Cocoa Pods
Podcast - Cocoa Pods Series: A feature of the Birth Center Foundation.
We discuss all things' women, all things' pregnancy, all things' after. Reasons why women fall very sick ( morbidity) or die (mortality) before pregnancy (adolescent girls and young adults),during pregnancy and after are discussed in this maternal morbidity and mortality reduction academy; especially with an emphasis on minority women, all over the world; and ways for all involved in care to work together collaboratively and mitigate and or eliminate risks in women’s health.
Cocoa Pods
Re-creating Access to Maternal Health in Non-urban America
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
I think it's very important for understanding what's happening for people living in their local communities when they no longer have access to that essential service at a time where their life and their families are changing greatly when they have a new child.
Dr Bola Sogade:Hello and welcome to CocoaPods, a podcast of the Birth Center for Natural Deliveries Foundation. My name is Bola Sogade i. I'm a women's health specialist. On this podcast, we talk about all the issues relating to women's health and identify the problems and talk about ways in which we can mitigate the problems.
Dr Julia Interrante :Hi there, how are you doing? Good, how are you?
Dr Bola Sogade:Thank you so much for your time Today. I'm very fortunate to have with me Dr Julia Itorante, phd, mph from the University of Minnesota. Welcome, dr Julia Itorante.
Dr Julia Interrante :Thank you very much for having me.
Dr Bola Sogade:Thank you. So I'm going to tell you listeners, a little bit about Dr. In She has a PhD, mph, and she's a research fellow and statistical lead at the University of Minnesota's Rural Health Research Center, with over 15 years of experience in applied epidemiology and health services research. She holds a BA, a Bachelor's of Arts, in Gender Studies and Global Politics from the University of Virginia, an MPH in Epidemiology from Emory University and a PhD in health sciences research from the University of Minnesota.
Dr Bola Sogade:She has spent six years as an epidemiologist at Centers for Disease Control and Prevention, the CDC, with research focused on gender disparities, maternal medication use and disease surveillance and prevention in both the domestic and international context. Her current research examines the effects of policy on maternal health outcomes and on access to maternity care services, with specific focus on geographic and racial equity, and includes topics such as disparities in severe maternal morbidity and mortality that is, things that could make a woman very sick or even die related to pregnancy, and also changing access to rural maternity care and the impact of payment policies on maternal and postpartum care. So thank you, , and welcome again.
Dr Julia Interrante :Thank you.
Dr Bola Sogade:So just to delve straight into the topics, we have the topics on that big headings, and the first one is the state of obstetric care in rural versus urban hospitals, and I know that you have worked very closely with Dr Katy Kozhimannil . You did publish a paper on the 4th of December 2024, in the Journal of the American Medical Association, and this was a research letter titled Obstetric Care Access at Rural and Urban Hospitals in the United States. You did an analysis of the net loss of obstetric care services from the year 2010 to the year 2022, highlighting critical disparities, particularly the disproportionate impact on rural hospitals. And Dr Kozimani, as a professor and director of the Rural Health Research Center at the University of Minnesota, her work documents challenges in rural maternal care access and emphasizes policy-based solutions to maintain and improve local access to care. So this is a lot, but I want you to talk to us about the net loss. There has been a loss of obstetric services. What does this mean to the mom and to the baby?
Dr Julia Interrante :Yeah, thank you so much for that important question and for highlighting the research that we have been doing at the University of Minnesota Rural Health Research Center and again, a lot of that work is just highlighting what is and documenting what has been happening for a long time in rural maternity care access. So loss of obstetric services and maternity care in rural areas is not anything that is new. It has been happening for years and years and we have been documenting it. The data to identify and show the extent of these losses is actually quite challenging to get. There's no national database of hospitals that do and don't provide obstetric services and when they come and go. So we go through an entire process to try to identify these hospitals and accurately track what's happening, which again, I think is very important for understanding what's happening for people living in their local communities when they no longer have access to that essential service at a time where their life and their families are changing greatly when they have a new child.
