By Jane Winik Sartwell
The paradox of rural women’s health care in North Carolina: Small, remote hospitals can’t afford to keep delivering babies and providing other critical OB/GYN services, but their communities can’t afford for them to stop.
If any hope exists to stop or reverse this trend, rural hospitals and health care professionals will require stronger accountability, incentives and support. An enhanced regulatory and legislative framework — constructed and maintained by North Carolina’s legislature and its Department of Health and Human Services — could help achieve this.
While these changes would be dramatic for North Carolina, similar measures to address rural women’s health services are already in place or under consideration in many other states.
“From a systems perspective, we’ve got a lot of opportunities for improvement,” said Dolly Pressley Byrd, chair of the obstetrics and gynecology department at the Asheville-based Mountain Area Health Education Center, or MAHEC. “There are some structural ways that our health care systems are created that exacerbate inequity and increase disparities, whether that be geographic, socioeconomic or racial.
“In an ideal state, if we could serve women and provide them with the care that they needed in the communities where they reside, and they didn’t have to travel and they had the supports around them, … we wouldn’t have such a dire infant mortality rate and worsening maternal mortality rate.”
Standards of care affecting rural women’s health
In North Carolina, the state enforces neonatal levels of care, meaning that hospitals are held to a predetermined standard of care they are expected to provide for infants.
If a hospital promises to treat babies on a level IV — the highest grade of medical care possible — but drops to a level III, the Division of Health Service Regulation takes action.
No analogous system exists for maternal care in North Carolina. But 16 other states have standards for levels of maternal care provided by hospitals, including North Carolina’s neighbors: Tennessee, Georgia, and South Carolina. And more could be joining them.
Mississippi, a state with very poor maternal and infant mortality rates, is building out a system of standards of both maternal and infant care in order to solve a problem there. It is slated to go live later this year, according to Mississippi state health officer Dan Edney.
“The statewide system will specifically target that really vulnerable window of labor and delivery, and immediate postpartum for both the moms and the babies,” Edney told CPP.
“Our goal is for high-risk pregnancies to deliver at the right level of care, so the mom has everything she needs, and the baby, especially low-birth weight, premature babies, will have immediate access to the right level of care. We are actively constructing the system right now.”
North Carolina policy makers are considering implementing levels of maternal care as well. But since more regulation would also end up increasing costs for hospitals, it would require a measured approach.
“We’ve had conversations in North Carolina around what levels of maternal care could potentially look like,” said Belinda Pettiford, chief of the Women, Infant and Community Wellness Section of the Division of Public Health at DHHS.
“We’ve been delving deeper into what it would look like if we updated our neonatal levels of care as well. We are still in those conversations, trying to figure out what would be needed to move that work forward.”
Data collection and other forms of accountability
DHHS currently does no rigorous or standardized data collection on maternal care in hospitals. A more robust data collection system could help the agency identify and address the problem. But legislators would have to pass laws requiring this oversight.
State Rep. Julie von Haefen (D-Raleigh), said enhanced data collection on North Carolina’s hospitals could be the first step to solving the issue.
“(DHHS) needs to have more data,” von Haefen told CPP. “If we don’t know what’s happening, how can we figure out how to solve it? Increased data collection will help us figure out where to target our efforts.”
County health departments have no ability to hold hospitals accountable either. Departments are expected to work with local hospitals to write Community Needs Health Assessments, but public health personnel don’t have a way to force hospitals to meet those identified needs.
Giving these departments more teeth and regulatory capabilities could prevent hospitals from eliminating or reducing rural women’s health services without facing any formal push back.
Financial solutions to promote rural women’s services
Since maternity services generally operate at a financial loss, funding and payment reform could encourage hospitals to sustain services. In rural areas, many patients have Medicaid, which makes maternity care even less profitable for hospitals.
And proposed cuts to Medicaid could nullify the equation entirely.
“The thing about maternity units is they’re not profit makers — they’re loss leaders,” said Ami Goldstein, a certified nurse-midwife and associate professor at the UNC School of Medicine’s Department of Family Medicine. “So if you have six births a month, the hospital is still paying staff to be available that entire time.”
Lower birth volumes lead to higher per-patient costs, making services financially unsustainable in many rural areas.
Increased Medicaid reimbursement rates for rural hospitals and physicians could help solve the problem. State Rep. Timothy Reeder (R-Greenville), who is also a medical doctor, told CPP he is advocating for these enhanced reimbursements.
But the future of Medicaid nationally is anything but certain, as Republicans in Congress have recommended substantial cuts to the program — to the tune of $880 million.
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Private insurance companies could also implement special payment models that account for the higher per-patient costs of rural health care, but most don’t. Some states have initiatives requiring insurance companies to better support rural hospitals, but North Carolina hasn’t done this so far.
Workforce solutions for hospitals
The dwindling rural health workforce is another urgent problem in need of a solution.
Creating incentives for specialists to work in rural hospitals is crucial, according to Rebecca Bagley, director of the midwifery education program at ECU. Training college students and other members of the burgeoning workforce to practice in rural areas — which is a different ballgame than urban practice — is also important, she said.
“It is better to provide care for patients close to their home,” Rep. Reeder said.
“Therefore, it is critical to provide support for rural hospitals and physicians. We won’t have successful communities in the rural area without access to health care. Health care is vital for economic development and growth.
“I have successfully advocated for several provisions to help support and grow care in rural areas. We have provided funds for rural residencies, loan repayment for several health professions, funding for rural health facilities, and expansion of health training programs through community colleges. … We must recruit and train health professionals in rural communities to increase their likelihood of staying.”
Rep. von Haefen is also in favor of incentives to get the health care workforce back into rural areas of North Carolina.
“We have to think outside the box when it comes to labor and delivery services, and OB/GYN services in general, because we have such a dire workforce problem,” von Haefen said. “This is especially true in rural communities.”
Von Haefen recommends a “Grow Your Own”-style program that incentivizes newly trained nurses and doctors to return to their hometowns to practice. When deployed in educational settings in North Carolina, this model incentivizes graduates from teaching programs to go back to their own school districts to work.
She also emphasized the importance of community colleges.
“More rural community colleges are trying to focus on the health workforce issue,” von Haefen said. “Investing more in community college programs is really important because they’re bringing in people who live in those areas to grow the health care workforce.”
Expanding the capabilities of the current workforce is another strategy: give family doctors and EMTs the opportunity to expand the scope of their practice. And keep them trained.
State Rep. Allen Buansi (D-Chapel Hill), prefers this strategy.
“Universities and hospitals can do a better job ensuring that they’ve got general physicians in those rural areas (who) have continued training in the basics of prenatal, delivery and postnatal care,” Buansi told CPP.
Buansi described a “big role” for hospitals “to ensure local doctors in those rural women’s health care desert areas are trained in the basics of OB/GYN care. The state could put up some money for that.”
North Carolina’s rural communities risk losing the women’s health care services that remain.
Through regulatory and incentive shifts that are already under consideration, North Carolina’s rural communities could hold onto essential maternity services through a combination of financial reforms, targeted workforce development and heightened accountability, saving the lives of women and children across the state.
The state could also potentially see a recovery of rural women’s services programs that hospitals have reduced or cut in some areas if the regulatory and incentive structure changes.
Instead of the rural women’s health care deserts growing, the oases of care could expand to create a new narrative for health care in rural North Carolina.
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