June 16, 2022, 3:20 p.m. News Staff — In many parts of the country — especially the rural United States, home to some 46 million people — family physicians are responsible for providing invaluable health care services to their communities. Perhaps the most important of these services is maternal care. Results from a September 2021 study, for example, found that family physicians delivered babies in two-thirds of rural hospitals and were the only physicians who delivered babies in 27% of these facilities. The study also found that if family physicians in these areas stopped delivering babies, many women would have to drive an average of 86 miles round trip for prenatal care visits and delivery — findings that drive home the essential role FPs play in providing rural maternity care.
To identify maternal health disparities and find ways to improve access to maternity care and improve health outcomes for pregnant women and children in the rural United States, the Office of Minority Health in 2018 created the Rural Maternal Health Initiative. OMH has since used a variety of methods to gather information, including informal working sessions, interactive forums, formal requests for information, case studies and reviews of state and county rural health policies.
In May, OMH issued a summary of the initiative’s activities between June 2019 and November 2021. The report illustrates OMH’s efforts to raise awareness about inequities in maternal health and develop potential solutions while highlighting how family physicians contribute to improving rural maternal health and health equity.
The initiative’s first event occurred in June 2019, when CMS held an interactive forum to help various entities (health care professionals, hospitals, insurers, professional health organizations, nonprofit groups, community health centers and government officials) better understand the difficulties women in rural communities face in obtaining appropriate access to high-quality maternal care. It was hosted in collaboration with the AAFP and six other organizations and featured a short presentation by then-President John Cullen, M.D. Following the event, attendees listed payment, workforce and clinical/quality improvement issues as the top priorities for improving access to maternal health services.
Building on the forum’s discussions, in September 2019 CMS released an issue brief on improving access to maternal health care in rural communities. The brief noted that, while family physicians comprised the largest group of rural obstetrical providers, the number of family physicians providing obstetrical services was decreasing, with only about 19% of FPs performing routine deliveries. The brief also cited efforts by Kearny County Hospital in Lakin, Kan., to provide continuing education to family physicians in perinatal care and to address health disparities in women of reproductive age — efforts that helped result in an increased volume of births, a reduction in the number of births of babies that were large for gestational age, and an increase in breastfeeding initiation.
During the following month, OMH contacted seven rural hospitals to learn about their participation in maternal health quality improvement activities such as the maternal safety bundles developed by the Alliance for Innovation on Maternal Health.
In February 2020, OMH issued a request for information seeking public comments on opportunities to improve health care access, quality of care and outcomes for women and infants in rural areas before, during and after pregnancy. The notice, which was open for comment through Apr. 12, 2020, also included a request for information seeking public comment on the readiness of rural healthcare professionals to handle obstetric emergencies in rural areas. OMS received 135 submissions focused on topics such as barriers to improvement, opportunities for improvement, impactful initiatives and obstetric readiness.
In September 2020, OMH conducted an informal literature review of rural stakeholder priorities, including maternal health, in preparation for fiscal year 2021 priorities, including the impact of the COVID-19 pandemic. Maternal health policy priorities noted in the review included expansion of Medicaid postpartum coverage, payment for maternal health services, addressing shortages of health care professionals, improving training and education, and quality improvement.
Between June 2020 and November 2020, on behalf of OMH, the CMS Alliance to Modernize Healthcare Alliance to Modernize Healthcare, a federally funded research and development center, convened a Rural Obstetric Readiness Workgroup made up of 26 experts in rural health, maternal health, pediatrics, emergency services and public health. Its goal was to develop solutions for rural health care providers — in particular, hospitals and emergency services groups that do not typically provide obstetric services — to improve their readiness for obstetric care.
The workgroup focused its discussions on four areas (care disparities; financial challenges; workforce, training and equipment inadequacies; and regional relationships) and developed two lists of more than 100 potential solutions: one for rural providers and one for rural health stakeholders such as government agencies, professional organizations and academic groups.
