[dropcap]E[/dropcap]very Wednesday morning, OB-GYN Suzanne Dixon makes a 70-mile drive west along mountainous roads that spiral in a dizzying loop, often with precipitous drops on one side. Her destination? Franklin, a tiny town of about 30,000 in Macon County. Her mission? To deliver pre- and post-natal care at the Mission Women’s and Children’s Center to women who otherwise would do without.
With appointments scheduled back-to-back, Dixon immediately starts seeing patients, many of whom have also traveled up to an hour. By day’s end she has checked the weight, blood pressure and swelling indicators of almost 25 moms-to-be and documented their baby’s growth and heart rate. She eats dinner at a local restaurant and spends the night in an area motel. She gets up early Thursday morning and does it all over again before making the return trek along I-40. She arrives home at or after dark, depending on the season. For her, few things are more satisfying.
Originally from Tallahassee, Dixon fell in love with the mountains while completing her residency at the University of North Carolina-Mountain Area Health Education Center campus. She practiced in South Carolina for almost a decade before joining the MAHEC practice and faculty in 2012. She stated it’s a challenge to practice maternity care in rural areas. “The town of Franklin had a thriving labor and delivery program as well as an ob-gyn practice that provided high quality care,” she said. “If the practice like that can’t be financially sustainable I’m not sure what would be in a small place.”
Mountain Area Health Education Center (MAHEC) is a nonprofit established in 1974 to improve training and retention of health care professionals in the 16 mostly rural counties in the western part of the state, a job made more difficult in a health care landscape increasingly driven toward urbanization and specialization. Wedged between the Blue Ridge and Great Smoky Mountains, the state-of-the-art Asheville campus houses a medical school and provides primary care, OB-GYN, dental care, sports medicine, behavioral health, pharmacotherapy, and nutrition services for area residents. In recent years, the education center has implemented three separate programs designed to save the region’s most vulnerable mothers and babies.
Rethinking the Healthcare Delivery Model
The continuing loss of maternity care in rural areas of North Carolina has made addressing the needs of pregnant women and new mothers even more urgent. While hospitals in towns like Rutherfordton, Spruce Pine and Franklin remain open, their labor and delivery units were shuttered, forcing women in the surrounding counties to travel a minimum of 20 miles for prenatal care or to give birth. “The region had six maternity care units and hospitals close, which resulted in a greater consolidation of maternity care into regional hubs,” says Jeff Heck, MD and CEO of MAHEC. “The average woman needs to travel greater distances to deliver her baby than she did even five years ago.”
Bryan Hodge, DO, director of Rural Health Initiative, says perhaps we should reframe the dialogue around the best way to preserve access to care, so that hospital closures don’t necessarily mean reducing services but rather a change in how services are delivered.
“Traditionally, care has been built around the infrastructure of the hospital. When closures occur, all that infrastructure goes away, leaving a desert and a void,” says Hodge. “We need to reimagine the way health care could be accessed that keeps people at home but also brings some resources and economy to those areas. Maybe we don’t need a 25 bed hospital, but we need physicians and care coordination. We need access to basic services like urgent visits and primary care.”
Hodge is describing what is known as the hub-and-spokes health care model, where community hospitals, family practices and other clinics operate as care satellites that feed the more demanding cases to the hub. As a Level III or higher trauma center, the hub could provide prompt assessment, resuscitation, surgery, intensive care and stabilization of injured patients and emergency operations. Mission Health Hospital in Asheville is the only Level III facility in the 16-county region.
Dixon exemplifies this new model of bringing care to the patients—what she calls a good start that needs more infrastructure. “Patients come to me for their prenatal care and when it comes time to deliver, they have to drive all the way to Asheville,” she says. “If patients need major surgeries, have complicated deliveries or want a well-supported maternity care unit, they have to drive sometimes two hours for that.”
“The average woman needs to travel greater distances to deliver her baby than she did even five years ago.”
Because of her previous high risk pregnancies, India Rutherford was advised to give birth in Asheville, nearly an hour away from her home in Nebo, NC. Doing so proved to be a wise decision that was backed up by extensive planning. Still, during the delivery, things went south and Rutherford hemorrhaged 6.5 liters of blood. It was touch-and-go for both mother and baby for a while. Thankfully, Mission Hospital has established OB hemorrhage protocols to make sure blood loss doesn’t result in organ failure, stroke or death. As a result, both mother and baby survived the traumatic experience.
It’s not always possible to identify at-risk women ahead of time or for practitioners to have the necessary resources on hand to operate at that level. Dixon recalls one patient with a life-threatening, ruptured ectopic pregnancy. The woman had just moved to Franklin with her toddler, with her partner due to follow later. In the meantime, she had no support. “She was doubled over in pain and there was no way to provide the surgical care she needed at Angeles hospital,” Dixon said. “I was trying to get her an hour-and-a-half away to Mission but there was nobody to take care of the child.”
Saving the mother required creativity and coordination. Dixon arranged for an ambulance to Asheville and the YWCA provided child care for the toddler while the mother underwent surgery.
Women of color are already more likely to experience pregnancy- and birth-related complications. Disappearing health care in rural communities only exacerbate the birth outcomes, as well as infant and maternal mortality rates. In a state where disparities are already stark, Buncombe County ranks at the bottom. Black babies die at nearly four times the rate of white babies before reaching their first birthday, regardless of a mother’s education or socioeconomic status. There is an acknowledgement that these disparities can’t be reversed without addressing the racial bias and structural and institutional racism that contribute to them.
