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National Rural Health Day Episode: Addressing Rural Maternal Health Disparities, with Kristen Dillon

Date: November 21, 2024
Duration: 17 minutes

Kristen Dillon An interview with Kristen Dillon, MD, Chief Medical Officer at the Health Resources and Services Administration's Federal Office of Rural Health Policy. In this special National Rural Health Day episode, we get an overview of the current state of rural maternal health, including access barriers and disparities in health outcomes, as well as exploring the ways that the Health Resources and Services Administration is working to improve outcomes for rural mothers.

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Organizations and resources mentioned in this episode:

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.

Today we're joined by Dr. Kristen Dillon, Chief Medical Officer for the Federal Office of Rural Health Policy. Thank you for joining us today, Doctor.

Kristen Dillon: Thanks for having me. It's great to be here.

Andrew Nelson: Maternal health and maternal mortality have been very prominent issues in the United States in the last few years. Research from the Commonwealth Fund has shown that the United States has the highest rate of maternal deaths of any high-income country. Significant differences in maternal mortality occur across racial and ethnic groups in the U.S., with the highest rates among Black mothers. In this special National Rural Health Day episode, we're going to be focusing specifically on maternal healthcare in rural communities, including disparities and access barriers, but also what is being done to improve maternal health outcomes in rural communities. Dr. Dillon, can you give us a little bit of a summary of the state of rural maternal healthcare in the United States right now?

Kristen Dillon: Thanks for that question, Andrew. I really appreciate the opportunity to come and talk about this issue, which is significant and really worth our attention. Within the context of some concerning trends for maternal health in the U.S., we see even more challenges in rural communities. So just as a couple examples, for the first time, as a result of several hundred birth units closing over recent years, we're now in a situation where more than half of rural hospitals do not offer inpatient obstetrics care. They don't have a birth unit. That's a first. The other thing that we're seeing in recent data from my colleagues at the Centers for Disease Control and Prevention is much higher rates of pregnancy-related death for rural residents. A woman who lives in a rural area in the US has approximately twice the risk of dying during pregnancy, childbirth, or within a year afterwards related to the pregnancy. That's twice the risk of dying compared to a woman who lives in a suburban area in this country.

Andrew Nelson: We know that in general, rural communities tend to face additional challenges when seeking to establish and maintain healthcare access. From your perspective, what are some of the challenges that drive the disparities in maternal health outcomes in particular?

Kristen Dillon: Many of the things that drive these disparities we see in maternal health outcomes are similar to what affects rural health otherwise, and in many cases, magnified for some particular reasons. We see the nature of rural communities affecting things. The population's more spread out, longer travel times, and many rural communities face economic challenges and issues like persistent poverty. And so those create some elements of risk upstream of healthcare that we especially need healthcare to be adept at identifying and responding to when they care for patients. And then we just also see that the rural healthcare in general is under pretty high financial stress in many areas. And like other parts of the country, struggling with workforce issues, recruiting clinicians and other healthcare staff.

Andrew Nelson: Can you tell me about some of the things HRSA is doing to help advance rural maternal healthcare delivery?

Kristen Dillon: Yeah, thanks for that question. So I'm with the Federal Office of Rural Health Policy, and we sit in the Health Resources and Services Administration, also known as HRSA, within the federal government's Department of Health and Human Services. And within our agency, we're really focused on responding to the disparities in maternal health outcomes through a range of programs. One program that runs out of our office is Rural MOMS. It empowers communities to create targeted responses to help their communities address the loss of obstetric units in their communities, the higher rates of maternal mortality in rural areas, and the risk factors that can contribute to those outcomes. We've got some other initiatives related to rural maternal health that include an Enhancing Maternal Health Initiative across all of HRSA meaning to accelerate our efforts to improve maternal health in partnership with the women across the country, grant recipients, community organizations, and also state and local health officials. And then in addition, we have early childhood home visiting programs which often reach pregnant and parenting people. Those come out of our Maternal Child Health Bureau. And finally, we're very proud of the National Maternal Mental Health Hotline and the service that it's provided over the last couple years since it launched on Mother's Day 2022. And the number for that line is 1-833-TLC-MAMA.

