Rural Pregnancy
Nurse Midwives Deliver Needed Services in Rural Areas
by Candi Helseth
Juliana Fehr began her career as a special education teacher, working with severely handicapped children in rural Virginia. Mothers of her students seemed to know little about the importance of caring for themselves during pregnancy and told her stories about their babies being born limp and lethargic, stories that left Fehr wondering if the children might have had different outcomes if they’d had less traumatic births.
“I realized I couldn’t change the outcome for children unless I began before birth and to do that, I needed to work with the moms,” Fehr said. “Ideally, the change begins before they’re even pregnant.” Fehr returned to college for a bachelor’s degree in nursing and then a master’s degree in midwifery. She worked as a certified nurse midwife (CNM) in rural Virginia and West Virginia for 17 years.
CNM Gail Stamler says she spends more time educating her patients about healthy living than she does delivering babies. And she’s delivered hundreds of babies during the last 30 years in Silver City, NM. (Overall, midwives deliver about one-third of New Mexico’s babies.) For Stamler, the long, erratic hours associated with a rural practice are offset by the rewards of small town living. Although Silver City is ripe with unemployment, poverty and one of the nation’s highest teen pregnancy rates, Stamler said, the isolated community is also rustically beautiful, tranquil, friendly and culturally interesting.
CNM Gail Stamler visits with patient Crystal Medina and her children, which she delivered.“I like the low-key lifestyle and I love my patients and really getting to know them,” she said. “I’m meeting women’s needs and that feels good. I guess I’m just cut out for this.”
As rural areas grapple with shortages in obstetrical services, midwives may help fill those gaps. The number of family medicine physicians and OB/GYNs delivering babies in rural areas continues to decline. But nationwide, from 1996 to 2006 when the most recent data was collected, the number of births attended by certified midwives increased by 33 percent, reaching a record high of 317,168 in 2006, according to the
American College of Nurse-Midwives (ACNM).
Practicing Midwifery
The original midwifery model focused on rural outreach. Frontier Nursing Service (FNS) founder Mary Breckinridge opened the first American midwifery school in Leslie County, in the mountain country of eastern Kentucky, in 1925. Midwives rode horseback into remote areas where there were no roads to deliver babies in the homes.
The first midwives trained by Frontier Nursing Service often visited women in eastern Kentucky on horseback to deliver their babies. Here, one of those midwives weighs a newborn.“Mary Breckinridge was a visionary before her time, able to see that the nursing degree brought public health and family skills into midwifery training, making a CNM a combination provider with unique skills,” said President Susan Stone, a Frontier graduate.
Today FNS’ outgrowth, Frontier School of Midwifery and Family Nursing (FSMFN) continues that rural emphasis with its operation of a college that offers graduate level nursing-related degrees and a rural health service that includes five clinics, home health, and a 25-bed critical access hospital where CNMs deliver babies.
While the term midwifery most commonly generates associations with labor and delivery, 90 percent of patient visits are for primary, preventive care, according to ACNM. CNMs provide physical assessments, gynecologic exams, family planning, prenatal and postpartum care, and care for the newborn infant.
The midwife model of care focuses heavily on prevention and education, said Fehr, who now heads the Nurse Midwife Initiative at Shenandoah University in Winchester, Va. “We guide women, educate them, counsel them and empower them. We provide evidence-based care. And we consider pregnancy and birth a normal process. We want them to have their babies the way they choose.”
Stamler spends much of her time educating patients. Like many rural areas, she said, their region has a poor, undereducated population with a high unemployment rate.
“My days can be 80 percent social work and 20 percent medical care,” she commented. “I spend a lot of time every day talking about getting good nutrition, getting off soda, getting exercise, getting dad to pay child support, getting an education to support that baby—things these women tell me doctors don’t talk about to them.”
Melinda Hoskins, a midwife and DNP student at Frontier School of Midwifery and Family Nursing, with her daughter and her husband, shortly after delivering her grandchild.Training Rural Midwives
To increase the number of rural midwives, several programs are providing long-distance courses to nurses already practicing in rural areas. Some ensure that their students take part in rural rotations, as well.
By offering distance education programming for midwives, FSMFN has students in all 50 states. About 80 percent of graduates work in areas HRSA has designated as rural or underserved, according to Stone.
“Our absolute goal is to significantly increase the number of CNMs over the next 10 years,” Stone said. “By taking nurses who already live in rural, underserved communities and educating them to be nurse-midwives, we can improve services in these regions.”
Midwifery students in Frontier’s distance education program do Web-based coursework at their own pace in their home communities. Students complete clinical rotations in their region under the direction of CNM preceptors approved by Frontier.
“The classroom is the community where these students live,” Stone said. “We have preceptor sites across the United States. We continue to add more.”
Midwives have long been a strong part of rural health care in New Mexico, said Julie Gorwoda, director of the UNM College of Nursing’s Nurse-Midwifery program. “Our mission at the University of New Mexico (UNM) is specifically to educate nurse-midwives to care for rural and underserved populations. Eighty-two percent of our graduates work in rural or underserved practices.”
