Obstetricians, Gynecologists, and Maternal Health in Rural America, with Anne Banfield

Organizations and resources mentioned in this episode:

• MedStar Health Women's Health at Leonardtown, Leonardtown, Maryland
• American College of Obstetricians and Gynecologists
• Perinatal Quality Collaboratives, Centers for Disease Control and Prevention
• Health Professionals Seeking Loan Repayment Options

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 two of a multipart series about maternal health in rural America. Today we're speaking to Dr. Anne Banfield. She's a physician administrative and clinical director at Women's Health at Leonardtown in Maryland, as well as a member of the foundation board of the American College of Obstetricians and Gynecologists, or ACOG, and a past Young Physician-At-Large on the ACOG board. Thanks for talking to us today.

Anne Banfield: Thank you for having me.

Andrew Nelson: Certainly! First of all, how have you found that rural practice is different for an OBGYN compared to practicing in a more urban environment?

Anne Banfield: So in more rural parts of the United States, in general, we have fewer resources at those rural locations. When we're practicing OBGYN in a metropolitan area, there are a lot of subspecialists in obstetrics and gynecology practicing there. Things like maternal fetal medicine or high risk OB doctors, urogynecologists, OBGYNs who specialize in the pelvic floor, GYN oncologist, so OBGYNs who specialize in female pelvic cancers, MIGSs, which is Minimally Invasive Gynecologic Surgeons, so they specialize in surgery with the least invasive techniques possible, pediatric and adolescent gynecologists specializing in that particular area age group of OBGYN, and reproductive endocrinologists, which are OBGYNs who specialize in fertility and disorders related to the endocrine system.

And when you're in a small rural community, none of those subspecialists are readily available there and just down the hall like they are in some of those larger areas. Small rural communities also don't necessarily have the other specialties in physician areas, so an example would be interventional radiology, which can do some techniques to help with a lot of gynecologic problems and ameliorate symptoms, and those are people that usually they have to go to larger care centers for a lot of the specialties, as far as surgery goes. So if we have patients who need other surgical specialties, those a lot of times are not available at smaller rural hospitals. And then some of the technology. So the robots, some of the newer laparoscopic equipment, things like that are not always available at smaller rural facilities.

Andrew Nelson: Yeah. Have you found that there are particular competencies or traits that make a provider more suited for or ready to practice obstetric care in a rural area, since rural areas often don't have the luxury of having the kind of specialists you were just mentioning.

Anne Banfield: I think that OBGYNs who are trained in programs that have a very high surgical volume. In a lot of cases in particular more of the open surgeries or vaginal surgeries still happening, they tend to be a little bit more ready to go out and practice in these rural areas because they have the skills to take care of some of those things closer to home that it's harder to have when you come out of four years of residency and don't have as much surgical experience. So I think that makes a huge difference.

And seeing what it's like to practice in those rural areas can also be very helpful if you've never experienced what you need to do in a small rural community hospital. When you have a situation that is out of your scope of practice, then sometimes it's hard to know is this the patient I should transfer, should I be transferring this patient now, when should I be doing this, because you're talking about taking someone out of their community and moving them to another location for care, and that can be very stressful for a patient, family, them having access to their support system, them being comfortable with where they're getting care. And so it's a big decision to make, but it needs to be made at the right time so that the patient gets the care that they need.

Andrew Nelson: Yeah. Workforce is one of the biggest challenges regarding the provision of OB services in rural areas. What challenges do rural facilities and communities face when they're trying to recruit OBGYNs?

Anne Banfield: It's very difficult to recruit OBGYNs to small rural communities. There are a couple of different reasons. Some of them are unfamiliarity. If you've never practiced or lived in a rural area, then it's unlikely you're going to suddenly decide to move to a rural area without significant reason to do so. It can also be challenging from a lifestyle perspective. Most residencies are in urban areas, so family members, spouses, children, they get used to being in that urban area and having access to the resources that are available in those urban areas, whether that be school districts and school curriculums, access to the arts and entertainment, access to transportation readily, a nearby international airport. Many of those things make a huge difference for someone's lifestyle, and so if your family and your support network are used to living in that particular environment it can be very challenging to make a decision to move them as well.

