By Jane Winik Sartwell
The paradox of health care of rural women in North Carolina: small distant hospitals cannot afford to continue to deliver babies and provide other Critical OB / GYN services, but their communities cannot afford to stop.
If there is hope to stop or reverse this trend, rural hospitals and health professionals will require more solid responsibility, incentives and support. An improved regulatory and legislative framework – built and maintained by the North Carolina legislature and its Ministry of Health and Social Services – could help achieve it.
Although these changes are dramatic for North Carolina, similar measures to approach the health services of rural women are already in place or under study in many other states.
“From the point of view of systems, we have many possibilities for improvement,” said Dolly Pressley Byrd, president of the Department of Obstetrics and Gynecology of the Mountain Area Health Education Center, based in Asheville, or Mahec. “There are structural means that our health care systems are created that exacerbate iniquity and increase disparities, whether geographic, socioeconomic or racial.
“In an ideal state, if we could serve women and provide them with the care they needed in the communities where they reside, and they did not have to travel and they had the supports around them, … We would not have such a disastrous infantile mortality rate and worsen the maternal mortality rate.”
Care standards affecting the health of rural women
In North Carolina, the state applies neonatal care levels, which means that hospitals are held at a predetermined level of care that they should provide to infants.
If a hospital promises to treat babies at level IV – the highest possible medical care – but falls to level III, the division of the regulation of health services takes action.
No similar system exists for maternal care in North Carolina. But 16 other states have standards for the levels of maternal care provided by hospitals, notably the neighbors of North Carolina: Tennessee, Georgia and South Carolina. And the more could join them.
Mississippi, a state with very poor Maternal and infant mortality rates establish a system of maternal and child care standards in order to solve a problem there. It should be posted later this year, according to the state of the state of the state of the Mississippi, Dan Edney.
“The state-scale system will specifically target this truly vulnerable labor and delivery window, and an immediate postpartum for mothers and babies,” EDNEY told CPP.
“Our goal is that high -risk pregnancies to deliver to the right level of care, so that the mother has everything she needs, and the baby, especially the birth weight, premature babies, will immediately have access to the good level of care. We actively build the system now. ”
The political decision -makers of North Carolina also plan to implement maternal care levels. But as more regulations would also eventually increase costs for hospitals, this would require a measured approach.
“We have had conversations in North Carolina around the levels of maternal care that could potentially look like,” said Belinda Pettiford, head of women, infants and community well-being of the DHHS public health division.
“We have deepened what it would be like if we also update our neonatal care levels. We are always in these conversations, trying to understand what would be necessary to advance this work in the future. ”
Data collection and other forms of responsibility
The DHHS is currently not collecting rigorous or standardized data on maternal care in hospitals. A more robust data collection system could help the agency identify and solve the problem. But legislators should adopt laws requiring this surveillance.
State representative Julie von Haefen (D-Raligh) said that an improved data collection on North Carolina hospitals could be the first step to solve the problem.
“(DHHS) must have more data,” Von Haefen told CPP. “If we don’t know what’s going on, how can we understand how to resolve it?” An increased collection of data will help us to determine where to target our efforts. ”
County health services also have the capacity to hold responsible hospitals. The services should work with local hospitals to write assessments of community needs, but public health personnel does not have a way to force hospitals to meet these identified needs.
Giving these departments more teeth and regulatory capacities could prevent hospitals from eliminating or reducing the health services of rural women without dealing with any formal thrust.
Financial solutions to promote the services of rural women
Since maternity services generally operate financial loss, financing and payments reform could encourage hospitals to maintain services. In rural areas, many patients have Medicaid, which makes maternity care even less profitable for hospitals.
And the cuts offered in Medicaid could completely cancel the equation.
“The thing about maternity people is that they are not profit manufacturers – they are leaders of loss,” said AMI Goldstein, certified -life nurse and associate professor in the Family Medicine Department of the UNC Medical School. “So if you have six births a month, the hospital still pays staff to be available all this time.”
Lower birth volumes result in higher patient costs, making services financially unbearable in many rural areas.
The increase in Medicaid reimbursement rates for hospitals and rural doctors could help solve the problem. The representative of the state Timothy Reeder (R-Greenville), who is also a doctor, told CPP that he pleaded for these improved reimbursements.
But the future of Medicaid on a national level is anything but certain, because the Republicans in the Congress have recommended substantial reductions in the program – up to $ 880 million.
Private insurance companies could also implement special payment models which explain the higher costs by patients in rural health care, but most do not. Some states have initiatives forcing insurance companies to better support rural hospitals, but North Carolina has not done this so far.
Labor solutions for hospitals
Another urgent problem of rural health that needs a solution.
Creating incentives for specialists to work in rural hospitals is crucial, according to Rebecca Bagley, director of the ECU midwife education program. The training of students and other members of the emerging workforce to practice in rural areas-which is a different ball game from urban practice-is also important, she said.
“It is better to provide care for patients near them,” said representative Reeder.
“Therefore, it is essential to support hospitals and rural doctors. We will not have successful communities in the rural area without access to health care. Health care is vital for economic development and growth.
“I successfully argued several measures to help support and develop care in rural areas. We have provided funds for rural residences, reimbursement of loans for several health professions, the financing of rural health establishments and the expansion of health training programs through community colleges.
The representative Von Haefen is also in favor of incentives to recover the workforce of health care in the rural areas of North Carolina.
“We have to go out of the beaten track regarding work and delivery services, and OB / GYN services in general, because we have a disastrous labor problem,” said Von Haefen. “This is particularly true in rural communities.”
Von Haefen recommends a “Develop your own” style program that encourages nurses and newly trained doctors to return to their hometown to practice. When deployed in educational Parameters in North Carolina, this model encourages graduates of teaching programs to return to their own school districts to work.
She also stressed the importance of community colleges.
“Other rural community colleges are trying to focus on the issue of health health,” said Von Haefen. “Investing more in community college programs is really important because they bring people who live in these areas to develop the health care market.”
Another strategy is expanding the capacities of the current workforce: giving family doctors and EMTs the possibility of expanding the scope of their practice. And keep them formed.
The representative of the Allen Buansi State (D-Chapel Hill) prefers this strategy.
“Universities and hospitals can do a better job by ensuring that they have general doctors in these rural areas (which) have continued to train in the bases of the prenatal, delivery and postnatal care,” Buansi told CPP.
Buansi described a “big role” for hospitals “to ensure that local doctors in these rural areas of the women’s health care desert are Trained at the bases of OB / Gyn Care. The state could install money for this. »»
The rural communities of North Carolina are likely to lose the health services of women who remain.
Thanks to regulatory and incentive changes that are already being studied, the rural communities of North Carolina could keep essential maternity services thanks to a combination of financial reforms, development of targeted workforce and increased responsibility, saving the lives of women and children from the whole state.
The state could also see a recovery from rural women’s service programs that hospitals have reduced or reduced in certain regions if the regulatory and incentive structure changes.
Instead of the rural deserts in the health care of growing women, the oases of care could expand to create a new story for health care in rural regions of North Carolina.
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