Nurse midwives step up to provide prenatal care after two rural hospitals close birth centers

MUSCATINE, Iowa – Bailee Tordai, who was 33 weeks pregnant, barely made it through the prenatal checkup. Her clunky old jeep couldn’t complete the 2-mile journey from her home to the University of Iowa outreach clinic in her hometown in southeastern Iowa. It was a hot day in June and a wiring problem left the Jeep on the street.

A passer-by helped Tordai, 22, push her battered vehicle off the road and into a parking lot. Then she called her stepfather for a ride to the clinic.

Jaclyn Roman, an obstetrician, walked into the examination room. “I heard your car broke down.”

“Yep. Want to buy it? Five dollars!” Tordai joked.

Her lack of reliable transportation will be no laughing matter in August when her baby is expected. She will have to arrange for someone to take her about 40 miles northwest to the University of Iowa Hospitals and Clinics in Iowa City. She is unable to give birth at Muscatine Hospital because it closed the maternity ward in 2020.

Roman is part of an unusual effort to minimize the damage caused by such closures. She is one of 11 certified obstetricians from the University of Iowa who travel regularly to Muscatine and Washington, another city in southeastern Iowa where the local hospital has closed its birthing ward. The university’s pilot project, which is supported by a federal grant, does not aim to reopen shuttered maternity wards. Instead, the midwifery team helps ensure that women in the area receive related services. Last year, it served more than 500 patients in Muscatine and Washington.

Muscatine is one of hundreds of rural areas in the US where hospitals have stopped giving birth services in the past two decades, often because they lack midwives and other specialized staff.

Hospital industry leaders say birth units also tend to lose money, largely because of the low payments of Medicaid, the public health insurance program that covers more than 40% of births in the U.S. and an even greater share in many rural areas.

The loss of labor and delivery services mainly affects women who do not have the resources and time to travel for care.

Muscatine, which sits on the Mississippi River, has more than 23,000 residents, making it a relatively large city by Iowa standards. But the hospital is one of 41 Iowa facilities that have closed their birthing units since 2000, according to the Iowa Department of Public Health. Most were in the countryside. Only one has reopened and only 56 Iowa hospitals now have birthing units.

The work of the nurse midwifery team includes critical prenatal checkups. Most pregnant people should have a dozen or more such appointments before going into labor. Health care providers use the checkups to monitor how a pregnancy is progressing and to watch for signs of high blood pressure and other problems that can lead to preterm birth, stillbirth or even maternal death. The midwives also advise women on how to keep themselves and their babies healthy after birth.

Karen Jefferson, director of obstetrics practice at the American College of Nurse-Midwives, said the University of Iowa team’s approach is an innovative way to provide for rural areas where hospital delivery units have disappeared. “How wonderful would it be to see a health care provider in your city, instead of driving 40 miles for your prenatal visits — especially towards the end of pregnancy, when you go every week,” says Jefferson, who is at the health care center. rural New York.

Midwives can provide many other forms of care for women and babies. In theory, they could even open birth centers outside of hospitals nationwide, Jefferson said. But they should allay concerns about funding and the availability of surgeons for emergency cesarean sections, which she says are rarely needed in low-risk births.

The University of Iowa midwives focus on low-risk pregnancies and refer patients with serious health problems to physicians in Iowa City. Often these specialists can visit the patients and the midwives via videoconference in the small clinics.

The loss of a hospital obstetrics ward can make finding local maternity care more difficult for rural families.

Tordai can confirm that if patients have to travel far for prenatal appointments, they are less likely to reach them all. If she had to go to Iowa City for each of hers, it would be difficult to repeatedly take three hours off her job as a pizza restaurant manager, she said. On that June day her Jeep had broken down, she would have canceled her appointment.

Instead, she ended up on an exam table at the Muscatine clinic listening to her baby’s heartbeat on a monitor and watching Roman measure her tummy.

“Nice job being perfect,” the midwife told her during the checkup.

Roman asked Tordai to describe her baby’s movements. “Constantly,” she replied with a smile.

Roman asked if she planned to breastfeed. Tordai said she wasn’t very lucky with her first daughter, Aspen, now 4.

“Have you thought about a breastfeeding course?” the midwife asked.

“I don’t have time for that,” Tordai replied. Roman continued to persuade her, noting where a breastfeeding course is available online.

Near the end of the appointment, Tordai asked Roman if she could schedule an inductive delivery at the University of Iowa hospital. The midwife told her that it is generally better to start labor on its own than start artificially.

But there was the issue of unreliable transportation. Tordai explained that planning the birth would help her make sure her mother took her to the hospital in Iowa City. Roman agreed that transportation is a legitimate reason and arranged for an introductory delivery on August 10.

The University of Iowa midwifery team began providing services in 2020 at a clinic about 2 miles from Trinity Muscatine Hospital. The hospital is owned by UnityPoint Health, a major not-for-profit hospital system that has blamed a lack of available midwives for the closure of the Muscatine birthing unit. At the time, UnityPoint leaders said they hoped to reopen the unit if they could recruit new midwives in the area.

Kristy Phillipson, a spokesperson for UnityPoint Health, told KHN in June that the company has continued to recruit doctors, including for Muscatine Hospital. While it has not reopened the birthing unit, the company regularly sends a midwife and other staff to provide prenatal care and related services, she said.

Most of the region’s pregnant patients who choose UnityPoint eventually give birth at the system’s hospital in Bettendorf, a 45-minute drive east.

The University of Iowa midwifery team has no plans to open birth centers of its own. But it hopes to expand its nationwide clinic service to other underserved cities. To do this, the university would need to hire more midwives, which could be a challenge. According to the Iowa Board of Nursing, 120 licensed midwives live in the state’s 3 million people.

The University of Iowa plans to address that by launching the state’s first nurse education program in 2023. The master’s degree, which will emphasize rural service delivery, will train registered nurses to become nurse midwives. It could eventually graduate eight people a year, said Amber Goodrich, a University of Iowa obstetrician who helped lead the effort.

Those graduates could fill gaps in rural areas, where even more hospitals could close their maternity wards in the coming years.

“This crisis is not going anywhere fast,” Goodrich said.

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