Megan Kalata, MD/MPH – Megan is an OBGYN practicing in Omaha, NE. She is a member of the NMA’s Health Equity Task Force and has a strong commitment to contributing toward the elimination of systemic racism and health disparities by engaging colleagues and community members so that all people feel heard, respected, and included in the healthcare system.
When I was a third-year medical student, I met a patient in the clinic one day who had recently found out that she was pregnant. After the congratulatory hug, discussing her first trimester nausea, and a brief overview of what to expect in pregnancy, my preceptor asked her what questions she had for us. I remember looking at our patient, seeing her look down at the ultrasound picture in her hand and ask, “Which visit is most important?” Puzzled, my preceptor asked what she meant. She responded that she lived over an hour from the clinic and had recently started a new job. She was not going to have the ability to take off half days from work to drive to and attend each appointment. She was struggling to balance meeting the needs of her healthcare with other needs of her family and her new position.
As I progressed through my training, it quickly became apparent that this was not going to be a unique conversation. Despite how commonplace lack of access to maternity care services has become, we seem to have yet to find a sustainable solution to reducing maternity care deserts. Maternity care deserts consist of counties where there are a lack of maternity resources, such as lack of access to hospitals or birth centers offering obstetric care and lack of obstetric providers. According to the March of Dimes 2023 Maternity Care Deserts Report, 51.6% of counties in Nebraska are considered maternity care deserts compared with 32.6% of counties in the United States overall.
Access to maternity care is essential for preventing poor health outcomes and eliminating health disparities. Hospital closures and the provider shortage are driving changes in access to maternity care, particularly within rural areas and among our patients who identify as Black, Indigenous, and people of color. County-level data from the U.S. Maternal Vulnerability Index shows that women living in 83.9% of counties in Nebraska have a high or very high vulnerability to adverse outcomes due to lack of availability of reproductive healthcare services. Equitable access to care is crucial in addressing the significant rates of maternal and infant morbidity and mortality in our communities. By focusing on disparities within care deserts, we can identify and address factors that contribute to adverse outcomes, including inadequate healthcare structures, systemic racism, and socioeconomic challenges.
If we want our patients to receive appropriate medical care, we must make it more accessible. In Nebraska, women living in counties with the highest travel times travel up to 78.7 miles and 80 minutes, on average, to reach their nearest birthing hospital. Currently, only 7.7% of maternity care providers practice in rural counties in Nebraska. In order to improve the health of Nebraska’s moms and babies, we must address this workforce challenge.
Nebraska is not the only state facing the challenge of worsening maternity care deserts and a dwindling workforce. When federal programs offering tuition reimbursement for healthcare professionals choosing to practice in rural areas did not significantly expand the rural maternity workforce, healthcare leaders had to become more creative. Equitable telemedicine policies, innovations in remote monitoring systems, and expanded Medicaid coverage have all been successfully implemented in other states.
The utility of telehealth has been examined as an adjunct to routine care to improve access to specialty care and ultrasound interpretation. It can also support rural providers through easier access to maternal-fetal medicine consultation during pregnancy. However, without attention to factors that will increase availability and uptake, obstetrical disparities have the potential to worsen with telemedicine as it is often patients with less access to this technology who are the ones that need it most. One method to combat this is through state and federal legislation to ensure that Medicaid coverage for telemedicine is seen as a necessity. Currently, in Nebraska, Medicaid reimburses live video and remote patient monitoring but does not reimburse for audio-only visits. In order to ensure equitable access for all populations, we must be sure that telemedicine options not only exist but can be reached by our most vulnerable Nebraskans.
Additionally, more intentional collaboration among providers, such as obstetricians, family medicine physicians, and midwives, has the potential to target solutions for patients who need them most. Creative models to increase access to education and community building have been seen through programs such as Utah’s Pregnancy Care ECHO (Extension for Community Healthcare Outcomes), which offers education on various pregnancy-related conditions for advanced practice clinicians, family physicians, obstetricians, and midwives. Rural maternity providers are also enlisting non-clinical partners as doulas, WIC counselors, and peer educators to ease some of the burden on providers and to offer more comprehensive care and support in the community. Partner organizations can also educate healthcare providers about the specific concerns and struggles of patients in the community so that more effective care can be provided. The Nebraska Medical Association’s Primary Care Desert Task Force, which includes maternity care, was formed with these goals in mind of finding long-term solutions in collaboration with other stakeholders.
Together, we, as physicians in Nebraska, must engage in thoughtful, enduring conversations and actions that are committed to addressing the needs of our patients living in maternity care deserts. All women deserve healthcare that is safe, timely, and equitable. When we improve access to quality healthcare, we will be able to make Nebraska a safer, better place to experience pregnancy and birth.