Dr Julia Interrante :So we use data from the American Hospital Association annual surveys and also combine that with data from the Centers for Medicare and Medicaid Services, data, along with review of hospital websites and news stories about obstetric service closures, and looked at that, starting in 2010 all the way through 2022, which is the most recently available data. So this included almost 5,000 short-term acute care hospitals and obstetric and gynecology specialty hospitals that were open during that time period, and we found that in 2010, only 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 offer obstetric care. So we saw a steady rise in the percentage of hospitals without obstetric services and, again, the number of hospitals that lost obstetric services and the number of hospitals that didn't provide obstetric services was consistently higher among rural hospitals.
Dr Bola Sogade:Wow, thank you. So I'm going to ask you a three-part question. Number one what factors contributed most significantly to the net loss of obstetric care services between 2010 and 2022? And number two why do rural hospitals appear to be disproportionately affected by the loss of obstetric care services compared to urban hospitals? And the last part of this question is how does the loss of obstetric services impact maternal and infant health outcomes in rural areas?
Dr Julia Interrante :That's great. Thank you. These are really important questions and they really are all quite interrelated. So there are a number of factors that really play into the loss of obstetric services and hospitals and again, these are really exacerbated in rural areas. So one of the main issues that we have been doing a lot of research on is the lack of financial support basically for these services.
Dr Julia Interrante :A lot of the way maternity care is financed is really centered around urban centers that have a high birth volume and so that payments for maternity care and childbirth services are based off of volume, so they're volume-based revenues. Now in a lot of rural hospitals there is lower birth volume so that there is less revenue coming in for that service line, but the fixed costs are the same. So the cost for having staff that is available at a standby capacity and is fully trained and equipped to handle whatever type of emergency situations may arise in childbirth requires a high fixed cost. And again, if the reimbursement, the revenue that comes in, varies based off of volume, that can be really challenging to maintain services like that, a volume that can be really challenging to maintain services like that. There's also reimbursement inequities between public insurance and private insurance and that can really impact how these services are able to be supported in rural hospitals, where there are more often higher proportion of patients in births that are paid for by Medicaid rather than private insurance, and Medicaid does generally pay less for maternity and childbirth services than private insurers do. So that can be quite challenging. Again, there's other factors around workforce shortages that have been really challenging and this has been, again, an issue that has been happening for years but has definitely been exacerbated in the last few years. So it's not just the workforce challenges specific to obstetricians, so it's not just challenges in recruiting and retaining obstetricians.
Dr Julia Interrante :In rural areas, family physicians who do maternity and childbirth services are the majority of the attendance for childbirth in those communities, as well as midwives, and so when there's a challenge for each one of these different clinicians, as well as workforce and retention challenges for nursing staff, that can be really difficult to maintain those services difficult to maintain those services. So I mentioned, we have talked with and worked with a number of rural hospitals where there are only one or two or three clinicians who are attending childbirth and if one of them has to go on maternity, leave themselves or retires or moves, that can make it really challenging to try to find and recruit another clinician to be able to provide that service to that rural community. So again I'd say the financing challenges, the workforce challenges, all of those are exacerbated in rural hospitals, making it more difficult to maintain that service line. And then you asked the last question of what is the impact of that service loss for maternal and infant health outcomes in rural areas.
Dr Julia Interrante :And from our research we have found rural hospitals that are more likely to lose obstetric services are those ones that are in the most remote rural areas. So where people may not have urban center in the next county over to go to, it's actually quite a longer distance that they end up having to drive. Those are the ones most likely to lose services. And we know that areas that lose 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 many are emergency unplanned births outside of the hospital setting. And we also see greater travel distances and other researchers have documented that greater travel distance is associated with increased risk of poor maternal and infant outcomes.
Dr Bola Sogade:Wow. So we'll talk about some of the possible solutions, but the next topic I want to talk about is just systemic disparities. Dr Cozimanel's research highlights disparities in access between rural and urban hospitals, and I want you to please elaborate on these disparities, how they manifest and their broader implications for healthcare equity. Now I like to ask my questions, three questions at a time. So the next question is what role do socioeconomic and geographic factors play in making these disparities worse in rural areas, and are there particular demographics or populations within rural areas that are even more vulnerable to the loss of obstetric care services?
