January 23, 2025 • 26 mins
Can Rural Hospitals Survive the Storm of Obstetric Care Closures?
Our latest episode features Dr. Julia Interante, who has collaborated extensively with Dr. Katy Backes Kozhimannil, Distinguished McKnight University Professor and Co-Director of the University of Minnesota Rural Health Research Center.
With Dr. Julia Interante from the University of Minnesota, we uncover the alarming disparities in maternity care access between rural and urban hospitals. Dr. Interante sheds light on the sharp decline in obstetric services from 2010 to 2022and the significant financial challenges rural hospitals face due to low birth volumes. This episode provides valuable insights into the ripple effects of these closures on maternal and infant health, emphasizing the urgent need for policy-driven interventions to bridge the gap.
Join us as we explore the complex landscape of rural maternity care, particularly within BIPOC communities, and discuss actionable policy measures to reverse these concerning trends. Discover innovative solutions such as telemedicine, remote monitoring, and learn how mission-driven recruitment and preconception care can sustain essential services.
We also discuss the importance of balancing patient demographics and offering diverse birthing options to attract and retain rural mothers. Don't miss this comprehensive discussion on improving maternal health outcomes in America’s heartland, as Dr. Interante shares strategies poised to transform rural healthcare by 2025.
#MaternalHealth #WomensHealth #MaternityCare #HealthyMoms #MaternalWellness #PregnancyCare #BirthEquity #HealthcareAccess #HealthForAll #BridgingHealthGaps #HealthEquity #AccessToCare #ImprovingHealthcare #NonUrbanHealth #CommunityHealth #HealthcareForAll #HealthInEveryCommunity #SmallTownHealth #LocalHealthMatters #HealthcareEverywhere #MaternalHealthPolicy #HealthAdvocacy #HealthcareReform #SupportMoms #HealthPolicyMatters #HealthcareInnovation #CollaborativeCare #PublicHealthSolutions #HealthcareInnovation
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr Julia Interrante (00:00):
I think it's very important for
understanding what's happeningfor people living in their local
communities when they no longerhave access to that essential
service at a time where theirlife and their families are
changing greatly when they havea new child.
Dr Bola Sogade (00:14):
Hello and welcome to CocoaPods, a podcast
of the Birth Center for NaturalDeliveries Foundation.
My name is Bola Sogade i.
(00:39):
I'm a women's health specialist.
On this podcast, we talk aboutall the issues relating to
women's health and identify theproblems and talk about ways in
which we can mitigate theproblems.
Dr Julia Interrante (00:48):
Hi there, how are you doing?
Good, how are you?
Dr Bola Sogade (00:52):
Thank you so much for your time Today.
I'm very fortunate to have withme Dr Julia Itorante, phd, mph
from the University of Minnesota.
Welcome, dr Julia Itorante.
Dr Julia Interrante (01:05):
Thank you very much for having me.
Dr Bola Sogade (01:07):
Thank you.
So I'm going to tell youlisteners, a little bit about Dr
.
In She has a PhD, mph, andshe's a research fellow and
statistical lead at theUniversity of Minnesota's Rural
Health Research Center, withover 15 years of experience in
(01:28):
applied epidemiology and healthservices research.
She holds a BA, a Bachelor's ofArts, in Gender Studies and
Global Politics from theUniversity of Virginia, an MPH
in Epidemiology from EmoryUniversity and a PhD in health
sciences research from theUniversity of Minnesota.
(01:52):
She has spent six years as anepidemiologist at Centers for
Disease Control and Prevention,the CDC, with research focused
on gender disparities, maternalmedication use and disease
surveillance and prevention inboth the domestic and
international context.
(02:13):
Her current research examinesthe effects of policy on
maternal health outcomes and onaccess to maternity care
services, with specific focus ongeographic and racial equity,
and includes topics such asdisparities in severe maternal
(02:34):
morbidity and mortality that is,things that could make a woman
very sick or even die related topregnancy, and also changing
access to rural maternity careand the impact of payment
policies on maternal andpostpartum care.
So thank you, , and welcomeagain.
Dr Julia Interrante (02:57):
Thank you.
Dr Bola Sogade (02:59):
So just to delve straight into the topics, we
have the topics on that bigheadings, and the first one is
the state of obstetric care inrural versus urban hospitals,
and I know that you have workedvery closely with Dr Katy
Kozhimannil .
You did publish a paper on the4th of December 2024, in the
(03:21):
Journal of the American MedicalAssociation, and this was a
research letter titled ObstetricCare Access at Rural and Urban
Hospitals in the United States.
You did an analysis of the netloss of obstetric care services
(03:42):
from the year 2010 to the year2022, highlighting critical
disparities, particularly thedisproportionate impact on rural
hospitals.
And Dr Kozimani, as a professorand director of the Rural
Health Research Center at theUniversity of Minnesota, her
(04:05):
work documents challenges inrural maternal care access and
emphasizes policy-basedsolutions to maintain and
improve local access to care.
So this is a lot, but I wantyou to talk to us about the net
loss.
