Family Physicians and Maternal Health in Rural America, with Julie Wood and Zita Magloire

Organizations and resources mentioned in this episode:

• American Academy of Family Physicians (AAFP)
• Advanced Life Support in Obstetrics (ALSO)
• Basic Life Support in Obstetrics (BLSO)
• Georgia Perinatal Quality Collaborative
• AIM Patient Safety Bundles, Alliance for Innovation on Maternal Health
• Alliance for Innovation on Maternal Health Community Care Initiative (AIM CCI)
• National Rural Health Association (NRHA)
• American College of Obstetricians and Gynecologists (ACOG)
• Society for Maternal-Fetal Medicine
• The EveryONE Project and its Neighborhood Navigator, American Academy of Family Physicians
• familydoctor.org, American Academy of Family Physicians

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. This is part three of a multi-part series about maternal health in rural America. Today we're talking to Dr. Julie Wood, who's the senior vice president of research, science and health of the public at the American Academy of Family Physicians and Dr. Zita Magloire who's a practicing family physician in Cairo, Georgia. Zita's daughter may also chime in from time to time. Thank you all for joining us today.

Zita Magloire: Glad to be here.

Julie Wood: Thank you. Glad to be here.

Andrew Nelson: Yeah, absolutely. First of all, why is the AAFP interested in and concerned about rural maternal health and what kinds of roles do family physicians play in providing maternity services for rural communities?

Julie Wood: Well, I'll start with AAFP and turn over to Zita. From the perspective of supporting our members and patients, especially, and a bit of my background too. I'm on staff with rural maternity care in my portfolio, I delivered for a number of years in my hometown, which is a town of about 5,000 in a Critical Access Hospital. So I have experience there, but then came to the Academy to apply that experience. So it's something near and dear to my heart, but also to help with policy and resources. But it's extremely important because of the shortage of any maternity providers, or pregnancy care providers in rural areas, as well as hospital closures, or pregnancy unit closures in rural areas.

And so we are doing a number of things to help advocate, to help support that, and also support our members that are delivering in rural areas like I used to, and we had an OB unit closure, and so Zita knows that that's really important to me, and try to help with her, and her colleagues and then also to help decrease maternal morbidity and mortality. I'll turn it over to Zita to answer a bit of that question as well.

Zita Magloire: Well, of course pregnant patients are our patients, but really maternal health is very closely related to the health of the family and the entire community. Mothers tend to not only bring their children, but they bring their mothers, they bring their sisters, they bring their spouses to the doctor, and that's something that I've seen over and over again, especially in our community. So when they know that they are being well cared for, when they know that they get good care, then they're going to be more likely not only to come back themselves throughout their life, but also bring in other members of the family, and that, in turn, improves the health of the entire community, because they see the value in having a primary care physician. One of the other things I didn't mention is in the area where I practice, we have a very large migrant and immigrant population.

Many of them do not speak English in the home. And so that is just an additional barrier for many patients throughout the country in finding healthcare services. And when they can come to a place, they get pregnancy care, they feel like they have received good care. And maybe where they're from, and from another country where they're from, people don't go to get a lot of medical care during the pregnancy, or they've only had home birth, and they've never delivered in a hospital before. And so when they come to you and they have that experience, and then you see that when they become pregnant again, they come back to you and they are now understanding the benefits of prenatal care.

And then you start seeing their kids and then they bring in their husband, who's has all these ailments, and they realize that benefit. Then you see that where that generational change is, that is why we care. Obviously as healthcare providers, we care about our patients, no matter who they are, no matter where they're from, but specifically with maternal health, this is going probably one of the things that's going to be the most impactful for the entire family.

Andrew Nelson: Yeah. What kind of skills and competencies does a family physician need to provide maternity care in a rural community?

Zita Magloire: So, that's a great question. So in family medicine training, we're trained to provide prenatal care, also be able to evaluate, diagnose, and treat most conditions during pregnancy, and be educated on when referral, and other testing, and resources are needed. We're also trained in delivery and postpartum care. So really that whole continuity continuum of care. We're also trained to care for newborns from the hospital at the time of the delivery all the way through adolescence, and into adulthood. And that, I believe, really gives us an advantage and an ability to really care for these patients in a holistic way. And again, as Julie had mentioned to reduce maternal mortality, which we know is both a demographic and a geographic issue. And in the rural setting, unfortunately, the outcomes are worse because of lack of access. And so since family physicians provide more patient visits, office visits in rural settings than any other specialty, we are really poised to kind of meet that need.