One-third of New Mexico’s CNMs are UNM graduates, Gorwoda said. From 1988 to 2009, New Mexico went from having six communities with nurse-midwives to 18 communities and 20 hospitals.
“In New Mexico, we’re worse than rural, we’re a frontier state,” Gorwoda said. “All of our students know coming in that two of their three clinical rotations will be in rural or underserved areas. If we immerse them in a rural clinical experience, they won’t be afraid to practice in a rural area. And the learning curve won’t be as steep when they do.”
Gorwoda said UNM actively recruits students from rural areas. Students complete coursework on campus and through distance education programming. They do more than 1,000 hours of clinical rotations near their homes, working with any of 100 preceptors throughout the state who donate their time.
“We keep them as close to their homes as we can,” Gorwoda said. “If they don’t move their family away from that rural area to go to school, they’re going to go back there.”
Students’ mean age has dropped from 38 to 28. UNM previously required that midwives have nursing experience before beginning the graduate midwifery program. However, Gorwoda said, “Now, we accept exceptional applicants straight out of their bachelor’s program. Graduating midwives earlier means they are likely to practice longer.”
Shenandoah’s Nurse Midwife Initiative has begun a distance-learning program and has initiated collaborative arrangements with five other graduate nursing programs. Students in Virginia, West Virginia and Maryland complete the core nursing curricula on the campus closest to their homes. Virginia’s Old Dominion University telebroadcasts core curricula to local community colleges in southern and central Virginia where, Fehr said, there are greater access barriers. Students take graduate courses through SU, receiving graduate nursing degrees from their home university and a certificate of endorsement in nurse-midwifery from SU.
Currently, there are 38 graduate programs nationwide with plans underway to add three more, according to ACNM spokesperson Yolanda Landon.
Overcoming Challenges
For the last 17 years, Stamler has worked collaboratively in medical practices with family medicine physicians and, more recently, OB/GYNs in Silver City, NM. The medical group provides primary care for women at their clinic and delivers babies at Gila Regional Medical Center, a rural hospital that serves a tri-county area. Prior to that, Stamler worked in a solo practice doing home births for 13 years. While she still has irregular hours and weekend call, she believes midwives are more likely to stay in rural areas when they can work in team situations.
“In a rural practice, you can’t make plans to go anywhere because even if you’re only delivering a few babies a month, you must be available all the time,” Stamler said. “I love my patients and living here. But I also like being able to have some time off. I know people who left because their work schedule was so disruptive.”
Geographic and professional isolation, physician shortages, high malpractice rates and decreasing numbers of rural hospitals with maternity units are among factors adding to the challenges of being a nurse-midwife in rural America.
Some of those challenges could be addressed through legislative change, according to Fehr.
“Nurse-midwives and other advanced practice nurses provide cost effective, evidence-based care. But laws and regulations regarding midwifery practice still differ widely from state to state.”
“The medical system needs to include midwives with nurse practitioners, physicians and other medical providers as part of a health care network that works in collaboration as a team providing a safe place for the woman and baby,” Fehr continued. “The major gap in those teams right now in many states is the midwife. Too often, she’s still not there.”
Rural Pregnancy
Innovative Programs Aim to Prevent Premature Births
by Candi Helseth
Having lost four babies since her son was born eight years ago, April McFadden successfully carried Michael, now three, to full term and is currently in the third trimester of another pregnancy. McFadden gives credit to Best Babies, a program begun in 2006 to reduce preterm births in four rural southern Georgia counties designated as Health Professional Shortage Areas.
“I get gestational diabetes and other problems when I’m pregnant,” McFadden said. “The Best Babies nurse comes to my house and checks on all these things, like my blood sugar and blood pressure and the baby’s heart beat. This is the best pregnancy I’ve had yet.”
For the first time in three decades, preterm birth rates for women of all age groups declined from 12.8 to 12.3 percent of live births, according to National Center for Health Statistics (NCHS) data. From the early 1980s through 2006, preterm birth rates had risen by more than one-third, increasing risk of life-long disability and early death for infants.
Kim Lovette (l), Tracy Salyer, and Debbie Mitchell (r)—nurses with the New Beginnings Birthing Center at Wilkes Regional Medical Center in North Wilkesboro, NC—admire one of their young clients.March of Dimes began a national Prematurity Campaign in 2003 to reduce premature births. March of Dimes Deputy Director Diane Ashton said that the Institute of Medicine’s report, Preterm Birth: Causes, Consequences and Prevention, and the Surgeon General’s Conference on Preterm Birth in 2008 also have contributed to a multi-focused effort to increase awareness and public education about the effects of preterm births.
“Our primary campaign has been heavily focused on educating women about the signs and symptoms of preterm birth,” Ashton said. “Many of our chapters work together with health care providers in their areas.”
Rural Factors
Preterm births and infant mortality continue to be higher in rural areas. In the 2006 book, Rural Women’s Health, researchers attributed this problem to several rural lifestyle issues including smoking, obesity and exposure to chemicals, which are more prevalent in rural areas. Geographic isolation, lack of access to care, increased poverty and psychosocial factors related to rural living are also factors, according to its authors.