And then I also think that it is difficult sometimes to go to those small communities where maybe you have never been in a rural community and it's a little hard to adapt. People are different regionally as well, and when you move to a new area it's always a challenge. And if it's a small community that's kind of closed, it can be difficult to find your footing, to start to fit into that community, to find those people who are going to be your people in that community. So I think it's a variety of things. I also think sometimes it's challenging when you've trained at a place that has all the access to the resources that we talked about previously, or if you've trained in a location where you're used to being able to do robotic surgery, and you're transitioning to a location where maybe none of those things are available, that can be very daunting.

Andrew Nelson: Yeah. In terms of attracting providers to rural communities, what do you think we can do to make moving to a rural community away from those urban conveniences more appealing, and what can individual facilities do to improve their success when it comes to recruiting?

Anne Banfield: So I think one of the things that has been a mainstay has been loan repayment and financial incentives, and I think that's incredibly important now more than ever. Physicians are coming out of medical school and residency with large amounts of debt. So having the ability to help your providers pay back that debt and getting your physicians on their feet very quickly financially can be a huge asset. But you also have to keep in mind all the other factors that we talked about, so having a system in place within your community and your hospital system to welcome their families into the community and help to start to integrate them, if they have family members coming with them to their community, so that it's an easier transition and you don't have family members who are struggling to make those connections while, in a lot of cases, the physician is very focused on work and immediately has a set of peers and immediately has a social group. But helping to work with that.

I also think communities really need to be forward thinking when it comes to their school districts, the educational opportunities available. Physicians obviously are highly educated folks. They want their children to have opportunity, and if rural communities want to attract them, being able to offer good educational opportunities to their children is incredibly important. And that is a hard nut to crack when you talk about many of the things that rural communities face, in addition to lack of access to healthcare, a lot of times they have underfunded education and other resource issues that can make some of those things challenging. But I think those are other things that are a little harder to think about as far as, oh, is this important for my physician? Yes, those are incredibly important things. We know physicians are considering those things when they're thinking about where they're going to relocate to.

Andrew Nelson: Sure. Workforce, of course, it's hugely important to be able to get those providers to rural communities. Are there any other systemic issues that come to mind that limit access to high quality maternal care in rural environments?

Anne Banfield: One of the biggest factors and things that we have faced is the closure of birthing units at hospitals across the country. Many rural hospitals, because of the way our payment system is set up for obstetrics, it is not really a high volume money maker. And we don't really prioritize maternal and infant health like we say we do. So we say lots of things about prioritizing it, but we don't really put our money where our mouths are in this case. And so it is a challenge for many rural hospitals to financially continue to support their birthing facilities. Because of that, those end up closing, and the areas that are unserved, completely in many cases, get larger and larger as scattered small hospitals end up closing their units and it happens more and more.

When I was practicing in West Virginia, the hospital that I was at, when you would go south from our facility, the next closest delivering hospital was two and a half to three hours away depending on the weather, because we had had closures in the middle of the state of our birthing facilities. Where I am now in Maryland, I'm on the southeastern shore, and it is also very isolated. We have one hospital in our county that does deliveries. And so leaving from our hospital, it takes about 30 to 40 minutes to get to the next closest hospital if you go northeast, and it takes about 40, maybe a little longer, to get to the next closest hospital if you're going northwest. And most recently, I actually heard that one of those hospitals is no longer doing deliveries. So even in places on the East Coast, we are starting to see these maternity deserts in the areas that are less populated, making it more challenging for patients who have limited access to resources to get to those delivering facilities.

Andrew Nelson: Do you have any thoughts for strategies or policies that might help to resolve that problem?

Anne Banfield: I think it all comes down to finances in the end, as far as getting birthing centers open again in some of these smaller rural areas. If obstetrics, and gynecology, secondarily, were as prioritized cost wise and reimbursed as well as orthopedic surgery, or urologic surgery, or some of these other surgical specialties that we say are also important, then we would definitely see hospitals better able to have the resources to keep these units open, to keep good providers on their staff, to keep the staff that is necessary to support those units in place.

Andrew Nelson: Do you think there are any ways that OBGYNs can support rural family physicians and other primary care providers when it comes to providing maternal health services?

