This story was originally published by North Carolina Health News.

Eight women — three OB-GYNs, three nurse midwives, one gynecologist and one nurse practitioner — comprise the maternity unit at Mission Hospital McDowell. In the 18-county region that makes up western North Carolina, the McDowell County facility is one of just eight hospitals where someone can deliver a baby.

To fill the gaps in obstetric and gynecological care in this mountainous region, the McDowell providers travel from the hospital in Marion more than thirty minutes across winding mountain roads up to Spruce Pine to offer regular prenatal clinics. They also spend time working out of the McDowell County Health Department — anywhere they can reasonably get to.

“There are some patients who come to our clinic in Spruce Pine that are kind of between us and Boone, so they are sometimes torn between delivering in Boone and delivering in Marion, because neither of them are close,” said Ellen Hearty, an OB-GYN at the hospital.

For these patients, the birthing unit at the Watauga Medical Center in Boone and the one in Marion are both probably 45 minutes or so away. For those who live in Yancey County, the Spruce Pine clinic (in Mitchell county) can be a good option for prenatal care, but it’ll probably be faster to drive to Mission’s Asheville location for their delivery.

All the back and forth creates disruptions in prenatal and maternal health care, and opportunities for critical health information to fall through the cracks. And that’s true for people even with uncomplicated pregnancies.

For risky pregnancies — in people who are older, have a chronic condition, or if their baby has any medical abnormalities — living in a maternal health care desert can be even more dangerous.

“Mostly we take care of people that everybody else throws their hands up at, like, ‘Oh my gosh, why is she pregnant? How did this even happen? She has so many medical problems!’” said Carol Coulson, one of three maternal fetal medicine physicians in all of western North Carolina. These specialists are the doctors who care for people with these high-risk pregnancies.

“We’re actually 2.6 [full-time employees] when you look at the amount of time that we work,” she said. “We cover 17 counties, roughly, so it’s a little bit insane.”

Coulson said between 20 and 40 percent of pregnant people could benefit from having a high-risk specialist on their care team, either as their primary provider, or for consultations. She works out of the Asheville-based Mountain Area Health Education Center, or MAHEC, a safety net facility which primarily cares for low income people. In her department, that means low income people with high risk pregnancies.

Some research shows that simply being low income — and all of the structural disadvantages to accessing care that come along with it — is associated with poor maternal health outcomes, including riskier and deadlier pregnancies. Two 2020 studies — one from the U.S. and one from South Korea — looked at the role non-medical health drivers might play in maternal health outcomes. The Korean study found that pregnant people with lower incomes had higher risks of postpartum death. The researchers found that likelihood corresponded more strongly with those who gave birth between ages 35 and 39, who lived in a rural area, had a cesarean section, or experienced other underlying health conditions.

The domestic study argued that one crucial step to reducing the rising maternal mortality rates in the U.S. is for providers to address the structural barriers that impact people’s health — poverty, poor access to food, structural racism, etc. — at all stages of their pregnancy.

“Probably 40 to 60 percent of our patients could have at least a consultation” with a maternal fetal specialist, Coulson said. “And then at least another 20 percent would primarily receive care with us or in very close coordination with their regional provider.”

It’s a heavy lift for 2.6 full time providers.

A county-by-county map of western NC with population numbers. There are just eight hospitals with labor and delivery units for this 18 county region. Image credit: Dogwood Health Trust

“One of my emails just popped up and it said offering $10,000 a weekend to cover an OB-GYN practice,” Coulson said. “I don’t make anywhere near that, nor does anyone I know. That’s the kind of need and that’s just general OB-GYN work.”

Accessibility of pregnancy care isn’t the only area that’s a glaring need for rural North Carolinians. According to the state health department, 93 N.C. counties are considered primary care shortage areas, 94 qualify as mental health care shortage areas, and all 100 counties qualify as dental health shortage areas.

Addressing all these gaps in care is more than any single organization can do, but two new training programs — one from MAHEC, one from Western Governors University — aim to do their best to address the region’s maternal health care needs.

Fix #1

MAHEC hosts various residencies, the training programs physicians complete after they’ve graduated from medical school. The center also hosts fellowships, which are programs where doctors who’ve already completed their residency can receive more specialized training.

Starting this summer, MAHEC will welcome its first fellow in maternal fetal medicine.

There are about 100 maternal fetal medicine fellowships nationwide, but few serve rural areas. Many states with large rural populations — West Virginia, Montana, the Dakotas — have no maternal fetal medicine fellowships. Even for the handful of programs that do work with this underserved group, few are based out of community clinics. Most are associated with large research universities.

“The hope is that we can provide a different sort of experience than you would get training in a big city,” Coulson said. “Community programs don’t do things like this because there are really intensive hoops to jump through.”

The three year program will host one student starting this summer, two by next summer, and three starting in 2024.

“We are faculty members, we do perform some research, we do take care of a lot of patients — we have our own patients, we have consultative patients,” she said. “Our hope is that by starting the fellowship, we can increase the pipeline for people who want to do a more hybrid type of MFM practice.”

The hybrid model, especially in rural areas, means providers need to feel confident in their ability to work with just a few other colleagues, and find a center to affiliate with that cares for high-risk pregnancies, such as a community hospital with a neonatal intensive care unit.

It’s not just a rural problem, though. Nationwide there’s a dearth of maternal fetal specialists. Some of that has to do with the unpredictable schedule. Coulson said she’s observed that many young physicians want a day job with predictable hours — something you’re unlikely to get in obstetrics. When she was trained, for example, physicians would do a day in the office and a night on call.

