Rural OB Care

Caroline Billings

Released: January 31, 2022

In 2015, the Center for Disease Control and Prevention (CDC) found that urban areas had a pregnancy-related mortality ratio of 18.2 per 100,000 live births, while rural areas had 29.4 (source). Additionally, rural women may be more at risk of maternal morbidity, possibly a 9% greater risk than urban women of experiencing severe maternal mortality and morbidity, even when controlling for sociodemographic factors and existing health conditions (source). The United States currently has the highest maternal mortality rate of all the world’s developed countries.

Factors Affecting Rural OB Care

Though these factors are not faced only by rural residents, these significant challenges are sometimes exacerbated for rural patients due to their proximity to healthcare facilities or lack of access to public services, such as transportation. These obstacles to receiving healthcare can also lead to more severe health consequences for rural patients. The Health & Human Services Department has stated that improving the United States’ maternal morbidity and mortality rates is a top priority. Unfortunately, the layers of barriers that rural patients face make it very challenging to solve the complications involved in rural maternal care.

  • Clinical Factors- healthcare workforce shortages
  • Social Determinants of Health- opportunities for transportation to receive healthcare, quality of housing, poverty status, food insecurity/security, domestic violence, trauma-related health issues, and racism

Cost Information

The initial start-up cost of an OB telehealth service line is quite expensive. These costs can be affected by the inconsistent reimbursement requirements of their state CMS programs and patients’ private insurance plans. Unfortunately, this variability in requirements produces barriers to telemedicine implementation. The cost of adding this service line is lessened if your hospital has an existing relationship with a Telehealth Platform. BMC Pregnancy and Childbirth Journal published a study on the long-term cost benefits of implementing a telehealth OB service line, such as OB Nest. A federal grant opportunity for expanding these services has been added to the “Other Resources” section at the end of this page.

The equipment required for performing at-home OB visits (scale, fetal Doppler, glucometer, and blood pressure cuff) can be provided (checked-out) by your hospital or purchased out-of-pocket by your patients. The Affordable Care Act requires insurance plans and Medicaid programs to provide coverage for maternity care without cost-sharing to the patient. However, there are currently no federal requirements for OB telemedicine reimbursements. These stipulations vary from state to state. However, in about half of the United States, if a telemedicine service is “medically necessary,” private plans are required to cover them. This protection is called “service parity.” Less than half of states require “payment parity,” where telehealth services are reimbursed at the same rate as their in-person equivalent service. To mitigate cost barriers to receiving care, many local and national organizations are advocating for the extension of Medicaid coverage for women from 60 days to 365.

Program Information

Obstetric Telehealth Model-

Rural hospital closures directly affect access to maternal healthcare. A study found that from 2004 to 2014, the United States’ rural counties that lack hospital-based OB services increased from 46% to 55% (source). Fourteen of the rural hospital closures that occurred during this same time left their rural counties without any obstetric services. In the rural hospitals that remained open throughout this decade, more than 165 OB units were closed (source). These losses mean that patients must travel increased distances to receive care, an obstacle that is unfortunately associated with higher risks of maternal mortality and morbidities.

Though telehealth models for OB care existed before the COVID-19 pandemic, a swift expansion of these services began quickly after COVID-19 was detected in the United States. With COVID-19 affecting vulnerable populations, such as pregnant women, it was imperative to expand access to safe and quality care. Currently, many hospitals are integrating virtual visits into the traditional prenatal and postpartum care schedule—recommended visits every 4 weeks until twenty-eight weeks gestation, then every 2 weeks until thirty-six weeks gestational age, and then weekly until labor and delivery. These visits do not include the additional appointments a pregnant woman might have for genetic testing and ultrasounds. Due to extensive monitoring of the fetus, high-risk pregnancies further increase the number of visits.

Telehealth models of obstetrics care can mitigate the impact of some of the barriers patients face when attending their prenatal and postpartum visits or receiving testing and imaging results. A 2019 study by the United States Census Bureau showed that 90.3% of households in the United States had a computer, 82.7% had access to the internet, and 68% have access to mobile broadband connection. Telemedicine offers more options for patients whose barriers to care are primarily related to childcare, transportation, proximity to care, infectious concerns, and schedule flexibility. Obstetric telehealth is primarily used in rural areas for remote monitoring of the mother and fetus, remote reading of any imaging, postpartum lactation consultations, postpartum follow-ups, and regularly scheduled virtual visits. According to CMS rules, these telehealth visits must include two-way audio/video communication on a HIPPA-compliant virtual platform.