Andrew Nelson: Can you tell me about some success stories or innovative projects that have been supported by HRSA?

Kristen Dillon: Yeah, I'd love to. So I can think about in some different areas. We've had some real success in the workforce area in a couple regards. One is the MatCare program, which comes out of the Bureau of Health Workforce and is now supporting the expansion of nurse midwifery programs in rural and underserved communities, and also on the workforce front.

Our office, the Federal Office of Rural Health Policy, administers a Rural Residency Planning and Development grant program that has created residencies that are now training hundreds of physicians with a special focus on training physicians in family medicine, including obstetrics practice and also rural obstetrics and gynecology. Within our technical assistance programs for finance and operations in healthcare, we're compiling what our consultants have observed around the ways administrators can support success in maternity care so that these approaches can be more widely available.

And then I think there's some great things also coming out of our Rural MOMS Project going back to our 2019 cohort which has finished out their work. We saw the Rural Obstetric Access and Maternal Services, ROAMS, in New Mexico which was a tele-obstetric service from Clayton Union County General Hospital, bringing in an obstetrician gynecologist from Miner's Colfax Medical Center every other Wednesday. And so it saved mothers driving 170 miles round trip to see that clinician. And over the little over a year that was operational, the 60-plus visits saved more than 10,000 miles of driving and 190 hours of patients in their cars. So, good for the planet, and also really good for patients who we know many of them have a lot of pressures on their time and resources, and it's just so great when we can get them care close to home.

One of our other successful stories comes from the Bootheel Perinatal Network, which is in Missouri. And BPN implemented a patient navigation program called the Clinical Community Integrated Care. And with that program, two care coordinators help the Rural MOMS participants access home visits, mental health support, Medicaid managed care services, and community resources. So the internal analysis showed that they were able to bump the percentage of their participants receiving what's considered adequate prenatal care by five percentage points compared to women who weren't enrolled and also support these patients to be much more likely to attend their specialty appointments for the women who develop high risk pregnancies.

Andrew Nelson: There is so much need for support that we see in rural areas. We just have to kind of figure out how we can do the most good with the funds that we have. Where do you think the federal government can have the most impact to move the needle?

Kristen Dillon: It's always hard. I mean, I think it's impossible, honestly, to name one thing because as I was talking about before, this is an issue that has multiple drivers getting us where we are. A big part of what we do at the Federal Office of Rural Health Policy is to listen and learn from what's happening in the field so that federal efforts can be aligned across agencies and programs and targeted to the places where we can be most helpful. I think as an example, something we've learned from our overall Rural MOMS program experience is about the impact of coordinated prenatal care, the benefits of leveraging telehealth for prenatal care and linkage to maternal fetal medicine specialists, and the benefit of creating networks across healthcare organizations that are independent of each other in their ownership and sometimes even competitors. Because when they can ally together, they can often create a much more integrated care experience for the patients, which we know improves outcomes.

Andrew Nelson: Can you go into a little more detail about what HRSA's doing to advance rural maternal healthcare delivery?

Kristen Dillon: One of the things we haven't touched on yet is our office also supports a network of rural research centers across the country. They're based in academic institutions in all parts of the US, and they focus on research specifically related to rural health. And we do it in a really collaborative way between our office and what we are learning from the field and the expertise that the centers bring. We don't have any say in the results of their research, but we do a lot of collaboration around the questions that they investigate. And so all of that is available on the rural research website, but it includes some recent work coming out of Minnesota on rural obstetric unit closures. There's a recent webinar just held in November summarizing a whole bunch of research related to access to maternity care and additional information from other centers, for instance, North Carolina, which does a lot of work around financial health and financial distress in rural hospitals.

Andrew Nelson: What are some insights or lessons from working with rural health organizations that might be valuable for other people working in the same field?