Julie Wood: And just as a follow-on to that, family physicians in their training all receive a core curriculum for pregnancy care. And most of the time when you see a family physician going out into a rural area, they are in a program that has enhanced training. So they have usually an increased number of deliveries, and some higher risk training as well. Zita and I both attended a program that had that type of training, but all family physicians have a core training.

Andrew Nelson: Yeah. What are some of the barriers that rural family physicians might encounter related to providing obstetric services specifically?

Julie Wood: Oh, there's several. And I think the counter to that we might want to discuss too, are what are some of the joys? A lot of times people ask us about what's the bad or scary stuff, but I had to throw that one in there too. I would say that it's several things. Sometimes it's actually finding a place to practice. Sometimes we find that there are more family physicians interested than can find a place to do it. I know I was on call 24/7 for a number of years. That could be very exhausting and really not sustainable until I had a couple of people move into town. Not every family physician provides surgical services. So sometimes finding someone to back that up — Zita and I were both trained to provide cesarean section, so that was not as big an issue, but you also don't want to always be the only person in town that does that.

So it's having those backup services. Arranging to have appropriate transfer services, because generally when you're in a smaller town, you still need to have that backup or that ability to transfer out, say very young babies, if they come way too early. So having all those appropriate levels of care to transfer to, they're not necessarily barriers, but it's very important that you have those kinds of things established so that you can get the mother or the baby to safe care when needed. So those are some initial thoughts. Zita, I'll turn it over to you for your ideas.

Zita Magloire: So some of the barriers that family physicians experience in providing maternal care, especially in rural areas, one of them is just, is volume. So many rural areas, there is not sufficient volume to keep certain skills up adequately, for instance, C-section, D&Cs, which is done for treatment of miscarriages, which is a very important and lifesaving procedure. And so having a relationship with neighboring institutions, and facilities, maybe in larger areas, or even sometimes institutions where the physicians train to be able to go back, and to continue to practice those skills and take them back to the community is really important. And so if that can be facilitated in any way, then I feel like those skills can be brought back to the community and really benefit patients who are in that community. Another potential challenge is call coverage and not wanting to be the only physician delivering because it's not sustainable.

And I will say that the AAFP has really provided a lot of resources for family physicians who are delivering. One of those is through the member interest group that we have for obstetrics, and family physicians from all over the country can really network with other physicians who are delivering. And it's really great because we have very, very involved administrative staff that can really carry those questions on to people like Julie, and get a response back. This is one of those things that is in the process of being addressed, but it would be great to continue to provide ways to really support more family physicians being able to practice in these areas so that you can help avoid burnouts and as well as unit closures.

Julie Wood: Yeah, I'll add onto that, too. I think it's a little bit of a catch-22 sometimes because Zita and I both talked to family physicians that are eager to deliver and serve their community and the community has needs for pregnancy care services. But the hospital also was losing money because of the volume and they'll close them down and then the community doesn't have services. So we also want to keep our skills up if the numbers are low, that's what happened in my community and they closed. And I ultimately left the community because I wanted to continue delivering and it really broke my heart. And those people didn't have any services anymore, any pregnancy care services, but the hospital just was losing money. And they said, we're not going to keep doing it. That was really, really heartbreaking and concerning because we were actually a small, Critical Access Hospital in the area that other hospitals, or were like transferring to, or we were having drive-by people stopping off that were already an area where it was just a little bastion of rural delivery.

And then we closed. So that was really hard from a financial standpoint. And you see that about a number of rural hospitals already. So there's that financial piece with hospitals staying open, particularly, on the OB part and just overall, and then there's the part of keeping your skills up. That's really important as well. Absolutely, my favorite part of practice rural practice can be really challenging, but delivering babies, being a part of that, growing the family, having those babies grow up with you. One of my favorite memories in my hometown was about five years into practice when the homecoming float went by, and they were five-year-olds from the kindergarten class.

And there were my babies up there waving at me. All the five-year-olds. And they're like, “Dr. Wood, Dr. Wood!” I mean, that was just so awesome. And just seeing the families come in and I really wanted, I really, really wanted to get to the, my babies having babies, which is happening now, but I wasn't able to make it to that because that OB unit closed, but I just loved when the babies came in and the brothers and sisters and the whole families, it really is the grandmas, the moms and dads. And it's just so rewarding.

