By Liora Engel-Smith
North Carolina’s rural maternal health crisis is an almost identical story of unit closures from the mountains to the coastal plain. It often goes something like this: A cash-strapped rural hospital does away with the maternity care unit because it’s too expensive to run in an area with relatively few deliveries. The community is outraged. Women and their babies would suffer, advocates say.
Over the objections of the community, the unit or even the entire hospital closes and women scramble to find other options, often requiring a drive of 45 minutes up to two hours. Over the last seven years, mothers in at least 10 rural North Carolina communities have been dealt the same blow. In most cases, there’s no coming back from a closure. Rural maternity wards don’t reopen and alternatives to the care once provided there are hard to come by.
But the tide seems to be shifting for women in two North Carolina communities. In the space of a little over two weeks, two projects have increased access to maternity care in regions where few options existed.
Chatham Hospital, a UNC Health facility that serves the rapidly expanding rural county near the Triangle, opened a maternity unit staffed by specially trained family physicians after an almost 30-year hiatus. And to the east, Vidant Health, a significant actor in the health care landscape in eastern North Carolina, opened a satellite obstetrics clinic in Martin County, a rural county that lost its maternity unit last October.
Embedded in each of these models is the attempt to make rural maternity care more affordable by lowering overhead costs. In Chatham County, the cost savings come from opting for primary care staff in the unit rather than specialists. And in Martin County, a satellite clinic — a far cheaper option than running a full-fledged unit in a hospital — gives women some prenatal and postnatal care options closer to home. Under that model, however, women from Martin County would still have to travel elsewhere to give birth.
“I think it’s a beginning to addressing the issue,” said Walidah Karim-Rhoades, director of the Cone Health Center for Women’s Healthcare and Maternal Fetal Care. Karim-Rhoades, who also co-chairs the North Carolina Institute of Medicine’s Perinatal System of Care task force, said models that preserve and expand rural maternal care resources in the state are a welcome development. But the crisis demands a regional approach to coordinate and bolster available resources.
“If we continue in these siloes, I don’t think that you’re going to make a dent in most of the issues that are happening,” she added.
Officials from both hospitals have said that these models likely won’t resolve the rural maternal health crisis entirely. Either approach, however, could be a blueprint that other hospitals may use to preserve or restore maternal care options in the state’s most remote areas.
Running a unit on less
The unit at Chatham is the first experiment of its kind in the state, but not in the nation, said Jeffrey Strickler, who heads the UNC Health facility.
“What we ultimately hope is that this model could be duplicated in other rural counties across North Carolina,” he said.
By employing primary care physicians who have additional obstetric and surgery training, the five-bed unit would be cheaper to run and could thus be financially viable at 350 annual deliveries, a relatively low volume.
The new unit would focus on “low-risk” deliveries exclusively — vaginal births or cesarean sections on women who are generally healthy. An obstetrician will be available to consult, according to Strickler, who said high-risk patients, such as women carrying twins and breech babies, will be transferred to UNC Medical Center in Chapel Hill, roughly 45 minutes away.
The construction of this new unit cost UNC Health Care roughly $2.5 million, and Strickler said the unit likely won’t break even in its first year. The backing of a much larger institution with the financial means to absorb losses is an important asset, he added.
“If we were a freestanding rural facility that didn’t have that level of relationship [with UNC] … the model would be difficult to duplicate,” Strickler said.
And though 350 deliveries is a relatively low volume to sustain a labor and delivery unit, some rural hospitals have far fewer births and would still be in the red even if they used primary care physicians, rather than obstetricians.
According to Vidant’s 2017 annual report, for instance, of the six rural hospitals that offer labor and delivery services, only two — Vidant Duplin and Vidant Edgecombe — had more than 350 births. Martin General had fewer than 300 births a year before its maternity ward closed last year, the hospital said in a statement.
Representatives from Martin General could not directly answer questions about the financial viability of Strickler’s model in their hospital, but CEO John Jacobson reiterated in an email statement that the hospital chose to focus on other community needs, including pulmonology, orthopedics and surgical services.
Care (mostly) closer to home
At roughly $86,000 for building improvements, Vidant’s new obstetrical clinic in Martin County comes at a far lower price than Chatham’s project. But the clinic has more limitations — women can receive much of their pre- and postnatal care there, but would still have to travel to neighboring Beaufort County to give birth.
The need for these services in Martin was evident from the get-go, said Dan Drake, president of Vidant Medical Group and Ambulatory Services. More than 80 patients came to the clinic in its first week, and Vidant projects that roughly 4,000 appointments would take place there this year.
Vidant has employed a similar approach in other areas of care in eastern North Carolina, he added, with the goal of keeping as much care as possible closer to home.
“We’ve got a model that’s serving the needs of our community,” he said. “But every community is different.”
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This isn’t really a “boost” to Mother-Baby care, because it leaves the baby – especially the SICK baby – out of the equation.
I have spent my entire professional life working in these rural/community hospitals . . . stabilizing services after “Pediatric meltdowns” (the MBA’s running these hospitals having done everything they could to devalue the contributions of the classically-trained Pediatricians – who covered their call “for free” for years). Then some wet-behind-the-ears financial whiz shows up and DESTROYS years of work trying to get by ON THE CHEAP. I’ve actually been told by these “suits” that my training/decades of experience (that newly-minted Pediatric Hospitalists are NOT getting now) makes me “a dime a dozen” – or that I can be “replaced” by a nurse.
I’ve watched community units be starved of experienced nursing staff (newbies are cheaper) and equipment to the point that NO ONE could function. I’ve been called to neonatal codes where no one knew how to set up the warmer or the bed or even the O2. I’ve rescued babies from the WORST kind of beginnings in these places.
Unexpected triplets, extreme premies, meconium aspiration and HIE, sepsis/GBS, undiagnosed congenital hearts . . . oh, and the horrific consequences of vacuum extractors used like weapons. ALL of this happens in the rural/community setting. My first whistle-blower situation in Asheboro starred a FP who couldn’t tell the difference between a pneumothorax and meconium aspiration. Called in by a terrified charge nurse, I saved the day/patient and was fired two weeks later – run out of my own hometown – by an executive who ultimately helped bankrupt the hospital.
If you want to bring expertise to these places – you have to RESPECT IT/PAY FOR IT. We could do it if we set LIMITS on the mega-salaries for the 9-5 suits that suck their livings off the top of our labor.
As a nation we’ve got to STOP “flying over” these places in terms of support/funding. We’ve got to get back to the old ways of local hospitals as communities facilities staffed by “work families”.
Disgruntled Doctor, fired so many times.
Yes. Indeed. Several times. Fired reporting very bad things – on more than one occasion putting my own personal/professional well-being on-the-line to serve/save a baby dying in front of my eyes. The firing is called RETALIATION. It’s sometimes compounded by a corporate BLACKLISTING. Every medical conglomerate everywhere says these things are prohibited. The state says blacklisting against the law.
Yet each time I turned to the state/Feds for the help and protection that they all say they provide. And each time, they turfed/dodged.
The nurses at Mission Memorial get it. This week they voted in a union. They had to do it because the state sold them out – first with the COPA and then with the sale to HCA. The barn door just got opened for collective bargaining in NC healthcare – because in almost thirty years, the state of NC has done NOTHING to protect doctors and nurses from the kinds of things I’ve repeatedly endured.
Not the Governor. Not the legislature. It’s not a political problem. It’s a human rights problem.
SO YEAH. Disgruntled. Many stories to tell. And ready to FIGHT for what is right.