Rural women face prenatal care challenge

Remote areas in U.S. can provide limited options during pregnancy

CASPER, WYO. — Every mother hopes to hear her baby cry in the seconds after giving birth. But Kelsey Wood’s son, Brenton, was silent when he came into the world on Feb. 8, 2013.

There are no words to describe the pain of giving birth to a stillborn baby, Wood said.

She recalls being asked a question she never imagined having to answer. Did she want her child buried or cremated? She remembers holding her son and thinking that he looked like his dad.

“He had his dark curly hair; a whole head of it,” she said.

The family had already prepared his nursery, the walls painted yellow and green — a nod to John Deere — and a hand-carved pinewood crib sat in the corner. But Brenton never came home — and Wood wonders whether a different outcome would have been possible had she received specialized care for her pregnancy.

Wood lives in Thayne, pop. 366. Like many women from rural parts of Wyoming, she sought prenatal care from a family doctor because there wasn’t an obstetrician nearby.

Even advanced equipment and the most experienced specialists can’t save every child. Brenton’s cause of death is unknown and it may have been unavoidable, Wood says. But she does wonder. “You torture yourself trying to figure it out,” she said.

Pregnant women who live in cities and suburbs will often have many obstetricians to choose from. But some rural communities lack even a single OB-GYN.

The problem isn’t limited to Wyoming. Pregnant women in rural areas nationwide are struggling to receive prenatal care, according to Dr. Colleen McNicholas, an assistant professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis.

McNicholas, a member of the American College of Obstetricians and Gynecology’s committee on Health Care Systems for Underserved Women, said some women in remote areas don’t have access to any treatment. Others have to rely on family practitioners.

These physicians are likely capable of handling normal pregnancies and deliveries, she said. But there’s no guarantee a pregnancy will go as planned.

“The problem with obstetrics is that you can go from a normal pregnancy to a catastrophic situation in a matter of seconds,” she explained. “(Having an obstetrician) can mean the difference between life and death for both mom and baby.”

But it can be difficult to find these specialists in smaller communities, partially due to issues with Medicaid, the professor said.

Medicaid’s reimbursement for prenatal and delivery services tends to be significantly less than what it costs to provide that care — and hospitals and private practices in the countryside often have a higher number of patients using Medicaid.

McNicholas said this means providers in rural areas can’t always afford to offer these services, which puts all pregnant women in that area — including those with private health insurance — at a disadvantage.

“The quality of health care you get is dependent on your ZIP code,” she said. “That’s a tragedy for one of the wealthiest countries in the world.”

In Wyoming, about one in four women receive less than adequate prenatal care, according to the Wyoming Department of Health Vital Statistics. That means, on average, they begin prenatal care after the fourth month or attend less than 79 percent of recommended doctor visits.

Twenty-two of the state’s 26 hospitals offer obstetrics services, according to Eric Boley, the president of the Wyoming Hospital Association. These facilities have a delivery space and equipment, but it doesn’t mean that the doctors who use it are obstetricians, he explained.

Some pregnant women opt to travel to see an obstetrician, which comes with its own set of challenges.

Ashley Walker, 34, resides in the countryside between Driggs and Victor in Idaho, west of the Wyoming border. But the expectant mother drove about an hour last week for her appointment at Jackson Hole Women’s Care.

On Monday morning, Walker lay down on an exam table and pulled up her pink top. Her obstetrician, Dr. Mary Girling, squirted a clear gel on her belly, flicked off the lights and ran an ultrasound transducer across her stomach.

“If you don’t have extensive experience, it can be really hard to tell what you’re looking at,” said Girling, as she inspected the gray-and-white image of Walker’s daughter that appeared on the screen.

The ultrasound was encouraging: The baby weighed about 6.9 pounds and was surrounded by enough amniotic fluid.

