Many rural healthcare providers have harrowing stories of
delivering babies. Dr. John Cullen, a family physician in
rural Valdez, Alaska, and president-elect of the American Academy of
Family Physicians, shares his story from three years
A woman expecting twins entered the Providence Valdez
Medical Center (PVMC) on a Friday for a prenatal
appointment before planning to leave for Providence
Alaska Medical Center in Anchorage that following Monday.
PVMC's policy for multiple-birth and other high-risk
pregnancies is to have women stay in Anchorage (a
five-hour car ride) for the duration of their pregnancies
in case of any complications.
That Saturday, she returned to PVMC, a Critical Access
Hospital, because she was feeling pressure and found out
that – only 31 weeks into her pregnancy – she had already
dilated to seven centimeters.
The Valdez providers called in a NICU team from
Anchorage, but it would take the team 12 hours to reach
the CAH, due to a winter storm. If they transferred the
woman to Anchorage by air ambulance, they were concerned
that she might rupture her amniotic membranes on the way
and lose one or both of the babies.
Instead, thanks to PVMC's culture of practicing Cesarean
sections, staff were able to perform a C-section and save
the mother and her twins.
For small communities like ours, if you don't do
obstetrics, you're still going to do obstetrics. Only
you're not going to be able to handle the emergencies.
Stories like these remind PVMC staff why they keep their
labor and delivery unit open while other rural hospitals
are closing theirs. “For small communities like
ours, if you don't do obstetrics, you're still going to
do obstetrics,” Cullen explained.
“Only you're not going to be able to handle the
Challenges facing rural communities
According to research by the University of Minnesota
Rural Health Research Center, many rural areas are
losing their labor and delivery units. In 2004, there
were 1,249 rural U.S. hospitals with OB services. Ten
years later, that number dropped to 1,044. In 2014, 22.1%
of micropolitan counties and 69.8% of noncore counties
did not have any OB services. Counties with a higher
percentage of Black people were more likely to lose their
labor and delivery units.
There's not one problem, which makes it in some ways a
really difficult and complicated problem to solve. In
other ways, it presents a lot of opportunities because
there are a number of different areas in which to
“The challenges are multifaceted,”
said Dr. Carrie Henning-Smith, Deputy Director of the
University of Minnesota Rural Health Research Center.
“There's not one main villain. There's not one
problem, which makes it in some ways a really difficult
and complicated problem to solve. In other ways, it
presents a lot of opportunities because there are a
number of different areas in which to
One challenge includes guidelines that ask facilities to
be within a certain distance of another facility that can
perform C-sections. If a rural facility is farther away
than recommended, insurers may hesitate to provide
In addition, OB services are not always reimbursed at a
high enough rate for facilities to cover the cost of
keeping a labor and delivery unit open.
“Medicaid can have low reimbursement rates for
obstetric care, and Medicaid pays for more than half of
all births in rural areas,” Henning-Smith said.
The reimbursement rates vary by state.
The low birth volume in rural areas also affects the care
these facilities can provide. “There's a
financial issue,” Henning-Smith said,
“but more than that, it's difficult for them to
staff a birthing unit if they don't know how many
deliveries they're going to have in any given week or
month.” In addition, the low volume means that
employees struggle to maintain their skills, making them
feel less confident in delivering babies when they do
Two approaches for the present and the future
The 10-bed PVMC and the Valdez Medical Clinic cover a
service area the size of Ohio, and the CAH delivers about
50 babies each year. One family physician has been
working in Valdez for 35 years, while two physicians
started three or four years ago. Cullen has been working
in Valdez for 24 years.
There have been a lot of close calls, but if we hadn't
had the culture and the team that we have, we would've
lost [babies and mothers], and that's just not
“There have been a lot of close
calls,” Cullen said of delivering babies,
“but if we hadn't had the culture and the team
that we have, we would've lost them, and that's just not
PVMC cross-trains the four family physicians and the
nurses in fields like anesthesiology and surgery so that
any combination of doctors and nurses can deliver babies.
“The nurses that we have at the hospital are
absolutely amazing,” Cullen said,
“and they are cross-trained to such an extent
that they'll go from taking care of somebody who's having
a heart attack in the emergency room to helping deliver a
baby to going to the operating room.”