There has been a loss ofobstetric services.
(04:28):
What does this mean to the momand to the baby?
Dr Julia Interrante (04:33):
Yeah, thank you so much for that
important question and forhighlighting the research that
we have been doing at theUniversity of Minnesota Rural
Health Research Center and again, a lot of that work is just
highlighting what is anddocumenting what has been
happening for a long time inrural maternity care access.
So loss of obstetric servicesand maternity care in rural
(04:57):
areas is not anything that isnew.
It has been happening for yearsand years and we have been
documenting it.
The data to identify and showthe extent of these losses is
actually quite challenging toget.
There's no national database ofhospitals that do and don't
provide obstetric services andwhen they come and go.
(05:20):
So we go through an entireprocess to try to identify these
hospitals and accurately trackwhat's happening, which again, I
think is very important forunderstanding what's happening
for people living in their localcommunities when they no longer
have access to that essentialservice at a time where their
life and their families arechanging greatly when they have
(05:41):
a new child.
So we use data from the AmericanHospital Association annual
surveys and also combine thatwith data from the Centers for
Medicare and Medicaid Services,data, along with review of
hospital websites and newsstories about obstetric service
closures, and looked at that,starting in 2010 all the way
(06:06):
through 2022, which is the mostrecently available data.
So this included almost 5,000short-term acute care hospitals
and obstetric and gynecologyspecialty hospitals that were
open during that time period,and we found that in 2010, only
(06:26):
43% of rural hospitals and 29%of urban hospitals did not offer
obstetric care, but by 2022,54% of rural hospitals and 35%
of urban hospitals did not offerobstetric care.
So we saw a steady rise in thepercentage of hospitals without
(06:47):
obstetric services and, again,the number of hospitals that
lost obstetric services and thenumber of hospitals that didn't
provide obstetric services wasconsistently higher among rural
hospitals.
Dr Bola Sogade (07:01):
Wow, thank you.
So I'm going to ask you athree-part question.
Number one what factorscontributed most significantly
to the net loss of obstetriccare services between 2010 and
2022?
And number two why do ruralhospitals appear to be
disproportionately affected bythe loss of obstetric care
(07:25):
services compared to urbanhospitals?
And the last part of thisquestion is how does the loss of
obstetric services impactmaternal and infant health
outcomes in rural areas?
Dr Julia Interrante (07:42):
That's great.
Thank you.
These are really importantquestions and they really are
all quite interrelated.
So there are a number offactors that really play into
the loss of obstetric servicesand hospitals and again, these
are really exacerbated in ruralareas.
So one of the main issues thatwe have been doing a lot of
(08:02):
research on is the lack offinancial support basically for
these services.
A lot of the way maternity careis financed is really centered
around urban centers that have ahigh birth volume and so that
payments for maternity care andchildbirth services are based
(08:23):
off of volume, so they'revolume-based revenues.
Now in a lot of rural hospitalsthere is lower birth volume so
that there is less revenuecoming in for that service line,
but the fixed costs are thesame.
So the cost for having staffthat is available at a standby
(08:45):
capacity and is fully trainedand equipped to handle whatever
type of emergency situations mayarise in childbirth requires a
high fixed cost.
And again, if the reimbursement, the revenue that comes in,
varies based off of volume, thatcan be really challenging to
maintain services like that, avolume that can be really
(09:08):
challenging to maintain serviceslike that.
There's also reimbursementinequities between public
insurance and private insuranceand that can really impact how
these services are able to besupported in rural hospitals,
where there are more oftenhigher proportion of patients in
births that are paid for byMedicaid rather than private
insurance, and Medicaid doesgenerally pay less for maternity
(09:32):
and childbirth services thanprivate insurers do.
So that can be quitechallenging.
Again, there's other factorsaround workforce shortages that
have been really challenging andthis has been, again, an issue
that has been happening foryears but has definitely been
exacerbated in the last fewyears.
So it's not just the workforcechallenges specific to
(09:54):
obstetricians, so it's not justchallenges in recruiting and
retaining obstetricians.
In rural areas, familyphysicians who do maternity and
childbirth services are themajority of the attendance for
childbirth in those communities,as well as midwives, and so
when there's a challenge foreach one of these different
(10:15):
clinicians, as well as workforceand retention challenges for
nursing staff, that can bereally difficult to maintain
those services difficult tomaintain those services.
So I mentioned, we have talkedwith and worked with a number of
rural hospitals where there areonly one or two or three
clinicians who are attendingchildbirth and if one of them
(10:35):
has to go on maternity, leavethemselves or retires or moves,
that can make it reallychallenging to try to find and
recruit another clinician to beable to provide that service to
that rural community.
So again I'd say the financingchallenges, the workforce
challenges, all of those areexacerbated in rural hospitals,
making it more difficult tomaintain that service line.
(10:55):
And then you asked the lastquestion of what is the impact
of that service loss formaternal and infant health
outcomes in rural areas.
