Maternity ward closings have left some significant gaps in Iowa‘s prenatal care and delivery services as rural hospitals struggle to keep their doors open.
Across the United States, hospital deliveries are the standard. Despite positive trends over the last two decades for home births and birthing centers, more than 98% of recored births in the U.S. in 2017 occurred in hospitals.
So, why are maternal mortality rates on the rise in America?
“Maternal mortality rates are increasing, which is asinine when you think about the wealth of our country and the capabilities of our country, and what’s going on in the rest of the world where maternal mortality rates are decreasing,” said Lina Tucker Reinders, executive director of the Iowa Public Health Association.
The U.S. already has one of the highest maternal morality rates in the world, and with obstetric clinics closing, it may time to re-evaluate how to provide some of the most crucial services to women in rural areas.
Trend Of Closings In Iowa
In Washington, Iowa, the local OB/GYN unit closed a few years ago, and the Washington County hospital stopped providing birthing services in April 2018.
Iowa City’s hospital is about an hour away and Fairfield is a little closer, but still quite a haul in an emergency.
“Access to care in rural areas is a problem across Iowa, it’s a problem across the U.S., and it’s a multifaceted problem, so there’s not one easy solution,” said Tucker Reinders, with the Iowa Public Health Association. “I think that there’s a multitude of factors that go into that from costs associated with care, population density, people who utilize to care, and getting providers to move there, even people who grew up in a rural area, to get them back.”
In September, UnityPoint Health in Marshalltown closed its obstetric clinic, which was the 34th hospital in Iowa since 2000 to close an OB/GYN unit, according to a KCRG report.
“So, attracting them to move there, and raise their family there, have good school for their children to educate them, economics for job opportunities of their spouses,” Tucker Reinders said. “There’s a lot that creates that environment and makes it sustainable.”
Economic Realities And Financial Obstacles
Population density and birth rates are significant factors for hospital resources, especially when considering the status of a maternity ward.
“I think specific to the birthing and maternity care in general, there’s all that, and the cost of maternity care is one of the biggest expenses for local hospitals,” Tucker Reinders explained. “So, if you look at the birth rate of a community, can they support that function in their hospital? Are moms choosing to go to an expert in the field?”
In Washington County, a majority of the mothers sought prenatal care outside their local obstetrics clinic. On top of a low birth rate, women in the area not using the service further strained the hospital’s finances.
“My understanding is about two-thirds of that community was already kind of going out of community, out of the county, for care. So that one-third of folks that were left, you know, that’s a lot of people who are in jobs that it’s really tough to get away, they’re working hourly,” said Laura Dellos, interim nurse-midwifery services director at the University of Iowa Hospitals and Clinics (UIHC).
Some maternity wards in rural areas have reported seven-figure loses in a single year.
“Fortunately, or unfortunately, depending on the way you see it, the reality is that health care is a market driven entity. You have that supply and demand. So, if the care isn’t readily available in a community where somebody lives, and they’re willing and able to drive to a city center that has that care, then they do that,” Tucker Reinders said. “The more they do that, the less demand in their local community, and the harder it is for their community to justify having that service.”
People who live in rural areas generally enjoy living there, but when critical services disappear, the benefits are weighed against the costs of having to travel to receive medical care.
“I saw a teacher in Muscatine and she said, ‘You know, they base our school funding, staffing, and planning on the birth rate in our county,” Dellos recalled. “And she said, ‘We already know a big number of people leave the county to have their babies elsewhere. How do they know how to fund stuff? How do you recruit people into the community when you know there’s so few services?'”
For those living in rural areas with more financial resources at their disposal, these obstacles may not seem overwhelming. But for those who are reliant on local services, that tipping point comes earlier.
“If I am able to, or willing to drive, and able to take time off work, or able to find someone to take care of my other children that I might have at home, to be able to spend an entire day driving an hour or more to my regional facility, I can do that. But what if I don’t?” Tucker Reinders asked. “What if I don’t have reliable transportation? What if I’m working a job that I’m not allowed to take time off? What if I’m not? What if I don’t have care for my other children?”
Could Midwifery Become More Common In The US?
We know now how expensive it is to operate a maternity ward in a rural area with a low birth-rate. From an economic perspective, it’s hard to justify without assistance.
After the Washington County hospital closed its obstetrics unit, the area is trying something new.
“We started going to Washington weekly in late May and are down there one day a week doing clinic,” Dellos, with UIHC, said. “Women still will need to come back to the university and deliver, but we are able to go down there.”
The University of Iowa has a midwifery program, which Dellos runs. They’ve expanded staff over the last few years, and the amount of midwives on its payroll has quadrupled over that period.
Midwives can travel to provide obstetric services and prenatal care in the home. This increases access for those soon-to-be moms who can’t travel for the care, and despite losing time in the car and spending resources on travel, it saves a significant amount of money versus keeping a maternity ward or OB/GYN clinic open in a rural hospital.
“[Midwives at University of Iowa] are in partnership the Washington County hospital. We’re using their space. They have a little specialty clinic area where different services go down there and we use their ultrasounds, their lab, and trying to make it as convenient for women in that county,” Dellos said. “We’ve lost nine clinics in the last two years, so we feel a need to provide that service in some way.”
Looking at other countries for guidance, midwifery is popular in other areas of the world. In some places, it’s actually a staple of care and more common than clinical care.
The World Health Organization declared 2020 to be the year the midwife.
“In the U.K. and Europe, and other areas that rely more heavily on midwifery to serve, I want to say the Netherlands as well, the majority of babies born are born out of hospitals because the system is set up more for home births with midwifery,” Tucker Reinders said.
Iowa currently lacks the infrastructure to train more midwives and expand their service reach in the state.
“We don’t have any programs to train nurse midwives. You know, there’s going to be a shortage of 9,000 OBs in the next five years, I think it is,” Dellos said. “So, we don’t have the capacity right now to ramp up and get a lot more midwives really quickly.”
“If you look at the history, actually, in this country of midwifery … You know, in Europe, midwifery just grew and flourished, and there were education programs started hundreds of years ago. In England, there’s something like 35,000 midwives and less than 1,000 OB/GYNs,” Dellos said. “That’s totally inverse in this country where we were almost completely stamped out by the medical profession as this country developed.”
By Josh Cook