Zita Magloire: I would definitely echo that. I'm coming up on my eighth year in practice here. And so that's how I kind of, there's certain families that I know how long I've been here based on how old the kids are. And it's really, really cool. And then you just see them just like sprout. You're just like, “You're so big. What does that mean? I'm so old.” It's so fun. And then I joke some of the best compliments or what I think is the best compliment is when I've had two patients actually tell me that they were referred to me by their grandfather who's my patient. So I just love that. I'm like, that's just… It's great. And everything else you said, I echo that. I love seeing the brothers, and sisters, and how they grow, and they learn how to be older siblings to the younger children that we deliver.

I love it when moms bring in their husbands or their partners and just bring them as in to be part of the family and also to make sure that their health is where it needs to be. And I think that's the biggest compliment that anyone can give you. So, I highly, highly, highly recommend this as a very rewarding profession, challenging as Julie described, but very rewarding as well.

Andrew Nelson: Yeah, it's really cool to hear about the degree of investment that you can develop with your community. How can rural family physicians, and their hospitals help to improve patient safety and outcomes? And then, in turn, decrease maternal morbidity and mortality, are there any evidence-based methods that AAFP specifically suggests for this?

Julie Wood: Well, one of the programs we have is called ALSO, our Advanced Life Support and Obstetrics, which is a program that many of our residents take in training, but then we also encourage practicing physicians, and their teams to take and including emergency room physicians. And we have a Basic Life Support in Obstetrics course as well for our first responders, but it's the team that's really important. And that includes some lecture type of learning, some hands on learning, simulation and drills. And it's something you can't just do once every five years, or something like that, something you practice. So say that there's something like a postpartum hemorrhage that happens, which can be very fatal, or at least cause a lot of harm.

And so you practice that. What would happen if that occurs? And you don't just do something when it's actually happening, you practice it ahead of time. Do we have the right supplies in place? What would happen? And that course teaches that. How do you think through that in a systematic way, and how do you work on that with your team across the whole facility, really. And so that course teaches a lot of those different principles across a lot of different scenarios. So that's one thing the AAFP has. And then there's some other evidence-based methods as well, but I'll let Zita speak to that, because I know she's been familiar with the ALSO course as well.

Zita Magloire: Absolutely. I'm an ALSO course instructor and we also held an ALSO course for our rural hospital, and it was really great because we were able to collaborate with our referral center in Albany. And we also got some midwives to come from our sister hospital in the neighboring larger town. So, it was a great way to really get hands on, and work with a multidisciplinary team. And it was a way for us to interact with our nurses and other delivering staff and in this constructive way, really going over our skills, and making sure that we're ready for emergencies. And this is definitely evidence-based, and is lifesaving. The other thing that I'll mention is that the most states have a perinatal quality collaborative and the state of Georgia has one, the Georgia Perinatal Quality Collaborative, or GAPQC for short.

And part of the perinatal quality collaborative is doing QI quality improvement projects, focus on the areas of high morbidity mortality for both neonates and maternal care as well. And so some of these, we call them AIM bundles and these bundles are meant to be used, and used to instruct hospitals to respond to emergencies. So, for instance, our hospital has a postpartum hemorrhage bundle, and we implemented that, and we're looking at our response to postpartum hemorrhages, and which patients require blood transfusions, and the number of incidents that we have during a given period of time. We also implemented the hypertensive bundle as well. And there's many more, but this is a really great program and it really reaches rural hospitals where they are, most of the support is given virtually, which is really, really great, especially during COVID. And I believe the Georgia Perinatal Quality Collaborative has been in existence since 2017. So, it wasn't in existence very long before we hit COVID. So, yeah, these are all evidence-based ways that family physicians, and our academy at large is really are really trying to address this issue.

Julie Wood: Yeah. AAFP has participated with the AIM bundles, and AIM project safety initiatives is a partner with ACOG [American College of Obstetricians and Gynecologists] on that. So I think that's really important and good work that ACOG's done and we've collaborated with. And there's also an AIM CCI project now, which is community care initiative. So they've recognized that the hospital piece of that's really important, but also there's a second wave of that in the community part. So there's a lot of focus now about what happens in the community. So we're also partnering on that AIM CCI project as well. So looking forward to continued work there, it's more of the postpartum focus out in the community.