And from our research we havefound rural hospitals that are
more likely to lose obstetricservices are those ones that are
in the most remote rural areas.
So where people may not haveurban center in the next county
(11:19):
over to go to, it's actuallyquite a longer distance that
they end up having to drive.
Those are the ones most likelyto lose services.
And we know that areas thatlose obstetric services have
higher rates of preterm birth,have higher rates of births
outside of the hospital setting,and it's not clear how many of
those are planned and how manyare emergency unplanned births
(11:41):
outside of the hospital setting.
And we also see greater traveldistances and other researchers
have documented that greatertravel distance is associated
with increased risk of poormaternal and infant outcomes.
Dr Bola Sogade (11:55):
Wow.
So we'll talk about some of thepossible solutions, but the
next topic I want to talk aboutis just systemic disparities.
Dr Cozimanel's researchhighlights disparities in access
between rural and urbanhospitals, and I want you to
(12:15):
please elaborate on thesedisparities, how they manifest
and their broader implicationsfor healthcare equity.
Now I like to ask my questions,three questions at a time.
So the next question is whatrole do socioeconomic and
geographic factors play inmaking these disparities worse
(12:40):
in rural areas, and are thereparticular demographics or
populations within rural areasthat are even more vulnerable to
the loss of obstetric careservices?
Dr Julia Interrante (12:55):
Yeah, Again, a lot of these are
interrelated as well.
So I had already mentioned thatrural communities that are the
most remote are at higher riskfor losing obstetric services.
We also see that ruralcommunities that are more likely
(13:17):
to lose services are also thosewhere their Medicaid programs
are less generous.
So again, in places where thereare more restrictions around
Medicaid, we also see higherrisk of loss in communities
where a majority of patients areBlack or Indigenous or people
(13:38):
of color, and again, some ofthat is tied to an overlap with
the rates of Medicaid coveredbirths.
We do know that BIPOCindividuals are overrepresented
among Medicaid beneficiaries andagain that I mentioned how
Medicaid often pays less formaternity care services.
So we see some of thatintersectionality coming in and
(14:01):
compounding the risk of serviceloss and thus also poor maternal
and infant outcomes.
Dr Bola Sogade (14:09):
So okay, when you say BIPOC just can you
explain that to the lay public?
Dr Julia Interrante (14:14):
Yes, yes, sorry.
So obviously there are lots ofdifferent terms used.
It's hard in research trying tofigure out.
I mean, by the nature ofresearch, you have to group
people, but obviously allcommunities are different and
diverse and come with their ownexperiences.
I use the term BIPOC, meaningBlack, Indigenous and people of
color, but again I just want tohighlight that all these
(14:40):
communities are different.
Communities with a higherproportion of patients who are
Black had greater risk of losingobstetric services or even not
have had services in thosecommunities prior to when we
started doing our research in2010.
So they already had seen lessaccess to maternity care
services, but they were alsomore likely to lose those if
(15:01):
they did have them.
We also see that happening in alot of states in the Midwest
and in communities where thereare a large proportion of
indigenous or native residents,and we already know that there
is a lack of services and accessto maternity care on
(15:22):
reservations and nearreservations, and a lot of
Native people gain access tohealth care through the Indian
Health Services and it is quiteunderfunded and has had
challenges with providingmaternity care.
There are actually very fewIndian Health Service facilities
that actually do childbirthservices as well, so a lot of
(15:43):
those patients end up having toeither get private insurance or
Medicaid and find anotherhospital to be able to give
birth if they need or arechoosing to give birth in a
hospital-based setting.
Dr Bola Sogade (15:56):
But still they have to travel because of risk
delivering at home withoutknowing their risk status right.
Dr Julia Interrante (16:04):
Yes.
Dr Bola Sogade (16:04):
Yeah, regulations.
(16:25):
What policy interventions doyou believe could help reverse
this trend of decliningobstetric services, particularly
in rural hospitals?
Dr Julia Interrante (16:30):
Yeah, so there are a few policies that
have either been proposed ordiscussed, some that have
actually been implemented.
There has been a lot ofattention to access to rural
maternity care service over thepast few years.
A lot of the policy changeshave been incremental, focusing
on trying to collect better data, which is important for
(16:52):
documenting challenges andevaluating potential solutions
or starting demonstrationprojects.
Solutions or startingdemonstration projects For
example, there is a Our Momsprogram.
It's rural I'm not going to beable to remember the acronym off
the top of my head but it'sbasically trying to support
rural maternity care networks tobetter provide services.
(17:14):
But these are small, short-termgrants and, again, it hasn't
fully been able to deal withsome of the long-term challenges
.
It's also in its infancy.
This has only existed for a fewyears now and it's not
available to all rural patientsand to all rural communities.
But some of the topics that weoften discuss are things like
(17:35):
around the financing challengesso providing some standby
funding capacity for hospitalsso that they're not completely
reliant on that volume-basedrevenue and also providing
funding to help cover thosefixed costs even when you have a
low birth volume at yourhospital.
