The United States has a rising maternal mortality rate that has more than doubled in the last two decades, the worst among high-income nations. Iowa’s maternal mortality rate has, unfortunately, been the same as the rest of the U.S.
Approximately one-third of births in Iowa are in a rural setting. Rural areas have higher incidence of chronic conditions, poverty and travel barriers. Rural women have an increased risk of childbirth-related hemorrhage and maternal and infant death.
In Iowa, family medicine physicians deliver more in rural settings while obstetricians and certified nurse midwives deliver more in urban settings. Obstetricians deliver approximately 70 percent of Iowa births. Iowa ranks last in the U.S. for the number of OB-GYNs per 10,000 women.
The number of family medicine physicians providing maternity care is on the decline nationally — the percentage of new family medicine residency grads intending to provide maternity care has approximately halved over the last 20 years, and the number of graduates from University of Iowa family medicine residency programs mirror this trend.
Nationally, rural maternity units are closing, and Iowa is no exception. Due to low reimbursement for maternity services and the expense of maintaining 24/7 coverage, a rural hospital saves approximately $2 million by eliminating obstetrics.
Before 2001, 75 of Iowa’s 99 counties had maternity services. Now 51 counties do. Eight maternity units closed in 2018.
Even though obstetric services may have left a community, patients arrive at the door with pregnancy complications. As Dr. John Cullen, president of the American Academy of Family Physicians, said, “Closing OB departments does not mean that hospitals will avoid obstetrics emergencies, just that they will not be competent at managing them when they happen.”
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Sixty percent of maternal deaths in the U.S. are preventable. Regardless of whether there is a maternity unit, emergency medical services personnel, emergency room physicians, and hospital providers and nursing staff should be trained to identify maternal early warning signs, provide proper emergent treatment, and transfer the patient in a timely manner if appropriate. Training for rare but potentially catastrophic events saves lives.
From 2006 to 2013, California lowered its maternal mortality rate by more than half, putting it in line with other high-income nations. How? Statewide, physicians and nurses were trained to recognize and respond to uncommon emergencies using standardized approaches and checklists. Deficiencies were identified and corrected. The effort included urban and rural settings. Iowa can do this, too.
We can expand perinatal regionalization efforts, across specialties, across disciplines, across health systems to provide standardized, evidence-based care using all the modern tools we have, including telehealth, with all team members practicing at the top of their license.
We can ensure consultation and transfer is immediately available when an emergency exceeds care demands or resources.
There are other ways that Iowa might address its looming maternity workforce shortage in rural areas:
The Improving Access to Maternity Care Act, signed into law by the president in December 2018, establishes maternity care shortage areas for potential placement by National Health Service Corps physicians. This could bring providers to rural Iowa.
The Conrad 30 program is a J-1 Visa waiver for international medical graduates for health-shortage areas. Iowa uses all 30 of its allotment annually. Other states do not. Flexibility in this program might allow Iowa to use a waiver unused by another state.
Rural rotations can provide increased exposure to rural life and practice for medical students and resident physicians. This may attract physicians in specialties compatible with rural practice. OB fellowship training for family medicine physicians, including training in caesarean delivery, could expand capability in rural hospitals.
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Other potential solutions are state funded medical student loan forgiveness programs, tax incentives, and assistance with medical malpractice liability insurance.
The bottom line is appropriate reimbursement for maternity services from both private insurers as well as Medicaid. Appropriate payment for maternity care allows hospitals and providers to pay their staff and overhead and simply stay in business.
We cannot stand by and watch Iowa mothers die of preventable causes. We must shine a light on the impending rural maternity crisis in our state and take action. We owe it to our sisters, our daughters and our granddaughters to commit to quality and safety in maternity care in Iowa.
• Dr. Marygrace Elson of Iowa City is an obstetrician and gynecologist. On Friday, she was installed as the 170th president of the Iowa Medical Society and this column is an excerpt from her prepared remarks.