Muscatine, Iowa – Bailey Tordai, who was 33 weeks pregnant, has just arrived for a prenatal checkup. His clunky old jeep couldn’t complete the 2-mile trip from his home to the University of Iowa Outreach Clinic in his southeastern Iowa town. It was a hot June day, and a wiring problem makes the jeep cone down the street.
A pedestrian helped 22-year-old Tordai push his injured car off the road and into a parking lot. She then called her honest father to go to the clinic.
Jacqueline Roman, a nurse midwife, entered the examination room. “I heard your car broke down.”
“Yeah. You want to buy it? Five bucks!” Tordai joked.
Her lack of reliable transportation will not be ridiculous in August, when her child will be born. He would have to arrange for someone to take him to the University of Iowa Hospital and Clinic in Iowa City, 40 miles northwest. She will not be able to give birth at a hospital in Muscatine because it closed its birth unit in 2020.
Roman is part of an unusual effort to reduce the damage caused by such closures. She is one of 11 certified nurse midwives at the University of Iowa who travel regularly to Muscatine and Washington, another in southeastern Iowa where the local hospital has closed its maternity unit. The university’s pilot project, backed by a federal grant, is not aimed at reopening shuttered birthing units. Instead, the midwife team helps women in the area ensure relevant services Last year, it served more than 500 patients in Muscatine and Washington.
Muscatine is one of hundreds of rural areas in the United States where hospitals have shut down maternity services over the past two decades, often due to a lack of obstetricians and other specialized staff.
Hospital industry leaders say birthing units are also losing money, mainly due to lower payments from Medicaid, a public health insurance program that covers more than 40% of births in the United States and more evenly distributed in many rural areas.
The loss of labor-and-delivery services is particularly difficult for women who do not have the resources and time to travel for care.
Located on the banks of the Mississippi River, Muscatine has more than 23,000 inhabitants, making it a relatively large city by Iowa standards. But its hospital is one of 41 Iowa facilities that have closed their maternity unit since 2000, according to the Iowa Department of Public Health. Most were in the countryside. Only one has been reopened, and only 56 Iowa hospitals now have birth units.
The work of the nurse midwife team includes important prenatal checkups. Most pregnant people should have a dozen or more such appointments before giving birth. Healthcare providers use checkups to track how the pregnancy is progressing and to look for signs of high blood pressure and other problems that can lead to premature birth, stillbirth or even maternal death. Midwives also advise women on how to keep themselves and their babies healthy after birth.
Karen Jefferson, director of midwifery practice at the American College of Nurses-Midwives, said the University of Iowa’s team approach is an innovative way to meet the needs in rural areas that have lost the hospital’s birthing unit. “How nice it would be to see a supplier in your town instead of driving 40 miles for your prenatal visit – especially towards the end of pregnancy, when you’re going every week,” says Jefferson, a resident of rural New York.
Midwives can provide many other types of care for women and children. Theoretically, they could also open a rural birth center outside the hospital, Jefferson said. However, concerns about the availability of surgeons for their funding and emergency caesarean sections need to be addressed, which he said is rarely necessary for low-risk births.
University of Iowa midwives focus on low-risk pregnancies, referring patients with significant health problems to medical specialists in the city of Iowa. Often, those specialists can meet with patients and midwives via video conference in small town clinics.
The loss of a hospital maternity unit can make it difficult for rural families to find local maternity care.
Tordai can prove that if patients have to go far for prenatal appointments, they are less likely to go to all of them. If he had to go to Iowa City for each of his, it would be hard to take a three-hour break from the work of repeatedly running a pizza restaurant, he said. If his jeep breaks down that June, he will cancel his appointment.
Instead, she was listening to her baby’s heartbeat on a monitor at an examination table at the Muscatine Clinic and watching Roman measure her abdomen.
“The perfect job is excellent,” the midwife told him during the checkup.
Roman asked Tordai to describe his baby’s movements. “Constant,” he replied with a smile.
Roman asked if she planned to breastfeed. Tordai said his luck with his first daughter Aspen wasn’t much, now 4 years old.
“Have you thought about breastfeeding classes?” The midwife asked.
“I don’t have time for that,” Tordai replied. Roman continues to explain to her by mentioning where online breastfeeding classes are available.
Towards the end of the appointment, Tordy asked Roman if he could schedule a persuasive birth at the University of Iowa. The midwife told him that, in general, it is better to start the delivery on its own than to start artificially.
But there was the matter of incredible transportation. Tordai explained that scheduling her birth would help her mother arrange for her to be taken to a hospital in Iowa City. Roman agrees that transportation is a valid reason and arranges a persuasive labor on 10 August.
The University of Iowa midwifery team began serving in 2020 at a clinic about 2 miles from Trinity Muscatine Hospital. The hospital is owned by UnityPoint Health, a large non-profit hospital system that blames the lack of available obstetricians for the closure of the Muscatine Birthing Unit. At the time, UnityPoint leaders said they hoped to reopen the unit if they could recruit new obstetricians in the area.
Christy Phillipson, UnityPoint’s health spokeswoman, told KHN in June that the company was continuing its efforts to recruit physicians, including Muscatine Hospital. Although it has not reopened the birthing unit, the company regularly sends a maternity specialist and other staff members to provide antenatal care and related services, she said.
Most of the pregnant patients in the area who choose UnityPoint for their care give birth a 45-minute drive east to the Bেরtendorf System Hospital.
The University of Iowa midwife team has no plans to open its own birth center. However, it hopes to expand its rural clinic services to other disadvantaged cities. To do this, the university needs to hire more nurse midwives, which can be a challenge. According to the Iowa Board of Nursing, 120 licensed nurse midwives live in the state of 3 million people.
The University of Iowa plans to address this by launching the state’s first nurse midwife training program in 2023. The master’s degree program, which will focus on rural services, will train registered nurses to become nurse midwives. It could eventually graduate eight students each year, said Amber Goodrich, a midwife at the University of Iowa who is helping lead the effort.
These graduates could fill vacancies in rural areas, where more hospitals could close their maternity units in the coming years.
“This crisis is not going anywhere fast,” Goodrich said.
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