Also, addressing some of theinequities for reimbursement for
(17:56):
maternity care services betweenpublic and private insurance
and generally just paying morefor maternity-related services,
and I don't mean just for theactual childbirth but also for
having good quality,culturally-centered prenatal and
postpartum care and eveninterpregnancy care, so making
(18:17):
sure that patients have accessto services between pregnancies
or even before we would call itpreconception care, so before
pregnancy, so people's health,if they have chronic conditions,
that that is managed beforethey even get pregnant.
And if you only gain access toMedicaid because you get
pregnant, that obviously is notgreat for helping prevent and
(18:38):
gain access and ensure betterhealth before you get pregnant,
which is quite connected to thehealth outcomes in pregnancy as
well.
And again, this recently cameout the Centers for Medicaid and
Medicare Services came out withsome new standards for
operating maternity services inall hospitals but this also
impacts rural hospitals andbasically just set some quality
(19:01):
and safety standards, but thatdidn't come with any resources
for those services, which againis going to be more challenging
for low birth volume, ruralareas that are already more
resource strapped.
And so in building thosequality and safety measures,
which are important, but tyingthat in with financial resources
to meet those standards, Ithink is a really important step
(19:23):
that needs to be taken.
Dr Bola Sogade (19:24):
Well, yeah, you touched on a very important
aspect in that, if we canoptimize a woman's health status
before pregnancy in a waybefore pregnancy that makes her
actually more likely to have alow risk pregnancy and delivery,
(19:44):
and so that's it would be niceto improve the quality of, you
know, pre-conceptional care,prenatal care and interpregnancy
care.
So that was a big topic youbrought up so, but as we move on
, you know what strategies youknow I want to ask you have
(20:05):
proven effective in preservingbecause there's still some, you
know obstetric care services insome rural places in the country
and we could study those asmodels to look at the strategies
that have proven effective inpreserving or expanding
obstetric care services in ruralhospitals and what other
(20:29):
options could help, you know,provide care to these women in
2025, america, so they don't dieat home trying to risk
delivering a baby withoutknowing whether they're low risk
or high risk pregnancies.
Dr Julia Interrante (20:47):
Yeah, so we did.
Actually, a few years ago we atthe Rural Health Research
Center did a series calledMaking Maternity Care Work,
where we really wanted tohighlight stories from places
who have these same challengesthat a lot of rural communities
are facing, with low birthvolumes and workforce challenges
(21:07):
and the same financialchallenges that a lot of
maternity care providers arefacing.
And we wanted to talk to themand learn from them about how
they are able to buck some ofthat trend of rural obstetric
unit closures and maintainservices and what they do to
support their community.
And so we talked to quite a fewplaces across the country and a
(21:29):
lot of these we turn into casestudies that are available on
our website for anyone to accessand read.
They told us things likerecruiting clinicians and staff
based off of their mission formaternity care, not just on
salaries and money, so drawingpeople in, drawing clinicians in
and nurse and administrators in, because they want to provide
(21:55):
maternity and childbirth carefor patients in the ways that
meet the needs of patients intheir communities.
So other things they told us wewere engaging with the local
birth community, so, again,talking to community members,
making sure there'srepresentation of the diversity
of views within thosecommunities and asking them how
(22:15):
they want to have their birthexperiences.
What types of clinicians dothey want attending their births
?
What types of clinicians dothey want attending their births
?
What types of locations do theywant?
What services would they like?
And so this included things likeproviding vaginal birth after
cesarean, which not allhospitals do support.
But having those kinds ofoptions, having options like
(22:36):
water birth again, things that alot of well, some freestanding
birth centers also do, alsooffering that midwifery model of
care, have been things thathave helped to draw patients in.
Again, I talked earlier aboutsome of the challenges with
maintaining services when amajority of patients who are
(22:57):
giving birth are Medicaidbeneficiaries and Medicaid is
paying less than privateinsurance.
But if hospitals are able todraw in patients with private
insurance, that can also helpbalance some of their we say,
payer mix, but basically makingsure that they have revenues
coming in from insurance thatpays more.
In the situation where we havewhere Medicaid is not paying
(23:18):
enough for these services, inthe situation where we have
where Medicaid is not payingenough for these services, again
offering things like childbirtheducation classes, postpartum
peer support groups andbreastfeeding support groups,
having those as services intheir hospital or having those
connections with local communitygroups that are already doing
(23:39):
that has been important in theseareas.
That have been able to maintainservices and we've even seen
things like just having anadministrator in the hospital
who really cares aboutmaintaining that service line
has been important for keepinghospital resources focused on
childbirth and maternity care.
Dr Bola Sogade (23:54):
So when we look at long-term solutions, you know
, I mean because there'sprobably a woman dying right now
, as we're talking, in a ruralcommunity in the United States,
either because she's driving interrible winter weather to a
hospital to deliver her baby, orshe's just like, forget it, I'm
(24:16):
just going to try to have thisbaby at home.
Or she just had a seizure frompreeclampsia.
Now it's eclampsia.