Another factor might be that fewer family practitioners are offering prenatal care in rural areas and prenatal visits in rural areas are 5.6 times more likely to occur with a family physician than an obstetrician, according to a 2009 study in the Annals of Family Medicine. When pregnant women have to travel great distances to get prenatal care, they are likely to make fewer visits, which could lead to poorer outcomes, according to the report’s authors.
But rural areas can bring attention to other factors that help reduce premature birth.
“We know smoking contributes to preterm birth and in rural areas, it tends to be almost double the rate of urban areas and even higher than that in some rural areas,” Ashton said. “Without additional expense, rural providers can counsel patients on smoking cessation. Ideally, it should begin before patients become pregnant and it should be a family intervention because of the effects of second-hand exposure. Another positive step that takes little resource investment is educating women prior to pregnancy about the importance of taking care of pre-existing conditions, such as diabetes and hypertension, and reducing obesity.”
Pregnancy Programs in North Carolina and Georgia
The Perinatal Quality Collaborative of North Carolina (PQCNC) launched an initiative, The 39 Weeks Project, last September to eliminate elective deliveries before 39 weeks of gestation. March of Dimes provided the 41 participating hospitals with staff training and educational materials to distribute to pregnant women explaining why the last weeks of pregnancy count. 39 Weeks Project Coordinator Kate Berrien said the initiative also targets providers and hospitals.
April McFadden, shown here with her two children, credits Georgia's Best Babies program for her healthy pregnancies.“Women who have an induction before the cervix is ready to dilate are more likely to have a C-section and these babies have a higher rate of complications and neonatal intensive care admissions,” Berrien said. “These health concerns were the impetus for this project. Hospitals have developed different action plans to make sure that safety and health of the baby drives the decision for an early delivery, not patient or physician convenience.”
At Wilkes Regional Medical Center in North Wilkesboro, scheduled inductions and C-sections were reduced by 8 to 10 percent within the first two months primarily by educating mothers and working with physicians to prevent elective deliveries, according to New Beginnings Birth Center Nurse Manager Debbie Mitchell.
Wilkes, which is among several participating rural hospitals, provides prenatal education, fitness classes and other instruction to help mothers and their babies have healthy outcomes.
“We assumed going in that this would be a greater challenge in rural settings because they have fewer resources but some of these rural hospitals are leading the way and have almost eliminated elective deliveries before 39 weeks,” Berrien said.
Six months into the project, data indicated an ongoing decline in elective deliveries less than 39 weeks. Final data will be compiled the end of August.
With enrollment in Georgia’s Best Babies, gestational age has increased to an average of 37.2 weeks, said Program Manager Greta O’Steen. Previous pregnancy data indicated a gestational age of 25.8 weeks for babies born in the four-county area to high-risk mothers. Best Babies provides prenatal intensive in-home case management, nursing assessment and care coordination.
“When you have problems, waiting a month to see your doctor can be too long,” said McFadden, who travels 80 miles round-trip to her doctor’s office. Only one of the counties that Best Babies covers has a hospital and OB/GYNs that deliver babies. Best Babies also helps women keep their prenatal appointments by providing childcare and transportation vouchers.
“This program is a partnership with a woman’s doctor to provide resources most OB offices don’t have time to do and to educate these women on how to reduce their risk of poor birth outcome,” O’Steen said. “Providing services in their homes ensures regular prenatal assessments and tells us a lot about the psychosocial dynamics taking place in that home.”
Following the baby’s birth, a perinatal health outreach worker (PHOW) is assigned to the family for two years. Because birth outcomes with high-risk mothers improve if pregnancies are at least two years apart, O’Steen said, the PHOW advises mothers on birth control methods. Babies are also regularly screened for appropriate development.
Assessing What Works
Preterm birth rates decreased in 41 states between 2007 and 2008, according to Ashton. March of Dimes linked many improvements to states that targeted three key risk factors for premature birth: smoking during pregnancy; lack of health insurance for pregnant women; and unnecessary or non-medically indicated inductions or cesarean sections done during the "late pre-term," or between 34 to 36 weeks' gestation. Thirty-three states and the District of Columbia reduced the number of women of childbearing age who smoke; 21 states and Washington, D.C. insured more women from 2007 to 2008; and 27 states, Washington, D.C. and Puerto Rico lowered the late pre-term birth rate.
March of Dimes is currently assessing the outcome of Healthy Babies are Worth the Wait, a three-year education-based program begun in 2007. March of Dimes partnered with the Kentucky Department for Public Health to provide moms-to-be with education and support to reduce preterm births and prevent unnecessary or non-medically indicated deliveries.
“We’re looking at rolling this program out on a larger basis,” Ashton said. “There were resources available that many providers in that area didn’t know about when we began this program. So I’d encourage rural providers to work closely with public health and look for other providers as partners.”
Ashton says the key to continuing to decrease preterm births begins with education, which has proven to be effective. The task ahead is still monumental. While the decrease is good news, March of Dimes’ statistics indicate 13 million babies are still born too early every year.
