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Maternity care is disappearing from rural Maine communities. How can we stop it? New study offers solutions

Northeastern University report offers hopeful workforce ideas to help Maine’s struggling rural maternity units remain open and thrive.

A hospital room in Maine Medical Center.
PORTLAND, ME – SEPTEMBER, 9: One of Maine Medical Center’s newer larger hospital rooms in the maternity ward Friday, September 9, 2016. The hospital hopes to add more similar rooms with an expansion. (Photo by Shawn Patrick Ouellette/Portland Portland Press Herald via Getty Images)

Almost one-third of hospitals in rural Maine have closed their obstetric units in the past 15 years, meaning that expectant mothers face longer drives for maternity care and increased health risks due to lack of access to obstetricians and delivery room nurses.

Now a team of researchers from Northeastern’s Roux Institute in Portland, Maine, is reporting on a way to grow flowers in the state’s maternity desert by keeping the obstetric programs that remain open and thriving.

The solutions laid out in the workforce needs assessment, which is already receiving praise from health care practitioners across the state, could serve as a template for other states facing a crisis in maternal health care, according to experts.

“If a rural hospital closes or they close their obstetrics services, that leaves a really big gap in the community,” says Louisa H. Smith, one of the authors of the assessment, an epidemiologist and assistant professor at Northeastern’s Bouvé College of Health Sciences.

And while Maine’s maternity clients are declining in number, they are also getting sicker, says lead author Katherine Simmonds, a Northeastern clinical professor in the School of Nursing.

“So hospitals staying open is really critical,” Simmonds says.

The researchers, who also include Roux Institue postdoctoral fellow Brianna Keefe-Oates and Jeni Stolow, a collaborator from Tulane University,  interviewed scores of nurses, doctors and administrators at 15 of 16 rural hospitals — one declined to participate — to come up with a comprehensive plan to address obstetrical workforce needs.

The recommendations include improving remote telemonitoring for high-risk patients, training general surgeons in C-sections, developing refresher courses at high birth volume hospitals for rural nurses and allowing nurse anesthetists to provide epidurals, among many other suggestions.

They “compiled a lot of very rich ideas,” says Dr. Dora Anne Mills, chief health improvement officer for the MaineHealth hospital system, which used a federal grant to hire the Northeastern team to do the assessment.

The Northeastern researchers combined a quantitative assessment of births and birth outcomes in rural Maine with site visits to hospitals and scores of anonymous interviews with everybody from frontline staff to hospital presidents and CEOs, Mills says.

“It is a very powerful report, in large part because people in rural Maine had a voice in this,” she says.  

“Some people on the front lines had ideas that were different, and sometimes the same, as what presidents of hospitals were saying. So that was interesting,” says Mills, who will discuss the report this week during the Maine Hospital Association’s Small and Rural Hospital Conference.

Preventing deadly outcomes

The rising cost of maternal health care combined with declining birth rates have dealt a  blow to rural maternity health units in Maine — and across the nation, Simmonds says.

The Northeastern report says that Maine births “are at their lowest in over a century, dropping by more than half since 1960.”

More than a dozen obstetric units have closed since 1970, “with half of those closures occurring in the last decade,” the report says.

“This leaves 21 hospitals with delivery services in the state, 16 of which are in rural areas. The trend in Maine reflects the broader national pattern of declining healthcare resources in rural areas.”

It’s a trend that can have dangerous implications.

In a report titled “Where You Live Matters,” the March of Dimes painted a bleak picture of maternity care deserts in rural and low-income areas, saying that maternal deaths in 2020 represented a 31% increase from 2018.

The phenomenon concerns the federal Health Resources & Services Administration (HRSA) which started the Rural Maternity and Obstetrics Management Strategies (RMOMS) program in 2019 to support state rural maternity care initiatives.

Mills, the principal investigator for the RMOMS grant in Maine, says the grant already has helped pay for things like high-risk birth simulations and the implementation of telehealth strategies to deal with perinatal depression.

The workforce needs assessment is the latest RMOMS development, she says, adding that the next step will be to meet with stakeholders to prioritize what needs to be done first.

Supporting dedicated staff

“One of the key findings is that the people who are working in the remaining 16 hospitals in rural Maine are amazing, hard working and really going above and beyond in so many cases to care for the communities they serve,” Simmonds says.

The staff at rural hospitals are tight-knit communities, often including several generations of one family working in the same building.

“They are on call for an ungodly number of hours,” says Simmonds, adding that researchers heard that a 73-year-old doctor is so devoted to making sure his hospital’s maternity unit stays open that he is willing to be on call three days a week.

“He has postponed retirement because the hospital has only one other OB, with whom he shares calls, which leaves a gap when one of them wants to go on vacation or is sick or injured,” Smith says.

The needs assessment report is aimed at nurturing and preserving staff by providing additional support in various forms.

They include cross-training nurse anesthetists to deliver epidurals, incentivizing staff to to receive additional credentials in areas such as lactation support and training family medicine and general surgery physicians in C-section and other reproductive health skills.

Keeping obstetric skills up to date has been an issue for labor and delivery nurses in low-volume birth hospitals. Nurses at those hospitals are often reassigned to medical and surgical floors, Mills says.

One solution outlined in the needs assessment would be to work with academic centers at more urban hospitals to offer them refresher courses over the course of several days, she says.

The needs assessment report also mentions the need to restructure the reimbursement for MaineCare, the state’s Medicaid insurance program for low-income residents.

“The good news is that is underway,” Mills says, who adds that the overhaul of MaineCare is rolling out over the next several weeks and months.

A stellar team

Health care and government officials will work on the needs assessment to see what can be accomplished in the next year or two and longer term, Mills says.

She says the Northeastern research team also will visit more urban hospitals in Maine to see what their needs are as they are assigned more maternity care cases from rural areas.

Mills says she looks forward to continuing working with the Roux Institute team, adding that the researchers are “stellar.”

“I’ve worked with many, many assessment teams that do many, many assessment reports. This was truly one of the best I’ve seen in terms of the team, the methodology and outcomes,” she says.

Mills says she’s been deluged with congratulatory emails and phone calls from people who have seen advance copies of the report, including one that a nurse emailed during her interview with Northeastern Global News.

The needs assessment exemplifies a way forward for other rural health care systems, she says, adding “there hasn’t really been a forum like that, for people to share,” in the past.