So the reality is there'sprobably a woman dying right now
as we're having this talk.
What do you see as thelong-term consequences number
one of these trends, if no realintervention?
(24:38):
Because there's a lot of talkaround.
Everybody wants to talk about apregnant woman and her baby.
So if there are no interventionsmade to improve access to care,
what do we see as long-termconsequences?
And then, how can data fromstudies, like from what people
like you guys have done, informfuture health care planning and
(25:04):
resource allocation for maternalhealth?
And now, in this age of AI andtechnology, what role does
technology such as telemedicineor remote monitoring, what role
could this play in improvingaccess to obstetric care in
underserved areas?
I know that even despite this,somebody has to lay hands on a
(25:28):
pregnant woman and help herdeliver a baby.
So there's a limit.
I mean we don't have robotsthat will deliver babies yet, so
there's a limit to what AI andtechnology can do.
So can you wrap up what thelong-term consequences of a lack
of intervention and thelong-term solutions could be to
(25:49):
this problem?
This is for the next episode.
I think it's very important for
understanding what's happeningfor people living in their local
communities when they no longerhave access to that essential
service at a time where theirlife and their families are
changing greatly when they havea new child.
Dr Bola Sogade (00:14):
Hello and welcome to CocoaPods, a podcast
of the Birth Center for NaturalDeliveries Foundation.
My name is Bola Sogade i.
(00:39):
I'm a women's health specialist.
On this podcast, we talk aboutall the issues relating to
women's health and identify theproblems and talk about ways in
which we can mitigate theproblems.
Dr Julia Interrante (00:48):
Hi there, how are you doing?
Good, how are you?
Dr Bola Sogade (00:52):
Thank you so much for your time Today.
I'm very fortunate to have withme Dr Julia Itorante, phd, mph
from the University of Minnesota.
Welcome, dr Julia Itorante.
Dr Julia Interrante (01:05):
Thank you very much for having me.
Dr Bola Sogade (01:07):
Thank you.
So I'm going to tell youlisteners, a little bit about Dr
.
In She has a PhD, mph, andshe's a research fellow and
statistical lead at theUniversity of Minnesota's Rural
Health Research Center, withover 15 years of experience in
(01:28):
applied epidemiology and healthservices research.
She holds a BA, a Bachelor's ofArts, in Gender Studies and
Global Politics from theUniversity of Virginia, an MPH
in Epidemiology from EmoryUniversity and a PhD in health
sciences research from theUniversity of Minnesota.
(01:52):
She has spent six years as anepidemiologist at Centers for
Disease Control and Prevention,the CDC, with research focused
on gender disparities, maternalmedication use and disease
surveillance and prevention inboth the domestic and
international context.
(02:13):
Her current research examinesthe effects of policy on
maternal health outcomes and onaccess to maternity care
services, with specific focus ongeographic and racial equity,
and includes topics such asdisparities in severe maternal
(02:34):
morbidity and mortality that is,things that could make a woman
very sick or even die related topregnancy, and also changing
access to rural maternity careand the impact of payment
policies on maternal andpostpartum care.
So thank you, , and welcomeagain.
Dr Julia Interrante (02:57):
Thank you.
Dr Bola Sogade (02:59):
So just to delve straight into the topics, we
have the topics on that bigheadings, and the first one is
the state of obstetric care inrural versus urban hospitals,
and I know that you have workedvery closely with Dr Katy
Kozhimannil .
You did publish a paper on the4th of December 2024, in the
(03:21):
Journal of the American MedicalAssociation, and this was a
research letter titled ObstetricCare Access at Rural and Urban
Hospitals in the United States.
You did an analysis of the netloss of obstetric care services
(03:42):
from the year 2010 to the year2022, highlighting critical
disparities, particularly thedisproportionate impact on rural
hospitals.
And Dr Kozimani, as a professorand director of the Rural
Health Research Center at theUniversity of Minnesota, her
(04:05):
work documents challenges inrural maternal care access and
emphasizes policy-basedsolutions to maintain and
improve local access to care.
So this is a lot, but I wantyou to talk to us about the net
loss.
There has been a loss ofobstetric services.
(04:28):
What does this mean to the momand to the baby?
Dr Julia Interrante (04:33):
Yeah, thank you so much for that
important question and forhighlighting the research that
we have been doing at theUniversity of Minnesota Rural
Health Research Center and again, a lot of that work is just
highlighting what is anddocumenting what has been
happening for a long time inrural maternity care access.
So loss of obstetric servicesand maternity care in rural
(04:57):
areas is not anything that isnew.
It has been happening for yearsand years and we have been
documenting it.
The data to identify and showthe extent of these losses is
actually quite challenging toget.
There's no national database ofhospitals that do and don't
provide obstetric services andwhen they come and go.
(05:20):
So we go through an entireprocess to try to identify these
hospitals and accurately trackwhat's happening, which again, I
think is very important forunderstanding what's happening
for people living in their localcommunities when they no longer
have access to that essentialservice at a time where their
life and their families arechanging greatly when they have
(05:41):
a new child.