Andrew Nelson: Both of you kind of spoke to the next question I was going to ask you, which is for family physicians in rural communities that don't have delivery services as such, are there any other special considerations for emergency deliveries?

Julie Wood: I think it's being prepared. One of the things we've been talking about a lot is that preparedness piece, and AAFP's been focusing on a term called OB ready. And so if a facility is not prepared, doesn't have services, and one of our main concerns is what if there is no facility? A lot of times that's a family physician in a community, or even on the roadside or whatever is what can we do as AAFP, and family physicians to help that community or our members be ready? And so we are working on a concept with a lot of our colleagues, for example, NRHA [National Rural Health Association], ACOG, and others to start promoting this concept of OB readiness, and what does that mean? So that is something that's a fairly new concept because there's a lot of work going on in hospital settings.

But what about units that have closed that don't have people that deliver? They don't have facilities anymore, or they're just no facilities. So I think some of those things we're talking about already, like drills, practice, making sure you really do have supplies, even if you are not a hospital that thinks of themselves as a delivery facility, or there just is no facility. Helping first responders be ready and learn those skills. And some of these courses we're talking about, like the ALSO course, and we didn't specifically allude to it, but some of the neonatal resuscitation type courses are really important as well.

Zita Magloire: I'll just piggyback off what you said. In addition to also the American Academy of Family Physicians also have a basic course as well, and it's geared more towards those that are not planning on doing deliveries, but just having a basic understanding and competency, so for paramedics, EMTs, and ER physicians as well, so that if patients do present to the emergency room and need immediate stabilization and care, that can be provided, or if they're on the roadside, which many times happens as patients are traveling to their delivering hospital because they live a distance from that hospital.

But the other thing that I feel is important to note is that some patients that are presenting to an emergency room, people who come to an emergency room, they kind of have a basic expectation that the medical care… about the medical care they're going to receive. For instance, there's no ER probably in the entire United States where you would go and say, “I have chest pain,” and someone there would not know what to do. Everybody would know what to do. It doesn't matter where you are, and if it involves transferring so that you can have a procedure or see a cardiologist, that's fine, but they would be able to stabilize you, and transfer you. But that is not the case with obstetrical emergencies. And this is why one of the reasons we are concerned that our maternal mortality rate is so high. There are several emergency rooms that you can present to even in… not necessarily in a very, very rural area where there may be a provider there that has no experience providing care to pregnant patients.

And so that's why it's so important. And this also kind of overlaps into some other things because family physicians also provide a lot of the emergency medicine care in rural areas. So by having family physicians that are trained, and had a core curriculum that involve taking care of pregnant patients, this is going to help hopefully decrease the morbidity that's associated with having a facility that does not provide obstetrical care, or doesn't have an obstetrical unit, but that the provider can stabilize the patient, and get them transferred.

Andrew Nelson: So family physicians have such an important role. And as you said, sometimes they have to kind of go above and beyond their regular responsibilities. What are some ways that either their community or the hospital they work at, or providers at tertiary hospitals can help to support family physicians who provide high quality maternal services?

Zita Magloire: One of the things that really helps facilitate that is having another provider on the other end, usually another OBGYN, or a maternal-fetal medicine specialist, where there's an established relationship and they understand the limitations of our facility. I think if there's any medical providers that are listening to this podcast, they know no matter what specialty how difficult it is when you are trying to transfer a patient who needs a higher level of care and in an area with limited resources I think a lot of people don't realize just how limited it can be that you don't have an ICU. You don't have even any type of a NICU, or newborn nursery. And so by them understanding the limitations, they're much more likely to readily accept that patient, and the transfer is not delayed.

Julie Wood: I would echo that. And it's been a while since I've been in my rural town, but we had the wonderful opportunity. I did co-manage several higher risk patients, or moderate risk patients with the maternal-fetal medicine specialist who really did support us. He and the neonatal team both came out to our facility, which was a small, Critical Access Hospital. It was 21 beds and a couple of OB beds included into that 21 beds. They would come out at least twice a year to the facility, and we would go there. We would go to the higher level facility and do courses. So we would take our neonatal resuscitation class there. They would come and provide lectures on different high risk topics to the physicians and the nurses. And then they would tour the facility. They would see where we were actually transferring from. That meant the world to us.