Rural hospitals looking to implement this service line must develop a protocol for these visits. There must be a uniform obstetric system for all low-risk patients. For example, a virtual care model called OB Nest (Mayo Clinic) includes 8 in-person appointments, 6 virtual appointments, an online portal system for patients to ask questions and receive education from their providers, and an online discussion forum for patients to communicate with one another (moderated by healthcare providers). As part of OB Nest, patients were mailed blood pressure cuffs and fetal dopplers to improve the quality of their at-home care and provide more information to their providers during online visits. Adding this level of participation in their own care encourages self-efficacy. This system can be implemented into an existing obstetrics service line at rural hospitals or as a foundation for a new obstetrics unit. Along with virtual visits, blood pressure cuffs, and fetal dopplers, patients must also have access to physical exams, ultrasounds, and labs as part of your hospital’s in-person OB appointments. More examples of Prenatal Care Programs with integrated telemedicine can be found here.  The use of telemedicine could be the answer to increasing the number of women who attend postpartum visits as well. Currently, around 40% of women do not attend any postpartum appointments.

An example protocol for combination in-person/virtual visits was developed with insight from the University of Utah and Mayo Clinic as well as consultation with midwives, specialists in Maternal-Fetal Medicine, and Academic OB/GYNs. This prenatal/postpartum schedule can be found below (source):

Nursing Virtual Visit 6-10 weeks
New OB Visit 10-14 weeks
Virtual Visit 15-19 weeks
In-Person Visit 20-22 weeks
Virtual Visit 23-26 weeks
In-Person Visit 27-28 weeks
Virtual Visit 29-34 weeks
In-Person Visit 35-36 weeks
Virtual Visit 37-38 weeks
In-Person Visit 39-40 weeks
In-Person Visit 40-41 weeks
Virtual Visit 2 weeks postpartum
Virtual Visit 6 weeks postpartum

Considerations of OB Telehealth Model Implementation

  • Structural Considerations- financing (mentioned above), technology, policy documentation, evaluation of policies and procedures, staffing, and other resources that might affect patients’ access to care
  • Leadership Considerations- communication, bioethics, training, and logistical processes should be created and implemented. Constant monitoring of your program’s goals and the quality of your OB services, satisfaction (patient and provider), and the number of healthy pregnancies is great metrics for measuring a program’s success. Another important aspect of your considerations must be monitoring how to maintain quality continuity of care throughout the transition from traditional prenatal/postpartum OB visits to telehealth.
  • American College of Obstetricians and Gynecologists Recommendations and Conclusions Regarding Telehealth Implementation

Common Systematic and Structural Issues-

There is a low number of births in rural hospitals that unfortunately prevents staff from knowing how to handle rare maternal complications. Additionally, there are high rates of medical errors, low-quality treatments, and poor care coordination in the rural hospitals that do provide maternal and OB care.

  • Care Coordination as a Possible Solution: Midwives/doulas offer an additional outlet for quality care, but some states impose restrictions on their ability to help the birthing process. Midwives and doulas attend more than 30% of births in rural hospitals. This is a drastic increase in use compared to the average 10% of births attended by midwives nationwide. Care provided by these providers can improve maternal and newborn health, decrease unnecessary medical interventions, and save hospitals money. The current concern about the use of these providers is whether they are safe alternatives to medical professionals. Many states require collaboration and supervision of a physician from local hospitals (no independent practice for midwives), even with the evidence that hospitals that implement midwives into their obstetrics teams have better health outcomes for both the mothers and their babies. Currently, many organizations are recommending that the Secretary of Health work with states to standardize and expand the scope of practice laws regarding maternal health care providers nurse-midwives.

Workforce Shortages Recruitment and Retention

Maternal healthcare is delivered by myriad providers- specialists, primary care physicians, midwives/doulas, NPs, nurses, pharmacists, lactation consultants, and community health workers. There is a massive shortage of maternal healthcare providers, and these jobs currently have high turnover rates. Recruitment and retention strategies are invaluable for avoiding workforce shortages as much as possible.

Rural areas lack specialists and other maternal healthcare providers, including those in maternal-fetal medicine (MFM). Telemedicine offers new chances for rural mothers and expecting mothers to videoconference with MFMs and other specialists rather than traveling to urban centers. Videoconferencing with maternal specialists also allows for MFMs to review ultrasound images while a technician conducts the exam in the mother’s local (rural) hospital. Your hospitals physicians should check that their malpractice insurance covers telehealth services, and that if they are seeing out-of-state patients, they are licensed to do so. Four studies on the use of telemedicine specialists in high-risk pregnancies and their promising results can be found here.

Possible solutions– Back to Telehealth: The use of telemedicine has increased in rural areas as broadband access has expanded. For communities and counties without obstetric units, telehealth visits with OB/GYN specialists can be a potential outlet for their residents needing care. Models of telemedicine have already been used successfully to improve patient outcomes in rural ICUs. Among the use of Telemedicine, performing safety drills and simulations of emergent labor scenarios in rural hospitals has also been shown to improve maternal patient outcomes in rural healthcare facilities. When possible, maternal air transport to larger hospitals can also be of use to decrease maternal morbidities and mortality rates. Some hospitals have begun induction of labor at 39 weeks for rural residents who travel to cities to have their children. This induction has been associated with reduced perinatal morbidity and mortality, maternal morbidity, and cesarean delivery rates and helps mitigate the logistical issues imposed by geographic distance from providers.

Other Resources