So we use data from the AmericanHospital Association annual
surveys and also combine thatwith data from the Centers for
Medicare and Medicaid Services,data, along with review of
hospital websites and newsstories about obstetric service
closures, and looked at that,starting in 2010 all the way
(06:06):
through 2022, which is the mostrecently available data.
So this included almost 5,000short-term acute care hospitals
and obstetric and gynecologyspecialty hospitals that were
open during that time period,and we found that in 2010, only
(06:26):
43% of rural hospitals and 29%of urban hospitals did not offer
obstetric care, but by 2022,54% of rural hospitals and 35%
of urban hospitals did not offerobstetric care.
So we saw a steady rise in thepercentage of hospitals without
(06:47):
obstetric services and, again,the number of hospitals that
lost obstetric services and thenumber of hospitals that didn't
provide obstetric services wasconsistently higher among rural
hospitals.
Dr Bola Sogade (07:01):
Wow, thank you.
So I'm going to ask you athree-part question.
Number one what factorscontributed most significantly
to the net loss of obstetriccare services between 2010 and
2022?
And number two why do ruralhospitals appear to be
disproportionately affected bythe loss of obstetric care
(07:25):
services compared to urbanhospitals?
And the last part of thisquestion is how does the loss of
obstetric services impactmaternal and infant health
outcomes in rural areas?
Dr Julia Interrante (07:42):
That's great.
Thank you.
These are really importantquestions and they really are
all quite interrelated.
So there are a number offactors that really play into
the loss of obstetric servicesand hospitals and again, these
are really exacerbated in ruralareas.
So one of the main issues thatwe have been doing a lot of
(08:02):
research on is the lack offinancial support basically for
these services.
A lot of the way maternity careis financed is really centered
around urban centers that have ahigh birth volume and so that
payments for maternity care andchildbirth services are based
(08:23):
off of volume, so they'revolume-based revenues.
Now in a lot of rural hospitalsthere is lower birth volume so
that there is less revenuecoming in for that service line,
but the fixed costs are thesame.
So the cost for having staffthat is available at a standby
(08:45):
capacity and is fully trainedand equipped to handle whatever
type of emergency situations mayarise in childbirth requires a
high fixed cost.
And again, if the reimbursement, the revenue that comes in,
varies based off of volume, thatcan be really challenging to
maintain services like that, avolume that can be really
(09:08):
challenging to maintain serviceslike that.
There's also reimbursementinequities between public
insurance and private insuranceand that can really impact how
these services are able to besupported in rural hospitals,
where there are more oftenhigher proportion of patients in
births that are paid for byMedicaid rather than private
insurance, and Medicaid doesgenerally pay less for maternity
(09:32):
and childbirth services thanprivate insurers do.
So that can be quitechallenging.
Again, there's other factorsaround workforce shortages that
have been really challenging andthis has been, again, an issue
that has been happening foryears but has definitely been
exacerbated in the last fewyears.
So it's not just the workforcechallenges specific to
(09:54):
obstetricians, so it's not justchallenges in recruiting and
retaining obstetricians.
In rural areas, familyphysicians who do maternity and
childbirth services are themajority of the attendance for
childbirth in those communities,as well as midwives, and so
when there's a challenge foreach one of these different
(10:15):
clinicians, as well as workforceand retention challenges for
nursing staff, that can bereally difficult to maintain
those services difficult tomaintain those services.
So I mentioned, we have talkedwith and worked with a number of
rural hospitals where there areonly one or two or three
clinicians who are attendingchildbirth and if one of them
(10:35):
has to go on maternity, leavethemselves or retires or moves,
that can make it reallychallenging to try to find and
recruit another clinician to beable to provide that service to
that rural community.
So again I'd say the financingchallenges, the workforce
challenges, all of those areexacerbated in rural hospitals,
making it more difficult tomaintain that service line.
(10:55):
And then you asked the lastquestion of what is the impact
of that service loss formaternal and infant health
outcomes in rural areas.
And from our research we havefound rural hospitals that are
more likely to lose obstetricservices are those ones that are
in the most remote rural areas.
So where people may not haveurban center in the next county
(11:19):
over to go to, it's actuallyquite a longer distance that
they end up having to drive.
Those are the ones most likelyto lose services.
And we know that areas thatlose obstetric services have
higher rates of preterm birth,have higher rates of births
outside of the hospital setting,and it's not clear how many of
those are planned and how manyare emergency unplanned births
(11:41):
outside of the hospital setting.
And we also see greater traveldistances and other researchers
have documented that greatertravel distance is associated
with increased risk of poormaternal and infant outcomes.
Dr Bola Sogade (11:55):
Wow.
So we'll talk about some of thepossible solutions, but the
next topic I want to talk aboutis just systemic disparities.
Dr Cozimanel's researchhighlights disparities in access
between rural and urbanhospitals, and I want you to
(12:15):
please elaborate on thesedisparities, how they manifest
and their broader implicationsfor healthcare equity.