Anne Banfield: I think that having a network set up within systems or within state organizations, like perinatal groups, can help to support other providers who are providing maternal care outside of some of the OBGYN departments by having joint grand rounds, by making sure that there's open communication about when patients should be being referred to higher levels of care, to making sure there's a seamless process for when that happens, to make sure that there's two way communication between the OBGYNs and the family practice docs, or the nurse midwives, or the family nurse practitioners. And making sure that all of those groups are able to communicate within their systems and their networks makes a huge difference in the ability of the system itself to provide good quality care.

Andrew Nelson: Healthcare, of course, it's always going to be a team effort. Can you just give us a little bit of a rundown, starting with OBGYNs, of the different members of a maternal health team that you would have ideally in order to provide the best possible care and the roles they play?

Anne Banfield: Certainly. So, ideally, you would have in any facility that provides births, unless it would be a freestanding birth center that should still have a relationship with some of these other folks I'm going to talk about, you ideally want to have providers who can do vaginal deliveries and also providers who can do C-sections if they're necessary. So that means you really need to have at least an OBGYN or a family practice provider who has completed the additional training necessary for them to be able to do C-sections, as well as whatever other compliment of delivering providers, whether that's OBGYNs, family practice doctors, or certified nurse midwives, available to provide deliveries. You also though need high quality labor and delivery nurses who help to provide care to that mother and that baby while they are in labor, and during the postpartum period.

Many people don't realize how specialized OBGYN nurses are when it comes to the care that they're providing. These are women and men who go from having one patient with another patient inside of them to two patients, and this is the only situation where your patients are literally multiplying. And people a lot of times don't recognize that we are dealing with two patients, and our nurses are. So highly qualified labor and delivery nurses is incredibly important. It's also really important to have good obstetric ultrasound available so that we can detect and determine if there are issues or concerns related to the wellbeing of the mother or the baby. It's important to have things like respiratory therapy available so that if we do have an emergency, we can immediately provide life sustaining support to those patients. It's important to have the support of the more extended medicine service at the hospital so that moms who are especially high risk, if they aren't being transferred, can have that extra medical team support.

It's important to have good OR staffing, because if you're doing a C-section having readily available well-trained operating room staff, nurses, and recovery room nurses is incredibly important. Techs who assist in the operating room. It really is an entire network of folks who are providing care to these women. Many people want to take advantage of the anesthesia options that are available as far as epidural anesthesia, and being able to have spinal anesthesia for when a patient has a scheduled C-section in particular, and having quality anesthesiologists and nurse anesthetists to provide those services is very important. So really, in these small rural hospitals, having everything that is ideal for really providing good quality maternal care is very challenging.

Andrew Nelson: What are some ways in which healthcare facilities and providers can provide more comprehensive support to mothers after pregnancy?

Anne Banfield: So I think having available, really before and after pregnancy, additional support services within the setting that prenatal care is being delivered in is ideal. Having a licensed social worker who can help to connect patients to things that they need both before and after delivery is incredibly important. Being able to access mental health services, being able to access substance use disorder services, and having those available, not only in the postpartum period, but also in that perinatal period and the antepartum period so that women can get locked into those services early, they can have those services delivered in a location that they are able to access readily, and then have them in places as they move forward through the process so that by the time you get to the postpartum period, they have things that they need. They have good supports in place. They know what services are available so it makes it a little easier.

I think it's also really important that we continue to provide high quality postpartum care and really consider that postpartum period as its own special trimester, as the American College of Obstetricians and Gynecologists recommend, and continue to see those patients at least twice during that period, as long as there are not reasons that the patient can't participate. I also think it's incredibly important that we continue to work towards having 12 months of postpartum Medicaid and Medicare available for these patients across the United States, given how much we know women tend to fall through the cracks during that first 12 months after having had a baby, and many of them run into more difficulties in that six weeks to 12 months window when they aren't getting care regularly anymore.

Andrew Nelson: In your time working in the realm of maternal healthcare, are there any disparities you've seen?