And they really did understand what supplies we had and did not have, what resources we had and did not have. And when we would call and say, “Here's what we have,” we would give a history, they trusted us, we trusted them. And they knew what we were dealing with and what we were preparing to handle and what we had to work with. And we had very smooth transfers. They also communicated very well. There was bidirectional communication and excellent care for those patients. We had regular protocols for some of the more moderate risk situations: deliver in the small town, automatically come and do… you know, we're just going to care for that here. I remember one patient that I found a large murmur on at one of the first prenatal visits. And it was something where they just really needed to deliver in a higher acuity of a hospital. Because of that, she ended up having a pretty significant heart problem that had not been detected prior to pregnancy.

And that one, the maternal-fetal medicine doctor said, “I really think she needs to deliver her actually in an ICU. I'm not even sure. I'm not sure I want to deliver her. She really needs a lot of attention.” And she did, and everybody did okay. But that was one where I'm really glad we had that plan. I've had some others where if all these things go well to this point, then she delivers in your little town and if not, we're going to have her do that.

And a lot of them, we did testing after a certain point. And so we always had plans in good communication, but that thing, like Zita said, them coming to us and us going to them on different occasions really opened up those lines of communication, and understanding about our various practice settings. And ultimately the patient did well because of that. It really improved their outcomes. And if they could deliver at home, great. And also if we had to separate mom and baby, which we really tried not to do, we communicated a lot, and we got them back together as soon as possible whenever it was healthy to do so.

Andrew Nelson: Yeah. Shifting gears a little bit. Can you tell us about the role that telehealth can play in facilitating OB care for rural folks?

Zita Magloire: Okay. Yeah. So, we were not using telehealth before the pandemic. And then during the pandemic, the Society for Maternal-Fetal Medicine had some guidelines on using telehealth for certain prenatal visits to limit the exposure to patients, and medical providers. And so we instituted that, and then not only with our pregnant patients, but non-pregnant patients as well, we have continued to provide telehealth services and the patients really do like it, something that's very important to be able to continue this, is to be able to have, for insurance companies to continue to reimburse for both video and telephone telehealth. And the reason this is so important, especially in rural communities is that internet is not reliable, especially in many of our rural areas. And so the video calls are really just not possible, and it can be actually very frustrating for patients and delay their care.

So being able to bill for a telehealth, especially acute visits, because we are still seeing pregnant patients with COVID, or other illnesses, and acute problems during the pregnancy that we would bill separately for. And so being able to do this, and not requiring them to necessarily have to come in, there's several benefits to that for the patient, not even just the fact that they're not having to be exposed, or exposed others to potential illness. So that's one for us. That's a really big area. That's really important. I know there's some areas where they're doing telehealth for consultations, for instance, maternal-fetal medicine consultations. And we're very fortunate that we have maternal-fetal medicine all within about an hour, and most patients are able to go to those visits. But I know that also has been a benefit and some communities have utilized that as well.

Andrew Nelson: So, what role have you seen that social determinants of health play in rural maternal health outcomes? And do you think there's a role for physicians in addressing those determinants?

Zita Magloire: Yeah social determinants of health, this kind of goes along and I'm just going to put a little plug in for implicit bias in here. It all falls under that concept. So basically the concept is that our health outcomes are determined by things that are maybe are not traditionally thought of as being clinical or medical in nature. So, having access to a grocery store that provides fresh produce if you have access to proper education, and that you have school choice, and those things all potentially can affect your health. And so how that's related to implicit bias is that a lot of our patients, maybe some of our patients come from an area, or from a community where eating a certain way is all they know. And so when we try to counsel them on healthier eating habits, this is applies to both pregnant patients, and non-pregnant patients, pediatric patients, adult patients. They really have a challenge to try and change that behavior.

And it's not because of necessarily an educational gap or because they're not smart. It's just because that is what they are… That's just where they're coming from. And so we have to really meet them where they are. And so where implicit bias, which is an unconscious bias that we have that can affect our patient's health outcomes, we may be biased into thinking that some patients are not motivated to make certain changes to improve their health, but what it is that they need more resources. And so that's where social determinants to health are so important. How physicians can help address those social determinants of health, one, is just by asking the questions and screening patients for potential issues regarding food security, housing security, and things like that, it doesn't have to be at every visit, but it could be implemented in a systematic way in your office that will allow you the opportunity as the provider to be able to better address that, or at least acknowledge that this is a barrier to your patient obtaining optimal health.

