Special Report: Distance for Delivery

(Source: Alabama Department of Public Health)
(Source: Alabama Department of Public Health)


Doctors say it's a national problem -- the decline in obstetrical services. And in rural Alabama, expectant mothers are facing a slew of obstacles. From a lack of specialized care to the decline of delivering hospitals, women are having to travel far distances for medical treatment, and that's putting a lot of added stress on families preparing for a new baby.

Julie Bentley is expecting her third child and enjoying getting her home in Chilton County ready for the new baby, but in the midst of expanding her family are concerns about the travel time to her hospital in Alabaster.

"We're centrally located so we're in between Montgomery and Birmingham, but that means for most moms, you have to go at least 30 minutes and for some, a lot go for an hour," Bentley said. "We've actually had several babies in this area that have been delivered at home because they couldn't get somewhere quick enough."

Dr. Daniel Avery, who chairs the Department of Obstetrics and Gynecology at the University of Alabama's College of Community Health Sciences, says half of the counties in the U.S. have no obstetric services, leaving some 10 million reproduction age women short of any OB care. And women who live in rural areas, including Alabama, are hit the hardest by the shortage.

"The big problem in Alabama is access to care, people having to travel farther and farther distances. Alabama is a poor state, the Black Belt which is probably our poorest section, has difficulty with access to care. They have difficulty traveling to larger hospitals and larger cities to deliver," Avery said. "It's not unusual for a woman to have to travel one to two hours to a delivering hospital in West Alabama now and sometimes that's difficult. Sometimes, that's impossible."

According to the Alabama Hospital Association, all pregnant women in Alabama are impacted by a lack of obstetric care.

Many families in rural counties must travel more than 50 miles to reach a hospital that delivers babies, and 20 percent of all births in Alabama are from residents of a county without obstetrical services available.

The Hospital Association's numbers show that in 1980, 58 counties provided obstetrical services. Today that has dropped by 50 percent to 29 counties. Rural counties have seen a 63 percent decline. In 1980, 46 rural counties had hospitals that provided obstetrical services. That number has now fallen to only 17.

It's a problem Dr. Jason Gentry is all too familiar with. Ten years ago he was recruited to do obstetrics in the Dale County town of Ozark and saw firsthand the struggles some rural mothers are facing.

"There's not only a large population of Medicaid patients, but there's a large proportion of these people who have fairly severe disease. They have high blood pressure, diabetes, they're overweight. They have limited access to healthcare. They may not even be healthy prior to getting pregnant. In addition, they also have financial issues, poor access to transportation, which limits their ability to access the healthcare," Gentry explained.

Add to that the fact that fewer medical students are choosing OB/GYN as a career because of the long hours and high malpractice insurance, and even fewer are choosing to locate in rural, underserved areas when they finish their residency.

"We are hardly keeping up with the attrition rate of OBGYNs retiring in this country much less any extra," Avery said.

Some OB/GYNs are stepping up to meet the needs in rural communities by providing satellite clinics, but there is still a shortage of such specialized care for many.

Then expecting mothers are forced to ask themselves where they will deliver their baby. Over the past fifteen years, more than a third of Alabama's delivering hospitals have been forced to close their labor and delivery units, including the Bryan Whitfield Memorial Hospital in Demopolis.

Dr. Grace Thomas, Assistant State Health Officer for Family Health Services with the Alabama Department of Public Health, says some expecting mothers in parts of West Alabama are having to travel to Tuscaloosa and even over into East Mississippi to deliver.

"Let's go back to 1999 and look across our state and we had 71 delivering hospitals, hospitals that provided obstetrical services. We've lost 22 hospitals over the last 15 years so we're down to 49 hospitals across the state that provide obstetrical services," Thomas said.

[DOCUMENT: Alabama's 49 Delivering Hospitals (.pdf)]

The situation could get worse. The Alabama Hospital Association says between 10 and 15 hospitals could close in the next few years because Alabama hasn't expanded Medicaid and cut from Washington that would have paid for healthcare for people without insurance.

"Labor and delivery typically is a high intensity, highly staffed acute care facility in a hospital. It requires a lot of nursing staff. It requires a lot of ancillary staff just to be able to take care of those patients. That in turn, costs a lot for the hospital and they're unable to recoup those costs and oftentimes, these labor and delivery units in small towns close in favor of sending the OB patients to larger facilities in larger communities such as Montgomery, Birmingham, Mobile and so then those communities have to soak up the access of these patients," Gentry said.

Dr. Avery added: "It's unfortunate that hospitals have had to drop OB care. OB care is expensive. You have to have specialized nurses. You have to have an operating room. You have to anesthesia. Unfortunately, when hospitals are struggling, like so many are, in this state, it's a service that often falls to the wayside despite the tremendous need that we have."

Doctors say there's no quick solution to the problem.

"We have got to find a way to encourage young physicians to enter into women's health as well as to publicize loan repayment programs and other efforts that would entice and encourage young physicians to stay in Alabama," Thomas told WSFA. "We've also got to look at collaborating with our arm extenders- certified nurse midwives, nurse practitioners as well as physician assistants to help us to provide services to these areas that are underserved."

"I think the immediate challenge is the support of hospitals to provide that care which sometimes is costly and is the first thing to go when finances are hard. We need everybody's help. We need OB/GYNs, we need family doctors to do OB. We need nurse practitioners. It's an effort that's going to require all of us to provide service," Avery added.

The nonprofit agency Gift of Life in Montgomery manages Medicaid's maternity care program in 20 counties across the state. The state's Medicaid maternity program is divided into 14 districts so that every county is covered, helping patients with care coordination. Social workers and nurses help expecting mothers in outlying areas with information, prenatal care and transportation so they can get to their doctor's appointments in larger cities.

"That is the reward -- to have optimal outcomes and healthy mothers and healthy babies. Also, we see patients that may be felt hopeless and helpless before and they now have a sense of 'I can do this. I know how to make those calls and access the services that are available to me.' So that's a good feeling to empower patients to know that they personally can change their life for the better," said Paige Mitchell, Care Coordination Director.

According to the state health department, there are agreements springing up between doctors in bigger cities and those in rural areas- a collaborative effort that helps provide a continuity of care for patients. Rural doctors are given privileges to deliver at bigger city hospitals and doctors from bigger cities can help treat patients in rural areas. Private insurance companies can tell patients what physicians are accessible to them.

Doctors say the struggle continues to get medical students to choose OBGYN as a career. The University of Alabama continues trying to bridge the gap, training family physicians to deliver babies, part of the traditional family medicine residency. The College of Community Health Sciences also offers an obstetric fellowship which enables new doctors to go to rural areas and provide full service obstetric care.

State health officials believe telemedicine may be an option for getting specialized OBGYN care to rural areas- doctors using two-way video, email, smart phones, wireless tools and other forms of technology to connect with patients. Alabama doctors have seen success in providing healthcare to AIDS and HIV patients with the help of telemedicine and officials think the model could also be used for patients seeking obstetrical care across the state.

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