It’s a quiet crisis, but a real one. Increasingly, pregnant women who are part of the 1.4 million Hoosiers living in rural areas face a forbidding truth: despite earnest efforts to maintain a full spectrum of healthcare services, more than 30 Indiana counties today have no obstetric capacity – the specialized medical ability to support childbirth. Further, many counties have birthing centers reduced to no regular access by mothers-to-be for professional prenatal and maternal care.
What does that mean? Pregnant Hoosier mothers in rural areas "have significantly higher chances of dying" from pregnancy-related complications than do their counterparts living in urban areas. Further, the mortality rate of infants is also "significantly higher," which is a polite way to describe higher-risk conditions leading to possible infant death. Details of these trends were recently published in Scientific American.
The really hard truth for rural Indiana? Babies die in rural areas at a rate of 29.4 per 100,000 live births, compared to 18.2 in urban areas, according to current CDC data. Indiana stats from the State Department of Health confirm these trending numbers in the Hoosier state. One death is too many. Upwards of 10 infant deaths per year is a very ugly number.
Here’s an unpleasant reality that many Indiana mothers face in rural areas: some babies are born in the back of ambulances. Or on an isolated farm. Or potentially even on the side of a road in the back seat of a car.
Ask a family physician who has delivered babies in rural areas (like the co-author) about what mothers in small towns and rural areas may face. Going into labor can happen anywhere and at any time. Labor can begin at an inconvenient time and location in rural areas, and some mothers-to-be barely make it to a local emergency room, where the medical staff fervently hopes that no extraordinary procedures are needed.
Those two trends – at-risk mothers and babies who face a higher mortality rate – represent a growing crisis in rural America and rural Indiana that currently has no full solution. That doesn’t mean that hospitals, clinics and physicians aren’t trying to find an answer.
But there’s more. Consider this: in these same Indiana counties where pre-natal care is lacking, there is also often the double whammy of poor nutrition and higher tobacco use. Both of these issues complicate and add more challenges to a mother-to-be and her unborn child.
Indiana unfortunately reflects a national trend. Disappearing maternal care in America has become all too common. Uncorrected, that represents a bad movement.
Some causes underlying this crisis are clear and others not are not so clear. It is clear that offering obstetrical -gynecological (OB-GYN) services is a high-ticket financial cost for any hospital. The uncertainty of delivery times and potential complications that can arise force OB-GYN services to be on call 24/7, complete with a full staff capacity of specialty physicians, nurses, anesthesiologists, surgeons and other medical professionals. That takes money and lots of it.
Here’s a major challenge: rural and small-city hospitals that struggle to keep their doors open often find that their OB-GYN capacity is just too costly.
Further, the role and type of physicians in rural Indiana and America is changing. Family physicians used to help fill the OB-GYN void in rural areas. For various reasons, today a mere 10 percent of family physicians now offer obstetrical services. Part of the reason is that family practice offices are generally overloaded. Little time exists for OB-GYN training that would help solve issues, particularly in rural areas.
What can be done? Even in the midst of crisis, there is some emerging good news. In the short-term, increased use of telemedicine allows OB-GYN professionals to “see” expectant mothers through secure digital connectivity. That can help with the pre-natal and post-natal sides of the treatment equation. Further, encouraging focused creativity and finding innovative ways to place OB-GYN physician extended resources, such as licensed physician assistants and nurse practitioners, in rural hospitals can be of benefit. Working through OB-GYN MD networks and oversight, these professionals can help provide more accessible prenatal clinical opportunities. Over time these measures may help identify potential challenges in advance and improve birth outcomes.
More is still needed. Counties, regions and state governments and medical officials need to find ways to prevent more rural hospitals from closing. A critical truth remains. Rural hospitals and clinics provide life-saving and life-enhancing services that cannot be replaced by apps and digital short-cuts, however well-meaning. Too many babies and mothers are dying or experience long term negative outcomes in rural areas – in Indiana and throughout the rural countryside of the nation – because 21st-century policies and resources are not in place.
Together we can find innovative solutions. The time for forward-looking thinking and intelligent change is now.
Greg Larkin, M.D. (a former rural area family physician) is a former Commissioner of the Indiana State Department of Health and Medical Director at Eli Lilly & Co. Don Kelso is the executive director of the Indiana Rural Health Association.