Initially, the CAH's obstetric services were vaginal
deliveries and emergency C-sections. “That was
not ideal,” Cullen said, “because it
was a lot scarier than it needed to be.” He
said that the nurses especially did not feel like they
had enough training to be comfortable with the C-section
When PVMC began to perform elective C-sections in 1996,
the physicians and nurses went through a number of drills
to prepare. “We had a Resusci Annie who had an
awful lot of C-sections,” Cullen quipped.
During a C-section, a surgeon and assistant perform the
procedure while a third physician watches over.
Cullen reported that PVMC's C-section rate in the last
five years was 18.6% of all deliveries (54 out of 289
deliveries), compared to the nation's
2016 rate of 31.9%. He added that the infant
mortality rate in his service area is less than 3.3
deaths per 1,000 births, compared to a rural national
average of 6.78 (National Vital Statistics System, Linked
birth/infant death data set, 2015).
Meanwhile, the University of Wisconsin-Madison is working
on training the next generation of OB-GYNs. About three
years ago, Department Chair Dr. Laurel Rice and her team
were able to create the nation's first rural track in
obstetrics and gynecology with a grant from the Wisconsin Rural
Physician Residency Assistance Program (WRPRAP). It
took two years to become accredited and develop
partnerships with rural hospitals in the state.
In 2016, UW-Madison began recruiting residents for its
new rural OB-GYN
residency program. Currently, the program recruits
one resident per year, and the program's first, Dr. Laura
McDowell, began the four-year training program in the
summer of 2017.
The program looks for residents who grew up in rural
areas, have completed a rural-based medical program like
Academy for Rural Medicine, and are interested in
general OB-GYN (instead of specializing) as well as
health disparities in rural communities.
McDowell was one of more than 100 applicants.
“For one spot, I know,” she said.
“That's the really humbling part.”
She completed an interview along with 11 other
applicants. The program invites rural preceptors to the
interviews so they can learn more about the applicants,
and then the applicants go on a field trip to one of the
rural rotation sites.
McDowell and future residents will complete 80% of their
training in Madison and 20% in rural communities within
an hour's drive of the state capital. “The hope
is that exposure [to rural communities] will not only
lead them to be more confident in their ability to go out
and practice but maybe feel like they're part of that
hospital or community and may even take a job at one of
the hospitals they rotate at,” said Jody Silva,
Rural Residency Program Manager.
One challenge facing the rural OB-GYN residency program
is the limited number of rural communities it can reach.
Since residents have to return to the same clinic every
Thursday, program coordinators do not send them to
rotations over an hour away from Madison. “The
most rural parts are obviously in northern
Wisconsin,” Silva explained, “but we
can't send them out to more of the remote places because
of the continuity guidelines.”
Silva hopes that the rural residency program will receive
more funding to increase the number of residency spots in
the future. “One of the things I've learned
over the course of developing this track is that people
are really interested in it,” Silva said. When
she holds a booth to promote the new program, medical
students tell her that they have seen rural tracks for
family medicine physicians but not for OB-GYNs, so
they're excited for this new opportunity.
It was really great to have integrated everything that I
have learned over the course of this year, and it
combines caring for women in both obstetrics and
This spring, McDowell completed her first rural rotation
in Portage, a community of about 10,300 people.
“That was probably one of my favorite
experiences so far this year,” she said.
“It was really great to have integrated
everything that I have learned over the course of this
year, and it combines caring for women in both obstetrics
and gynecology well.”
The biggest challenge for McDowell was adjusting from the
call experience she had at the academic center. There,
she would have a 12-hour shift and then go home, but in
Portage she was basically on call 24/7. “I was
even shielded from that [24/7 call experience] a fair
amount because my attending fielded the calls. Then she
would call me in,” said McDowell.
The joys of delivering rural babies
Despite the challenges, McDowell and Cullen find their
work rewarding. McDowell remembers one patient coming in
for a prenatal visit with a higher-than-usual blood
pressure reading. McDowell and her preceptor asked her to
come in for a follow-up visit. At that next appointment,
they diagnosed her with gestational hypertension and
recommended inducing labor.
“It was just really cool to see that trust in
that relationship that you develop seeing a patient
multiple times. She's like, 'Oh! Well, yeah, of
course,'” McDowell said. “Seeing her
through that whole process was really
One of the first babies Cullen delivered in Valdez was
via emergency C-section in the middle of a snowstorm.
Both the mother and baby survived, and Cullen said he
just recently saw the son around town.