Now I like to ask my questions,three questions at a time.
So the next question is whatrole do socioeconomic and
geographic factors play inmaking these disparities worse
(12:40):
in rural areas, and are thereparticular demographics or
populations within rural areasthat are even more vulnerable to
the loss of obstetric careservices?
Dr Julia Interrante (12:55):
Yeah, Again, a lot of these are
interrelated as well.
So I had already mentioned thatrural communities that are the
most remote are at higher riskfor losing obstetric services.
We also see that ruralcommunities that are more likely
(13:17):
to lose services are also thosewhere their Medicaid programs
are less generous.
So again, in places where thereare more restrictions around
Medicaid, we also see higherrisk of loss in communities
where a majority of patients areBlack or Indigenous or people
(13:38):
of color, and again, some ofthat is tied to an overlap with
the rates of Medicaid coveredbirths.
We do know that BIPOCindividuals are overrepresented
among Medicaid beneficiaries andagain that I mentioned how
Medicaid often pays less formaternity care services.
So we see some of thatintersectionality coming in and
(14:01):
compounding the risk of serviceloss and thus also poor maternal
and infant outcomes.
Dr Bola Sogade (14:09):
So okay, when you say BIPOC just can you
explain that to the lay public?
Dr Julia Interrante (14:14):
Yes, yes, sorry.
So obviously there are lots ofdifferent terms used.
It's hard in research trying tofigure out.
I mean, by the nature ofresearch, you have to group
people, but obviously allcommunities are different and
diverse and come with their ownexperiences.
I use the term BIPOC, meaningBlack, Indigenous and people of
color, but again I just want tohighlight that all these
(14:40):
communities are different.
Communities with a higherproportion of patients who are
Black had greater risk of losingobstetric services or even not
have had services in thosecommunities prior to when we
started doing our research in2010.
So they already had seen lessaccess to maternity care
services, but they were alsomore likely to lose those if
(15:01):
they did have them.
We also see that happening in alot of states in the Midwest
and in communities where thereare a large proportion of
indigenous or native residents,and we already know that there
is a lack of services and accessto maternity care on
(15:22):
reservations and nearreservations, and a lot of
Native people gain access tohealth care through the Indian
Health Services and it is quiteunderfunded and has had
challenges with providingmaternity care.
There are actually very fewIndian Health Service facilities
that actually do childbirthservices as well, so a lot of
(15:43):
those patients end up having toeither get private insurance or
Medicaid and find anotherhospital to be able to give
birth if they need or arechoosing to give birth in a
hospital-based setting.
Dr Bola Sogade (15:56):
But still they have to travel because of risk
delivering at home withoutknowing their risk status right.
Dr Julia Interrante (16:04):
Yes.
Dr Bola Sogade (16:04):
Yeah, regulations.
(16:25):
What policy interventions doyou believe could help reverse
this trend of decliningobstetric services, particularly
in rural hospitals?
Dr Julia Interrante (16:30):
Yeah, so there are a few policies that
have either been proposed ordiscussed, some that have
actually been implemented.
There has been a lot ofattention to access to rural
maternity care service over thepast few years.
A lot of the policy changeshave been incremental, focusing
on trying to collect better data, which is important for
(16:52):
documenting challenges andevaluating potential solutions
or starting demonstrationprojects.
Solutions or startingdemonstration projects For
example, there is a Our Momsprogram.
It's rural I'm not going to beable to remember the acronym off
the top of my head but it'sbasically trying to support
rural maternity care networks tobetter provide services.
(17:14):
But these are small, short-termgrants and, again, it hasn't
fully been able to deal withsome of the long-term challenges
.
It's also in its infancy.
This has only existed for a fewyears now and it's not
available to all rural patientsand to all rural communities.
But some of the topics that weoften discuss are things like
(17:35):
around the financing challengesso providing some standby
funding capacity for hospitalsso that they're not completely
reliant on that volume-basedrevenue and also providing
funding to help cover thosefixed costs even when you have a
low birth volume at yourhospital.
Also, addressing some of theinequities for reimbursement for
(17:56):
maternity care services betweenpublic and private insurance
and generally just paying morefor maternity-related services,
and I don't mean just for theactual childbirth but also for
having good quality,culturally-centered prenatal and
postpartum care and eveninterpregnancy care, so making
(18:17):
sure that patients have accessto services between pregnancies
or even before we would call itpreconception care, so before
pregnancy, so people's health,if they have chronic conditions,
that that is managed beforethey even get pregnant.
And if you only gain access toMedicaid because you get
pregnant, that obviously is notgreat for helping prevent and
(18:38):
gain access and ensure betterhealth before you get pregnant,
which is quite connected to thehealth outcomes in pregnancy as
well.
And again, this recently cameout the Centers for Medicaid and
Medicare Services came out withsome new standards for
operating maternity services inall hospitals but this also
impacts rural hospitals andbasically just set some quality
(19:01):
and safety standards, but thatdidn't come with any resources
for those services, which againis going to be more challenging
for low birth volume, ruralareas that are already more
resource strapped.