Dr Julia Interrante :Yeah, Again, a lot of these are interrelated as well. So I had already mentioned that rural communities that are the most remote are at higher risk for losing obstetric services. We also see that rural communities that are more likely to lose services are also those where their Medicaid programs are less generous. So again, in places where there are more restrictions around Medicaid, we also see higher risk of loss in communities where a majority of patients are Black or Indigenous or people of color, and again, some of that is tied to an overlap with the rates of Medicaid covered births. We do know that BIPOC individuals are overrepresented among Medicaid beneficiaries and again that I mentioned how Medicaid often pays less for maternity care services. So we see some of that intersectionality coming in and compounding the risk of service loss and thus also poor maternal and infant outcomes.
Dr Bola Sogade:So okay, when you say BIPOC just can you explain that to the lay public?
Dr Julia Interrante :Yes, yes, sorry. So obviously there are lots of different terms used. It's hard in research trying to figure out. I mean, by the nature of research, you have to group people, but obviously all communities are different and diverse and come with their own experiences. I use the term BIPOC, meaning Black, Indigenous and people of color, but again I just want to highlight that all these communities are different.
Dr Julia Interrante :Communities with a higher proportion of patients who are Black had greater risk of losing obstetric services or even not have had services in those communities prior to when we started doing our research in 2010. So they already had seen less access to maternity care services, but they were also more likely to lose those if they did have them. We also see that happening in a lot of states in the Midwest and in communities where there are a large proportion of indigenous or native residents, and we already know that there is a lack of services and access to maternity care on reservations and near reservations, and a lot of Native people gain access to health care through the Indian Health Services and it is quite underfunded and has had challenges with providing maternity care. There are actually very few Indian Health Service facilities that actually do childbirth services as well, so a lot of those patients end up having to either get private insurance or Medicaid and find another hospital to be able to give birth if they need or are choosing to give birth in a hospital-based setting.
Dr Bola Sogade:But still they have to travel because of risk delivering at home without knowing their risk status right.
Dr Julia Interrante :Yes.
Dr Bola Sogade:Yeah, regulations. What policy interventions do you believe could help reverse this trend of declining obstetric services, particularly in rural hospitals?
Dr Julia Interrante :Yeah, so there are a few policies that have either been proposed or discussed, some that have actually been implemented. There has been a lot of attention to access to rural maternity care service over the past few years. A lot of the policy changes have been incremental, focusing on trying to collect better data, which is important for documenting challenges and evaluating potential solutions or starting demonstration projects. Solutions or starting demonstration projects For example, there is a Our Moms program. It's rural I'm not going to be able to remember the acronym off the top of my head but it's basically trying to support rural maternity care networks to better provide services. But these are small, short-term grants and, again, it hasn't fully been able to deal with some of the long-term challenges. It's also in its infancy. This has only existed for a few years now and it's not available to all rural patients and to all rural communities.
Dr Julia Interrante :But some of the topics that we often discuss are things like around the financing challenges so providing some standby funding capacity for hospitals so that they're not completely reliant on that volume-based revenue and also providing funding to help cover those fixed costs even when you have a low birth volume at your hospital.
Dr Julia Interrante :Also, addressing some of the inequities for reimbursement for maternity care services between public and private insurance and generally just paying more for maternity-related services, and I don't mean just for the actual childbirth but also for having good quality, culturally-centered prenatal and postpartum care and even interpregnancy care, so making sure that patients have access to services between pregnancies or even before we would call it preconception care, so before pregnancy, so people's health, if they have chronic conditions, that that is managed before they even get pregnant.
Dr Julia Interrante :And if you only gain access to Medicaid because you get pregnant, that obviously is not great for helping prevent and gain access and ensure better health before you get pregnant, which is quite connected to the health outcomes in pregnancy as well. And again, this recently came out the Centers for Medicaid and Medicare Services came out with some new standards for operating maternity services in all hospitals but this also impacts rural hospitals and basically just set some quality and safety standards, but that didn't come with any resources for those services, which again is going to be more challenging for low birth volume, rural areas that are already more resource strapped. And so in building those quality and safety measures, which are important, but tying that in with financial resources to meet those standards, I think is a really important step that needs to be taken.