Anne Banfield: Of course. I think every place in healthcare we see disparities. I think some places obviously are worse and some places are better. But we know, in addition to the rural disparities that we see, just complete lack of access in many counties across the United States to any type of maternal care, we also see those same kinds of disparities in our urban areas. Many people in urban areas also have difficulty with transportation and getting to services, and if you have to take multiple modes of public transit that is in maybe cities where it's not as reliable to get to your care, that also creates disparities in those urban populations. We know that those disparities exist, they exist for both black and brown women, they also exist across socioeconomic ranges, and they also exist across zip code. If you live in the right place, you can get the right care. If you don't live in the right place, you can't get the right care. And many of those disparities overlap each other because of the way the United States has evolved over time. But definitely have seen a lot of disparities.

Andrew Nelson: So, in practical terms, if somebody who is in labor shows up at a hospital that doesn't provide delivery or doesn't have anybody on staff that provides delivery services, are they just going to get into an ambulance at that point and go to someplace that does, or what happens in those situations?

Anne Banfield: In those situations, emergency room physicians get to do deliveries, kind of like you hear about EMTs doing deliveries on the way to the hospital because somebody waited too long to call or their labor progressed that quickly. Of course, that's really not ideal because then these are places that patients may be delivering that don't have postpartum services available. There may be no one on staff who can do newborn nursery care for that baby. There may be no one on staff who can do postpartum care for that mother. So in reality, what tends to happen is if they are not stable for transfer immediately to a facility that has birthing facilities, then they deliver. And then the consequences of that have to be dealt with, whether that's transferring, potentially, mom and baby postpartum, whether that's dealing with some non-ideal outcome because something emergent was happening and there weren't the resources available at that facility where they ended up delivering to provide the care that they needed.

But that's basically what happens. It's not always ideal, obviously. Sometimes when someone comes in and is laboring very quickly, that's a pretty easy delivery, right? And we know that women can have babies really with nothing else happening. They can just have a baby, if everything goes well and if all things being equal. It's the things that are higher risk, it's the things that we aren't expecting that we really are preparing for all the time in obstetrics and gynecology. It's all those things that we hope never happen that we're always getting ready for and being prepared for so that when they do happen, we don't have a bad outcome.

Andrew Nelson: Yeah. It must just be so nerve wracking for some of those pregnant people in areas that are that far removed from somebody who's actually specialized in providing that kind of care. I can't even imagine.

Anne Banfield: There are some places too now, and depending on someone's diagnosis, there are circumstances where a patient will go and will stay in a special facility, whether that's a Ronald McDonald type house or some other living situation that is available to them through their healthcare system, or because of the type of care that they need, but obviously that's not ideal, right? You don't want to have to go and live away from your home for an extended period of time so you can have access to care that you need.

But yeah, many systems now do have those kinds of services, if they need to, to bring patients closer to them until such a time as they can either deliver safely in their home community, or have a scheduled delivery potentially at a tertiary care center because of the level of risk that their pregnancy carries.

Andrew Nelson: So certainly, there are some shortcomings that we have to deal with when it comes to providing rural maternal care. Are there any things in particular that keep you up at night when you think about maternal care and rural birth outcomes?

Anne Banfield: I think the fact that we continue to see closures of units is incredibly daunting. Right now, we have not seen a reversal of that. We have not really seen a significant slowing in that trend. So that particular problem is just going to continue, I think, to get worse. The other thing I'm really worried about now is that the fall of Roe is going to compound some of these issues we've seen. I mentioned already that I think the importance of onsite social services and evaluation, getting access to social workers who can really be looking at the needs of these patients, but I also think having appropriate support services during labor can be incredibly helpful. We know that well-trained doulas make a huge difference in maternal mortality, and so I think having availability of those services also can be really helpful. Many of the patients who would benefit most from those services are not going to necessarily be able to afford those services, so I think having those doula services and other support services available within the system itself would also be incredibly helpful.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today, we spoke to Dr. Anne Banfield. She's a physician administrative and clinical director at MedStar Health Women's Health at Leonardtown, as well as a member of the foundation board of the American College of Obstetricians and Gynecologists, and a past Young Physician-At-Large on the ACOG board. Look in our show notes for more information about her work, and visit ruralhealthinfo.org for all things pertaining to rural health. Join us next time as we conclude our multipart series on maternal health here on Exploring Rural Health.