Filling NC’s maternal health care desert

By Clarissa Donnelly-DeRoven

Eight women — three OB-GYNs, three nurse midwives, one gynecologist and one nurse practitioner — comprise the maternity unit at Mission Hospital McDowell. In the 18-county region that makes up western North Carolina, the McDowell County facility is one of just eight hospitals where someone can deliver a baby.

To fill the gaps in obstetric and gynecological care in this mountainous region, the McDowell providers travel from the hospital in Marion more than thirty minutes across winding mountain roads up to Spruce Pine to offer regular prenatal clinics. They also spend time working out of the McDowell County Health Department — anywhere they can reasonably get to. 

“There are some patients who come to our clinic in Spruce Pine that are kind of between us and Boone, so they are sometimes torn between delivering in Boone and delivering in Marion, because neither of them are close,” said Ellen Hearty, an OB-GYN at the hospital.

For these patients, the birthing unit at the Watauga Medical Center in Boone and the one in Marion are both probably 45 minutes or so away. For those who live in Yancey County, the Spruce Pine clinic (in Mitchell county) can be a good option for prenatal care, but it’ll probably be faster to drive to Mission’s Asheville location for their delivery.

All the back and forth creates disruptions in prenatal and maternal health care, and opportunities for critical health information to fall through the cracks. And that’s true for people even with uncomplicated pregnancies. 

For risky pregnancies — in people who are older, have a chronic condition, or if their baby has any medical abnormalities — living in a maternal health care desert can be even more dangerous. 

“Mostly we take care of people that everybody else throws their hands up at, like, ‘Oh my gosh, why is she pregnant? How did this even happen? She has so many medical problems!’” said Carol Coulson, one of three maternal fetal medicine physicians in all of western North Carolina. These specialists are the doctors who care for people with these high-risk pregnancies. 

“We’re actually 2.6 [full-time employees] when you look at the amount of time that we work,” she said. “We cover 17 counties, roughly, so it’s a little bit insane.”

Coulson said between 20 and 40 percent of pregnant people could benefit from having a high-risk specialist on their care team, either as their primary provider, or for consultations. She works out of the Asheville-based Mountain Area Health Education Center, or MAHEC, a safety net facility which primarily cares for low income people. In her department, that means low income people with high risk pregnancies. 

Some research shows that simply being low income — and all of the structural disadvantages to accessing care that come along with it — is associated with poor maternal health outcomes, including riskier and deadlier pregnancies. Two 2020 studies — one from the U.S. and one from South Korea — looked at the role non-medical health drivers might play in maternal health outcomes. The Korean study found that pregnant people with lower incomes had higher risks of postpartum death. The researchers found that likelihood corresponded more strongly with those who gave birth between ages 35 and 39, who lived in a rural area, had a cesarean section, or experienced other underlying health conditions. 

The domestic study argued that one crucial step to reducing the rising maternal mortality rates in the U.S. is for providers to address the structural barriers that impact people’s health — poverty, poor access to food, structural racism, etc. — at all stages of their pregnancy. 

“Probably 40 to 60 percent of our patients could have at least a consultation” with a maternal fetal specialist, Coulson said. “And then at least another 20 percent would primarily receive care with us or in very close coordination with their regional provider.” 

It’s a heavy lift for 2.6 full time providers. 

A county-by-county map of western NC with population numbers. There are just eight hospitals with labor and delivery units for this 18 county region. Image credit: Dogwood Health Trust

“One of my emails just popped up and it said offering $10,000 a weekend to cover an OB-GYN practice,” Coulson said. “I don’t make anywhere near that, nor does anyone I know. That’s the kind of need and that’s just general OB-GYN work.”

Accessibility of pregnancy care isn’t the only area that’s a glaring need for rural North Carolinians. According to the state health department, 93 N.C. counties are considered primary care shortage areas, 94 qualify as mental health care shortage areas, and all 100 counties qualify as dental health shortage areas.

Addressing all these gaps in care is more than any single organization can do, but two new training programs — one from MAHEC, one from Western Governors University — aim to do their best to address the region’s maternal health care needs. 

Fix  #1

MAHEC hosts various residencies, the training programs physicians complete after they’ve graduated from medical school. The center also hosts fellowships, which are programs where doctors who’ve already completed their residency can receive more specialized training. 

Starting this summer, MAHEC will welcome its first fellow in maternal fetal medicine. 

There are about 100 maternal fetal medicine fellowships nationwide, but few serve rural areas. Many states with large rural populations — West Virginia, Montana, the Dakotas — have no maternal fetal medicine fellowships. Even for the handful of programs that do work with this underserved group, few are based out of community clinics. Most are associated with large research universities. 

“The hope is that we can provide a different sort of experience than you would get training in a big city,” Coulson said. “Community programs don’t do things like this because there are really intensive hoops to jump through.”

The three year program will host one student starting this summer, two by next summer, and three starting in 2024. 

“We are faculty members, we do perform some research, we do take care of a lot of patients — we have our own patients, we have consultative patients,” she said.  “Our hope is that by starting the fellowship, we can increase the pipeline for people who want to do a more hybrid type of MFM practice.”

The hybrid model, especially in rural areas, means providers need to feel confident in their ability to work with just a few other colleagues, and find a center to affiliate with that cares for high-risk pregnancies, such as a community hospital with a neonatal intensive care unit.

It’s not just a rural problem, though. Nationwide there’s a dearth of maternal fetal specialists. Some of that has to do with the unpredictable schedule. Coulson said she’s observed that many young physicians want a day job with predictable hours — something you’re unlikely to get in obstetrics. When she was trained, for example, physicians would do a day in the office and a night on call.

Mission Health, headquartered in Asheville, is the sixth largest health care system in North Carolina and the biggest health care provider in the state’s mountain region. It is one of just eight hospitals with a labor and delivery unit within the 18 county region that makes up western NC. Photo credit: Liora Engel-Smith.

“So it’s at least 24 hours, and some might even do a part of the next day,” she said. “You get really good at not sleeping.”

But the maternal health field is moving toward shift work, where physicians work three 12-hour shifts a week. The practice is common in other specialities, too, such as emergency medicine. 

“There are pros and cons to everything, of course, and generating more handoffs in patient care is not necessarily always a good thing because you have to be really meticulous in shifting your team every 12 hours,” she said. “There is that trade off of when you’re not exhausted, your brain is working better and you’re a little more facile and efficient.”

The other big change has been the specialization of medical care. When Coulson trained in maternal health in the 80s and 90s, she ran a diabetes clinic every Friday for her pregnant patients. Now, OB-GYN residents refer patients to a pharmacist to manage their diabetes.  

“The pool of general OB-GYNs who want to tackle or feel able to tackle some of the even more common pregnancy problems get smaller all the time,” she said. 

Specialization can lead each provider to use their time more effectively. It can be safer for patients and allow treatment changes to be made more quickly. On the other hand, it does mean new doctors have fewer opportunities to learn certain skills. 

This shift has been more complicated for patients. Namely, she said, “A patient who then has to travel from the westernmost reaches of North Carolina to talk to a specialist about something.”

Eleanore Beatty

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