According to the CDC, black mothers are more likely to be targets of demeaning behavior during their prenatal care, as well as in the delivery room. Researchers use the term “weathering” to describe the overt and structural racism that leads to women of color being dismissed, ignored and discriminated against by health care professionals in greater numbers than white women. A growing body of research shows racism-induced stress is also linked to health disparities.
MAHEC is leading tough conversations about implicit bias and searching for solutions. When a study found that racism plays a role in mistreatment of black women during labor and delivery, the center sought to alter these social determinants of health. The result was SistasCaring4Sistas, a doula program that is part of a larger social justice movement to eliminate health disparities for mothers and infants. Best described as a birth coach, a doula provides emotional and educational pre- and post-natal support to expectant mothers.
Driven by her own personal childbirth experience, Cindy McMillian became a doula in 2016. McMillan spent three long, frustrating months in the hospital with her first child. Five years later, she nearly hemorrhaged to death giving birth to twins, only one of which survived. “The way the hospital and doctors treated me was unreal,” McMillan recalls. “They put me in this room that was like a broom closet for a week and I had to go outside for the restroom. I had a general cesarean and all this pain but nobody explained anything to me.”
Black women have the highest rate of cesarean births, according to the National Center for Health Statistics. But studies show doulas can help lower that rate and also increase the rate of breastfeeding. McMillan first heard about the profession during a discussion about self-care with other women in her apartment complex. The more she learned, the more she asked: ‘where was my doula?’ “If I had someone there to explain things like what was going on, how my body would react and the procedure, it would have made all the difference,” she says.
In order to become a nationally certified doula, McMillan had to, among other things, complete an extensive three-day, hands-on training in birth and breastfeeding, chart three births under doctor supervision, and pass an exam. SistasCaring4Sistas’ four doulas work closely with OB-GYN and family medicine providers and have established working relationships with local hospital labor and delivery staff. Each has a caseload of seven or eight expectant moms who come through clinic referrals. Financial assistance is available on a sliding scale for women of color or white women struggling with substance use disorder.
Marina Vallejo’s partner was incarcerated early in her pregnancy. As it became clear that he would not be released by the time she gave birth, she reached out to SistasCaring4Sistas for a supportive lifeline. “I was carrying a huge burden and feeling alone,” says Vallejo. “Cindy provided the emotional support that took this weight off my back. I felt like I had a partner.”
Together the two women developed a birthing plan for the delivery. Vallejo insisted on a birth without medical interventions but changed her mind as her labor progressed. McMillan was at her side when things got tough. “When she lost her cool, I grabbed her face and we were forehead to forehead,” recalls McMillan. “I started hugging her really tight, telling her she could do this. After a while, she started breathing and got it back together.”
Although she didn’t have the natural, epidural-free delivery she initially wanted, Vallejo says she nonetheless felt respected and supported throughout the process. “There are so many women who go through this and it’s so traumatic not having that extra person to have your back in a different capacity. Cindy and I have built a connection over a period of time and we’ve built a friendship,” says Vallejo.
Care Without Judgement
When Becca realized she was pregnant, she was so deep into her addiction, she couldn’t understand how she was still alive, let alone pregnant. She knew she needed help but feared seeking it would result in losing custody of her baby.
Few people in Appalachia have been spared the ravages of the opioid epidemic, including pregnant women. Area hospitals report a 400 percent increase in babies who were regularly exposed to opioids in utero. Melinda Ramage is the medical director for Project CARA, a substance use treatment program house at MAHEC’s high risk obstetrics unit. “I can’t remember the last time I had a new patient who had opioid use disorder and they were using pills,” she says. “Because we became very aggressive in not prescribing as many opioids, we then saw an increase of heroin and fentanyl.”
Project CARA is both a clinic and a network of resources aimed at eliminating barriers and decreasing the stigma that prevent pregnant women from seeking care and treatment. “Pregnancy presents a unique opportunity for women to break the cycle of addiction and trauma,” says Ramage. “Nearly 70 percent of pregnant women with substance use disorders tell their OB-GYN provider first. Our job is to ensure that our patients feel safe enough to tell us what’s going on and then help them access the resources they need to have a healthy pregnancy and birth.”
A friend eventually convinced Becca that her secret would be safe with Project CARA, where she would also have access to medication-assisted substance use disorder treatment. “I had so many different support people,” Becca recalled. “Whenever I needed to talk to someone or check in, they were always available to meet with me before, during, or after my prenatal visit.”
The average Project CARA patient is 26 years old, Caucasian, and in her second or third pregnancy. To provide wrap-around care, the team partners with a detox and treatment facility, and a residential facility for pregnant and/or parenting women. The program also helps moms receive WIC.
The emphasis on keeping mothers and babies together after pregnancy is one reason Project CARA is effective. Seventy-eight percent of clients come to their expected number of prenatal visits, and 58 percent are illicit drug free and delivery. When asked what’s most important, they say being healthy, having a healthy baby and staying clean. They also say that being able to receive treatment along with OB services makes taking the steps into recovery more comfortable and convenient.
Filling the Medical Pipeline
None of these initiatives would be possible without an adequate, well-trained workforce, so MAHEC is laser-focused on providing more training and getting more providers in rural areas. The recruitment efforts begin in junior high. Research shows that physicians who graduated from a rural high school are 4.5 times more likely to practice in a rural area and 8.5 times more likely if they trained in a primary care field.
“We want to help them keep their vision and inspiration,” says Heck. “Once they get into medical, pharmacy school or whatever, the next challenge is to make sure they stay connected and inspired about practicing in rural areas. Two new physicians in a county of 15 or 20,000 can make the difference between being an underserved area and an adequately served area.”