Kristen Dillon: It's so easy to spend so much of our time looking at the challenges and the problems, of which there are many. I've recently had some good experiences with focusing on successes and some of the bright spots and seeing what we can do to spread that. So we participated, along with some private foundations academic organizations, in a meeting that brought together six hospitals from all across the country from a diverse range of settings that were all doing well in their maternity care programs. So all rural facilities that came to this Rural Maternity Innovation Summit and shared with us their success factors.

And so coming out of that, Milbank Fund helped fund some academic analysis and writing related to that. The sponsors helped fund a publication of the outcomes of those meetings and what we heard, basically, and some of the things that came out of that. One is governance, the leadership in the health system needs to understand the importance of maternity care, both for the health of individuals, but also for the economic and social wellbeing of the community. Another thing that came out as a success is having clinical staff with a broad scope of practice. So in five out of the six hospitals, it was family medicine physicians who included OB in their practice, who were the core of the clinical workforce. And in addition, many places cited that having nurses cross-trained to work in different parts of the hospital, including maternity care, was really important. All of the facilities prioritized high-quality care and really high-quality patient experience, knowing that local referrals and good reputation in the local community was key. Next was savvy financial management, including the cost reporting, providing outpatient care in Rural Health Clinic or Federally Qualified Health Center settings, securing grants and managing insurance contracts. So really, the business end of managing a maternity unit could make or break whether a hospital could keep something like that open. And then finally, many of the hospitals were able to get government support, for instance, through a supportive state Medicaid program or a local tax district. So, five different success factors that we were able to identify across hospitals and communities where maternity care is alive and well in a rural community.

Andrew Nelson: Looking forward, are there any places where you see a particular need for improvement or expansion?

Kristen Dillon: So, big picture, when it comes to rural maternal health in the U.S., when we need to turn the tide, we're seeing trends that are continuing to go in the wrong direction around losing outpatient care in communities, losing hospital-based obstetric units, and in poor outcomes for the pregnant birthing people who live in those communities. So we need to turn things around.

You know, when it comes to rural maternal health, there's a lot to be concerned about. And actually, one of the things that I'm seeing, and I think it's coming out of some of the stories I shared with you, is that attitude makes a difference. And I'm not going to pretend like a positive attitude is all it takes, but if we are convinced that the trends we're seeing are going to continue, they will. And so I am feeling optimistic as we're identifying these success factors and learning how to distill down, not, "Oh, that's an unusual community and they're doing great just because they are," but actually parsing out the pieces of "Here's the ingredients of building a thriving maternity care program," or "Here's the ingredients of keeping prenatal care and postpartum care local in a community, even if the hospital doesn't provide birth services." We're seeing people succeeding at that, and I'm just really optimistic that we're able to start to understand what's going into that success so others can replicate it.

Andrew Nelson: Are there any resources you'd recommend for folks who want to learn more about this topic?

Kristen Dillon: Oh, yeah. We've got so many good resources for folks out there. I mean, I think one of the lead places we send people is right here to the Rural Health Information Hub. I think the Rural Maternal Health series that our office put on earlier this year and is archived on the site is a great starting place for especially folks working in hospitals that want to start to move things forward. The materials from the Rural Maternity Innovation Summit that I mentioned, those identified success factors are also on the RHIhub site. And then the partner site, the Rural Health Research [Gateway] site includes many of the academic and whitepapers and research products that I mentioned from our research hubs. I think the National Maternal Health Hotline is a really important resource. And at their website, they also have downloadable and printed publicity materials so that clinicians, schools, anyone else who serves pregnant and postpartum people, anyone who encounters young families, can promote that resource. And then finally our Federal Office of Rural Health Policy sends out an announcements email every week. It's a great way for folks to stay updated on grant opportunities from HRSA and also educational and grant and other support opportunities from other entities that are relevant for rural health.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Dr. Kristen Dillon, Chief Medical Officer for the Federal Office of Rural Health Policy. Look in our show notes for more information about her work and visit ruralhealthinfo.org for all things pertaining to rural health.