Julie Wood: Yeah. We have a social needs screening tool that AAFP helped put together through our healthcare… We have a project called The EveryONE Project that's trying to get access to healthcare for everyone, hence the name. And we have a Neighborhood Navigator that's helping people anywhere by putting in their zip code and I'm looking now, so I get it right. It's https://navigator.aafp.org. And that's available also on our familydoctor.org website to anyone, so that they could go in either a family physician that helps screen with our social needs tool, and or any patient or anybody in the office to help screen at any visit to help them access an inner rural area or anywhere where they live to help them find different social needs.

Andrew Nelson: Yeah. And Dr. Wood, I think you made mention up top of the fact that maternal health disparities exist, not just along geographical lines, but also among racial and ethnic groups. How do you think rural providers, and facilities, and communities can work to help improve health equity, especially around maternal health?

Julie Wood: Well, I think it's definitely a team approach. It can't be any one person or any one group in the office or in the community. It's got to be a team approach as far as how we practice as physicians, but also community. So coming together, and working for a pregnant person throughout that pregnancy or before, so that we're recognizing it. So, ideally, we're helping before the person gets pregnant, or the family gets pregnant, but ideally before, during, and after the pregnancy to support the person.

Zita Magloire: I would just echo what Julie said. I think that we can, especially family physicians being in the position where we are, we are at really an important… We are an important position to really address those needs for the patient. And I think with the proper support, as we've already kind of talked about during the podcast, both from our academy, which has really done a really outstanding job in voicing the issues surrounding maternal care, as well as from the community, from the hospital at administrative level, the department of health just recognizing that we are on the front lines and then empowering us to help those patients. I think that's what's going to make the biggest difference.

Julie Wood: Yeah. I'm glad you brought up public health, Zita, too, because it's really important that we work together, and in many communities that's already happening, but it's another area of focus for AAFP is aligning with public health, whether that's at the local, state, or national level. I think the most important thing from my perspective is a lot of what we've already said that, and Zita as well, that family physicians are well positioned because of our diverse training and that we see the whole family, but also we can't do it alone. And it's really important that we work with other healthcare providers, others in the community, and the whole family. And we're really excited to do that. And we want to work to help achieve healthy pregnancies, and healthy families, and lower those maternal morbidity and mortality rates.

Zita Magloire: And then in terms of the joys of practice, Julie listed several of them, and I'd have to echo the same seeing the kids grow up that you deliver. And it's just something that we really can't even describe. It's really a beautiful thing to watch. And then the other thing is just seeing the other family members come, whether it be the spouse of your patient that you delivered, or their extended family, really getting the opportunity to see the whole family is very rewarding. And it's the biggest compliment anyone can ever give you to bring, or recommend a family member to you.

Julie Wood: And I think just the honor of being with the family at the moment of birth.

Zita Magloire: Absolutely. And for some reason I was thinking like all of the office interactions and things, but I mean the actual mo… Yeah, the actual moment. Yeah it's the actual moment, the tears, the joy, the pain that they're experiencing. And then to hear that first cry. I mean, it never, I ask you Julie, I mean, it never gets old. I tell every patient that they're like, “Oh, you've seen a ton of babies delivered.” I said, “It doesn't matter. It never gets old.”

Julie Wood: Nope. Always awe inspiring and talk about being able to bond with the family. I mean, that is the best.

Zita Magloire: Yes, absolutely. And then helping mom breastfeed, too. So, yeah, no, I was just… And then the next step, it's like, “Okay, baby's here. Now what?” Okay, baby's got to eat, we've got to do this. And interacting with the family, engaging the family, it is one of the greatest honors I can imagine. So, yeah, it's just kind of like a whole new phase, now you carried them through this pregnancy, now baby's here. The family's grown now what? And dealing with that dynamic. And I'll just throw this out there, being able to help patients and their family kind of through these milestones in life, doesn't stop with delivery. I mean, sometimes you have pregnancies that don't end in a live birth, and that can be extremely devastating and difficult. And so again, that dynamic working with the family, working through grief support through mental health support is so, so important. So, yes, I think it's, again, it's a challenge and also a joy all at the same time.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today, we spoke to Dr. Julie Wood, who's the senior vice president of research, science and health of the public at the American Academy of Family Physicians, as well as Dr. Zita Magloire, who's a practicing family physician, in Cairo, Georgia. Look in our show notes for more information about their work and visit ruralhealthinfo.org for all things pertaining to rural health.