Dr Bola Sogade:Well, yeah, you touched on a very important aspect in that, if we can optimize a woman's health status before pregnancy in a way before pregnancy that makes her actually more likely to have a low risk pregnancy and delivery, and so that's it would be nice to improve the quality of, you know, pre-conceptional care, prenatal care and interpregnancy care. So that was a big topic you brought up so, but as we move on, you know what strategies you know I want to ask you have proven effective in preserving because there's still some, you know obstetric care services in some rural places in the country and we could study those as models to look at the strategies that have proven effective in preserving or expanding obstetric care services in rural hospitals and what other options could help, you know, provide care to these women in 2025, america, so they don't die at home trying to risk delivering a baby without knowing whether they're low risk or high risk pregnancies.
Dr Julia Interrante :Yeah, so we did. Actually, a few years ago we at the Rural Health Research Center did a series called Making Maternity Care Work, where we really wanted to highlight stories from places who have these same challenges that a lot of rural communities are facing, with low birth volumes and workforce challenges and the same financial challenges that a lot of maternity care providers are facing. And we wanted to talk to them and learn from them about how they are able to buck some of that trend of rural obstetric unit closures and maintain services and what they do to support their community. And so we talked to quite a few places across the country and a lot of these we turn into case studies that are available on our website for anyone to access and read. They told us things like recruiting clinicians and staff based off of their mission for maternity care, not just on salaries and money, so drawing people in, drawing clinicians in and nurse and administrators in, because they want to provide maternity and childbirth care for patients in the ways that meet the needs of patients in their communities. So other things they told us we were engaging with the local birth community, so, again, talking to community members, making sure there's representation of the diversity of views within those communities and asking them how they want to have their birth experiences. What types of clinicians do they want attending their births? What types of clinicians do they want attending their births? What types of locations do they want? What services would they like?
Dr Julia Interrante :And so this included things like providing vaginal birth after cesarean, which not all hospitals do support.
Dr Julia Interrante :But having those kinds of options, having options like water birth again, things that a lot of well, some freestanding birth centers also do, also offering that midwifery model of care, have been things that have helped to draw patients in.
Dr Julia Interrante :Again, I talked earlier about some of the challenges with maintaining services when a majority of patients who are giving birth are Medicaid beneficiaries and Medicaid is paying less than private insurance. But if hospitals are able to draw in patients with private insurance, that can also help balance some of their we say, payer mix, but basically making sure that they have revenues coming in from insurance that pays more. In the situation where we have where Medicaid is not paying enough for these services, in the situation where we have where Medicaid is not paying enough for these services, again offering things like childbirth education classes, postpartum peer support groups and breastfeeding support groups, having those as services in their hospital or having those connections with local community groups that are already doing that has been important in these areas. That have been able to maintain services and we've even seen things like just having an administrator in the hospital who really cares about maintaining that service line has been important for keeping hospital resources focused on childbirth and maternity care.
Dr Bola Sogade:So when we look at long-term solutions, you know, I mean because there's probably a woman dying right now, as we're talking, in a rural community in the United States, either because she's driving in terrible winter weather to a hospital to deliver her baby, or she's just like, forget it, I'm just going to try to have this baby at home. Or she just had a seizure from preeclampsia. Now it's eclampsia. So the reality is there's probably a woman dying right now as we're having this talk. What do you see as the long-term consequences number one of these trends, if no real intervention? Because there's a lot of talk around. Everybody wants to talk about a pregnant woman and her baby.
Dr Bola Sogade:So if there are no interventions made to improve access to care, what do we see as long-term consequences? And then, how can data from studies, like from what people like you guys have done, inform future health care planning and resource allocation for maternal health? And now, in this age of AI and technology, what role does technology such as telemedicine or remote monitoring, what role could this play in improving access to obstetric care in underserved areas? I know that even despite this, somebody has to lay hands on a pregnant woman and help her deliver a baby. So there's a limit. I mean we don't have robots that will deliver babies yet, so there's a limit to what AI and technology can do. So can you wrap up what the long-term consequences of a lack of intervention and the long-term solutions could be to this problem? This is for the next episode.