After the workgroup’s final meeting, representatives from the CDC, CMS, the Health Resources and Services Administration, and the Indian Health Service convened to discuss the results to that point. They developed an additional set of 25 recommendations for improving obstetric readiness through actions by federal, state and local agencies, by communities and by individual health care professionals.
Family physicians and AAFP programs designed to improve rural maternal health were mentioned specifically throughout both lists of potential solutions as well as in the list of recommendations from federal partners. For example, one suggestion for addressing training and workforce inadequacies was to require obstetric trainings such as the Academy’s ALSO and BLSO programs for rural health care professionals. To strengthen regional relationships, another proposed solution was to provide opportunities for rural family physicians and other health care professionals to participate in rotations at higher-volume facilities so that they could gain more exposure to diverse obstetric cases and different levels of care. (These lists are included as appendices to the OMH summary.)
Finally, between May 2021 and November 2021, OMH convened an internal Rural Maternal Health Workgroup to review information obtained through the office’s rural health efforts since 2018. The objective this time was to identify projects and actions that CMS could undertake to advance rural maternal health for marginalized populations and support future maternal health strategies.
According to the summary, the Rural Maternal Health Initiative’s activities have laid the groundwork for future collaborative efforts between government agencies and communities that will advance rural maternal health care and health equity. These include
Zita Magloire, M.D., a practicing family physician with Cairo Medical Care, L.L.C., in Cairo, Ga., and co-chair of the Academy’s obstetrics member interest group, said that the summary spotlighted the multiple roles FPs play in rural maternal care as well as the challenges they face in some instances.
“It does highlight the importance of FPs as part of the solution, but it also cites that the numbers of FPs are declining,” Magloire said. “I think we need to emphasize that specifically increased payments for FPs performing obstetric care is critical, particularly in rural areas. FPs also see a larger proportion of Medicaid pregnant patients, so it hits our practices hard but is an issue for OB/Gyns as well.”
In an email to AAFP News, Magloire shared some of the personal challenges that go with offering maternal care in a rural setting.
“I just had a patient transfer to me for OB care from another state with a history of suicide attempts, severe postpartum depression and PTSD, who lost her insurance three years ago and has not been on her mental health medications,” Magloire said. “Her OB provider was not comfortable prescribing psychiatric medication [and] put her on low-dose sertraline. The waiting list for mental health care in her area was an average of six months. Having the training as a family physician to also provide mental health care allowed me to restart the patient’s medications without delay and refer her to telehealth cognitive behavioral therapy to accommodate her lack of transportation.
“Additionally, rural maternity care involves a lot of care coordination as well as innovating within our practice. We now perform ultrasounds, nonstress tests and various screening tests in office that many years ago were not available to patients. One reason we are able to do this is through our successful blending of FPs with OB-GYNs in our practice — a true win-win situation for our patients.”
Of the potential solutions listed in the summary, Magloire said increasing Medicaid reimbursement for postpartum care would be the fastest and most critical in the short term.
“Last year, we saw expansion of Medicaid postpartum coverage up to six months in some states, with the goal being a year postpartum,” said Magloire. “However, in order to ensure gaps in care do not occur that could lead to severe morbidity, we have to look at how these patients can continue to have appropriate coverage long-term.”
Overall, Magloire said the solutions and recommendations listed in the summary were important for promoting long-term improvements in rural maternal care. “There may be more than what has found initially,” she added. “We just have to keep this as a top priority in medicine, in our communities and as a nation.”
Magloire also had advice for young FPs considering practicing or providing maternal care in a rural setting.
“Consider doing a rural rotation in medical school or residency,” she said. “Also know that while rural medicine is very interesting and rewarding, that same skill set is much needed in larger cities throughout the country, and there are opportunities to practice OB and family medicine in these areas as well.”
Magloire encouraged FPs to reach out to AAFP members through the obstetrics member interest group.
“We love to receive questions and provide support for students, residents and practicing physicians who desire to or who are providing OB care,” she said.