And so in building thosequality and safety measures,
which are important, but tyingthat in with financial resources
to meet those standards, Ithink is a really important step
(19:23):
that needs to be taken.
Dr Bola Sogade (19:24):
Well, yeah, you touched on a very important
aspect in that, if we canoptimize a woman's health status
before pregnancy in a waybefore pregnancy that makes her
actually more likely to have alow risk pregnancy and delivery,
(19:44):
and so that's it would be niceto improve the quality of, you
know, pre-conceptional care,prenatal care and interpregnancy
care.
So that was a big topic youbrought up so, but as we move on
, you know what strategies youknow I want to ask you have
(20:05):
proven effective in preservingbecause there's still some, you
know obstetric care services insome rural places in the country
and we could study those asmodels to look at the strategies
that have proven effective inpreserving or expanding
obstetric care services in ruralhospitals and what other
(20:29):
options could help, you know,provide care to these women in
2025, america, so they don't dieat home trying to risk
delivering a baby withoutknowing whether they're low risk
or high risk pregnancies.
Dr Julia Interrante (20:47):
Yeah, so we did.
Actually, a few years ago we atthe Rural Health Research
Center did a series calledMaking Maternity Care Work,
where we really wanted tohighlight stories from places
who have these same challengesthat a lot of rural communities
are facing, with low birthvolumes and workforce challenges
(21:07):
and the same financialchallenges that a lot of
maternity care providers arefacing.
And we wanted to talk to themand learn from them about how
they are able to buck some ofthat trend of rural obstetric
unit closures and maintainservices and what they do to
support their community.
And so we talked to quite a fewplaces across the country and a
(21:29):
lot of these we turn into casestudies that are available on
our website for anyone to accessand read.
They told us things likerecruiting clinicians and staff
based off of their mission formaternity care, not just on
salaries and money, so drawingpeople in, drawing clinicians in
and nurse and administrators in, because they want to provide
(21:55):
maternity and childbirth carefor patients in the ways that
meet the needs of patients intheir communities.
So other things they told us wewere engaging with the local
birth community, so, again,talking to community members,
making sure there'srepresentation of the diversity
of views within thosecommunities and asking them how
(22:15):
they want to have their birthexperiences.
What types of clinicians dothey want attending their births
?
What types of clinicians dothey want attending their births
?
What types of locations do theywant?
What services would they like?
And so this included things likeproviding vaginal birth after
cesarean, which not allhospitals do support.
But having those kinds ofoptions, having options like
(22:36):
water birth again, things that alot of well, some freestanding
birth centers also do, alsooffering that midwifery model of
care, have been things thathave helped to draw patients in.
Again, I talked earlier aboutsome of the challenges with
maintaining services when amajority of patients who are
(22:57):
giving birth are Medicaidbeneficiaries and Medicaid is
paying less than privateinsurance.
But if hospitals are able todraw in patients with private
insurance, that can also helpbalance some of their we say,
payer mix, but basically makingsure that they have revenues
coming in from insurance thatpays more.
In the situation where we havewhere Medicaid is not paying
(23:18):
enough for these services, inthe situation where we have
where Medicaid is not payingenough for these services, again
offering things like childbirtheducation classes, postpartum
peer support groups andbreastfeeding support groups,
having those as services intheir hospital or having those
connections with local communitygroups that are already doing
(23:39):
that has been important in theseareas.
That have been able to maintainservices and we've even seen
things like just having anadministrator in the hospital
who really cares aboutmaintaining that service line
has been important for keepinghospital resources focused on
childbirth and maternity care.
Dr Bola Sogade (23:54):
So when we look at long-term solutions, you know
, I mean because there'sprobably a woman dying right now
, as we're talking, in a ruralcommunity in the United States,
either because she's driving interrible winter weather to a
hospital to deliver her baby, orshe's just like, forget it, I'm
(24:16):
just going to try to have thisbaby at home.
Or she just had a seizure frompreeclampsia.
Now it's eclampsia.
So the reality is there'sprobably a woman dying right now
as we're having this talk.
What do you see as thelong-term consequences number
one of these trends, if no realintervention?
(24:38):
Because there's a lot of talkaround.
Everybody wants to talk about apregnant woman and her baby.
So if there are no interventionsmade to improve access to care,
what do we see as long-termconsequences?
And then, how can data fromstudies, like from what people
like you guys have done, informfuture health care planning and
(25:04):
resource allocation for maternalhealth?
And now, in this age of AI andtechnology, what role does
technology such as telemedicineor remote monitoring, what role
could this play in improvingaccess to obstetric care in
underserved areas?
I know that even despite this,somebody has to lay hands on a
(25:28):
pregnant woman and help herdeliver a baby.
So there's a limit.
I mean we don't have robotsthat will deliver babies yet, so
there's a limit to what AI andtechnology can do.
So can you wrap up what thelong-term consequences of a lack
of intervention and thelong-term solutions could be to
(25:49):
this problem?
This is for the next episode.
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