginia Uhlenkamp and Ashleigh Wiederin from St. Anthony's Regional Hospital in Carroll, Iowa. Look in our show notes for more information about their work and visit for all things pertaining to rural health. Join us next time as we continue our multi-part series on maternal health here on Exploring Rural Health.