Other updates were concerning. Walker’s blood pressure, which had been mildly elevated throughout her pregnancy, was higher than usual on this morning. She also had a minor headache. Girling sent her patient to the nearby St. John’s Medical Center to check for pre-eclampsia, a potentially life-threatening pregnancy condition characterized by high blood pressure and the presence of protein in the urine.

Girling instructed Walker to remain in Jackson regardless of her diagnosis. She explained that Walker’s cervix was already 5 centimeters dilated, meaning she could likely have a fast delivery.

“I’m afraid you wouldn’t make it back here in time,” the doctor said.

Walker, who runs a property services business with her husband, was planning to return to work after her checkup. But she quickly decided not to chance it.

Her drive home involves crossing Teton Pass, she said. The highly elevated roadway has limited passing opportunities and often gets clogged with tourists in the summer.

“That makes me a little anxious,” she said, explaining that the image of giving birth in her Subaru while stuck behind an RV wasn’t appealing.

Many of the patients at Jackson Hole Women’s Care come from other places, according to Girling, who owns the practice.

Traveling for appointments isn’t convenient for anyone, she acknowledged. But she urged those with the means to seek care from a specialist.

Girling explained that seeing an OBGYN is especially crucial for those women with additional risk factors, like hypertension, gestational diabetes or a history of miscarriages.

“If you only see one high-risk pregnancy patient a year, you’re probably not going to be very good at it. You get better and better with practice,” she said.

But traveling for care isn’t a realistic option for all pregnant women. The closest OB-GYN might be hours away, making visits a challenge — especially for lowerincome patients.

Jackson Hole Women’s Care has partnered with the Mountain Sage Family Clinic in Dubois to try to help the patients who can’t jaunt back and forth.

Dubois, pop. 971, is about 80 miles from Jackson. It has a handful of lively restaurants, some hotels and a gas station with a giant jackalope exhibit. But there aren’t many options for soon-to-be mothers, according to Tracy Baum, the family nurse practitioner who runs the clinic.

“The access to prenatal care is a big, big issue in Dubois,” she said, adding that many patients appreciate the partnership.

Either Girling or her practice partner make monthly visits to the tiny town and communicate frequently with Baum about her pregnant patients.

Girling once met Baum and a laboring patient halfway between Moran and Jackson, and the pair delivered a baby on the side of the road.

Girling said she feels calm during emergencies, as long as she’s there with her patients. But the physician worries around the clock once they return home.

After hours of monitoring and testing, doctors told Walker she did not have pre-eclampsia. She still heeded her physician’s advice and remained in Jackson.

Walker checked into the Hitching Post Lodge, a low-cost housing facility that caters exclusively toward patients traveling for medical purposes. The lodge consists of 33 well-maintained cabins, each featuring private bathrooms, televisions and refrigerators. A barbecue pit and playground sit in the center.

The lodge is owned by St. John’s Medical Center, which purchased the property in 2001 to help patients who needed to stay in Jackson for care, said Karen Connelly, the hospital’s chief communications officer.

The cabins cost about $40 a night, she said.

Monica Lesley, the hospital’s director of obstetrics, said it’s a great asset for many pregnant patients.

“We have a lot of high-risk moms and they need to be monitored frequently. They live far away and if something goes wrong, they need to be able to deliver right away,” she explained.

Connelly said the hospital’s obstetricians also make visits to smaller communities.

Walker said she appreciates the lodge and any efforts to bring more attention to the challenges pregnant woman face.

“I think the risks of pregnancy aren’t really talked about — people aren’t aware,” she said.

Wood agreed. The 30-year old said she never expected to have a pregnancy that went awry.

“You expect a normal pregnancy and a normal delivery,”” she said.

Since losing Brenton, Wood has given birth to three healthy boys. Despite the 90-minute drive and the sometime daunting weather conditions, all of them were delivered by Girling in Jackson.

“It’s the biggest joy; you’re crying and you’re happy and you just can’t stop looking at them,” she said. “There is nothing in the world that can compare to that feeling.”

Wood wants that outcome for every woman.