“Just the absolute coolest thing in the world
is to watch kids that I've delivered grow up,”
Cullen said. “It just brings tears to my eyes,
every time I think about this, even though I see this
The clinic and hospital in Valdez also nurture a teaching
culture. Cullen and family physician Dr. Kathy Todd teach
new physicians coming to the area as well as medical
students and residents. Teaching the next generation and
cross-training the current staff means that medical staff
like Cullen and Todd can take vacations or retire
someday, knowing that the remaining staff is competent
and confident to face any challenges.
Rural preceptors have told Silva that bringing in
residents has helped them hone their own skills and feel
good about the future of OB-GYN services in their
communities. “Most of them are very close to
retirement,” Silva said, “so I think
it gives them peace of mind.”
New physicians also appreciate the chance to teach.
“It actually is a better recruitment tool for
newly graduated physicians if they know they're going to
be able to still be in contact with an academic
center,” Silva said.
Cullen added that being able to deliver babies has
broader implications for rural hospitals. For example,
his staff's ability to provide pain medication during
labor and anesthesia during C-sections means that they
can also provide anesthesia for appendectomies and hernia
repairs. Plus, the staff's commitment to cross-training
and practice drills allows them to better respond to
“I think that it's important not to look at
obstetrics just in a single silo, to see whether it's a
profitable center for the hospital,” said
Cullen. “Rather, look at it from a community
and global perspective: what the impact of providing
these services has for a community.” For
example, young families may be more willing to move to or
stay in a rural community if it provides obstetric
Other strategies to improve pregnancy outcomes
McDowell advises medical students and residents to gain
experience in a rural setting to make sure that's what
they want to do. She interviewed for some programs that
only offer a third-year elective and give students a
one-month experience in a rural facility. “You
don't get what it would be like to be at a place with one
OB-GYN or with five, with differences in practice,
community size, and what-not,” she said.
“I think that [the UW-Madison] program is
certainly unique in that way.”
Henning-Smith said that facilities could look into
simulations and trainings to help their staff maintain
their skills. A scholarship for an OB simulation course
is available for family physicians and certified midwives
practicing in the rural Southeast. As the number of
births outside of a labor and delivery unit increase,
Henning-Smith said, first responders should also receive
ongoing training on how to deliver a baby.
Silva suggested reaching out to teaching centers for help
in improving pregnancy outcomes. Even if the centers
can't send a resident, they may be able to assist through
services like telehealth.
Successful Strategies #1: Childress Regional
In 2015, Childress Regional Medical Center in
Childress, Texas, established a telehealth
collaboration with Children's Medical Center Dallas,
about 250 miles away. Telehealth allows the Dallas
hospital's 50+ pediatric subspecialty physicians and
neonatologists to remote-monitor babies and consult
with CRMC physicians.
Cullen advises rural communities to contribute to their
hospitals' and clinics' loan repayment programs, like
Valdez does. In addition to improving community members'
health, continuing OB-GYN services brings in economic
benefits. He cited a 2014
study that found that a family physician brings a
rural Alabama community an average of $1,000,000 per year
in economic benefit. A family physician capable of
delivering babies brings in an average of $1,488,560 per
Successful Strategies #2: Mercy
Mercy Hospital in Moose Lake, Minnesota, is one of only
two CAHs in the state to be designated a Baby-Friendly
facility. Baby-Friendly designation is a four-phase
process, which involves implementing the “Ten
Steps to Successful Breastfeeding” and
quality improvement activities as well as passing an
onsite assessment. Rhonda Skelton, RN, was the
obstetrics department manager who began the designation
process around 2008, but she passed away before the
process was complete. Her staff continued her efforts,
and Mercy Hospital was declared Baby-Friendly in
February 2018. Skelton posthumously won the National
Rural Health Association's
Louis Gorin Award for Outstanding Achievement in Rural
“Rural communities need to be able to provide a
full spectrum of services because otherwise we have to
accept a much higher infant and maternal mortality
rate,” said Cullen. “The small
community hospitals will need to up their game, and it's
possible. I mean, we're doing it out in the middle of
nowhere in Alaska.”
Allee Mead is a web writer for the Rural Health Information Hub. She has written on important rural issues, including maternal mortality and farmers' mental health, and has presented nationally on RHIhub's opioid resources. Originally from rural North Dakota, she has a master's degree in English. Full Biography