Mission Health, headquartered in Asheville, is the sixth largest health care system in North Carolina and the biggest health care provider in the state’s mountain region. It is one of just eight hospitals with a labor and delivery unit within the 18 county region that makes up western NC. Photo credit: Liora Engel-Smith.

“So it’s at least 24 hours, and some might even do a part of the next day,” she said. “You get really good at not sleeping.”

But the maternal health field is moving toward shift work, where physicians work three 12-hour shifts a week. The practice is common in other specialities, too, such as emergency medicine.

“There are pros and cons to everything, of course, and generating more handoffs in patient care is not necessarily always a good thing because you have to be really meticulous in shifting your team every 12 hours,” she said. “There is that trade off of when you’re not exhausted, your brain is working better and you’re a little more facile and efficient.”

The other big change has been the specialization of medical care. When Coulson trained in maternal health in the 80s and 90s, she ran a diabetes clinic every Friday for her pregnant patients. Now, OB-GYN residents refer patients to a pharmacist to manage their diabetes.

“The pool of general OB-GYNs who want to tackle or feel able to tackle some of the even more common pregnancy problems get smaller all the time,” she said.

Specialization can lead each provider to use their time more effectively. It can be safer for patients and allow treatment changes to be made more quickly. On the other hand, it does mean new doctors have fewer opportunities to learn certain skills.

This shift has been more complicated for patients. Namely, she said, “A patient who then has to travel from the westernmost reaches of North Carolina to talk to a specialist about something.”

Fix #2

Part of expanding care for pregnant people includes expanding postpartum care, in particular, mental health care. A new masters program from Western Governors University, an online school, aims to help fill this gap.

The curriculum is for nurses looking to become nurse practitioners with a specialization in mental health and psychiatry.

The online university offering the program was founded 25 years ago to help nontraditional students — primarily working adults and rural people — attend college in an environment that would work for them. The school is a nonprofit and it’s fully accredited, unlike many for-profit online schools dubbed diploma mills.

“Our admissions requirements are very rigorous, and holistic. We want to make sure that our applicants understand the role that they’re training for, and that they have demonstrated academic and professional skills ,” said Corbett Brown, the chair of the Psychiatric Mental Health Nurse Practitioner program.

The school operates asynchronously, admitting students every month. Once in the program, students learn from modules, which they can complete as fast or as slow as they need. Instructors who know the course material are available for office hours 40 hours per week. After students pass their courses, they complete three clinical internships, which correspond to 650 contact hours with patients.

“We’re not pulling them from the community,” Brown said. “What happens in a traditional setting is that providers are trained in urban settings at major universities, and it actually makes it harder for them to go back, especially if they come from a rural community.

”Our focus is on breaking down those barriers. We want to keep our students where they reside.”

Research shows that students who train or study in rural areas are more likely to stay and work there. Part of the clinical internship students at WGU complete is through a partnership with a working psychiatric nurse practitioner or a psychiatrist in the student’s area. The university helps students find these people and makes sure the working relationships are beneficial for everyone involved.

“Across the nation we need over 6,500 mental health providers. In North Carolina alone, we need 199,” Brown said. “There’s over 3.5 million individuals in North Carolina that need that, who live in areas where there aren’t enough mental health providers.”

Scope of the Fix Remains Limited

But, expanding the health care workforce can only impact so much. Many of the crises in care that rural patients face come from other structural barriers.

As of April 2021, North Carolina was one of just 11 states where nurse practitioners need physician oversight to diagnose and treat patients and write prescriptions. Nurse associations in the state have been lobbying for looser restrictions for years.

“It really is an artificial barrier to practice,” Brown said. “The individual that suffers the most is the patient.”

He explained that part of the full scope of practice for nurse practitioners includes knowing when something is beyond their abilities and they need to refer that patient to a physician.

Green: State practice and licensure laws provide for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribe medications and controlled substances—under the exclusive licensure authority of the of the state board of nursing. Yellow: State practice and licensure law reduces the ability of nurse practitioners to engage in at least one element of NP practice. State requires a career-long regulated collaborative agreement with another health provider in order for the NP to provide patient care or limits the setting of one or more elements of NP practice. Red: State practice and licensure law restricts the ability of a nurse practitioner to engage in at least one element of NP practice. State law requires career-long supervision, delegation or team-management by another health provider in order for the NP to provide patient care. Map courtesy: American Association of Nurse Practitioners

“Oftentimes, there’s minimal oversight of actual day to day practice,” he said. “The restrictions on the scope of practice really hinder nurse practitioners’ ability to meet the needs of patients, especially in rural areas. So where the nurse practitioner has to have that consulting physician, if physicians are not willing to sign up to be the consulting physician, then that nurse practitioner can’t practice.”

And what good can more medical professionals in an area do if the places where people go to seek care — namely rural hospitals — are closed?

Since 2014, 13 rural maternity units in North Carolina have closed either on their own or as part of an entire hospital closure. Hospital leadership often say that they had to close a maternity unit because it was too expensive to operate.

Coulson argues everybody who works in hospitals knows that operating a maternity unit usually comes at a financial loss.

“Nobody in the OB world makes money if you serve primarily a Medicaid population,” she said. “You don’t get paid enough to break even, so you have to accept it as an entry point.”

Some argue that until hospital systems can figure out how to swallow that loss and compensate for it somewhere else, the fundamental problem will remain.

“We need to provide services where people live,” Hearty, the OB-GYN from Mission McDowell said. “And the problem is that maternal health and labor and delivery and neonatal services are just undervalued in this country. They’re not financially supported. And so, until that changes, nothing’s gonna change.”