Throughout the United States, rural communities suffer from a lack of a precious resource: access to maternal health care for women before, during and after they give birth. The problem springs from one of the country’s great divides.
Simply put, people who live in rural areas of the United States have dramatically poorer access to reproductive care than those who live in urban areas. For example, only about one-quarter of rural counties in the country has an obstetric hospital, while all urban areas do. That disparity has sobering consequences. In rural communities, rates of maternal and infant mortality, maternal complications, and teen births are significantly higher than in urban areas. The challenges are even more pronounced for people of color who live in rural areas.
The lack of perinatal care – and more broadly, inpatient care – in rural communities can lead to compounding problems. For example, substance use disorders, mental and behavioral health challenges and medical problems like diabetes and hypertension may go unaddressed and lead to poor outcomes, not only for pregnant and postpartum people but also for their children.
Colorado faces these challenges. In 2022, 13 counties in the state had no hospital, and two had neither a hospital nor a clinic. The unsurprising result is a lack of providers, including physicians, registered nurses, and advanced practice providers, such as physician assistants, certified nurse-midwives and clinical nurse specialists, said Dr. Amy Barton, professor and Daniel and Janet Mordecai Endowed Chair in Rural Health Nursing with the University of Colorado College of Nursing.
“Even though we may experience a nursing shortage in the Denver metro area from time to time, it’s nothing like the shortage of providers in rural communities,” Barton said.
Barton is working with colleagues, including Jessica Anderson, director of Midwifery Services and associate professor of Clinical Practice at CU Nursing, to close the maternal health care chasm by implementing telehealth services, bolstering educational opportunities in local communities and strengthening the diversity of the nursing workforce.
Confronting a rural care crisis in obstetric services
These and other efforts are critical in a country where health care crises like the COVID-19 pandemic and opioid scourge are “actually amplified in rural areas” and worsened by provider scarcity, Barton said. That’s due to economic pressures that today threaten hundreds of rural hospitals with closure.
Barton and Anderson have been at the forefront of finding ways to stave off that devastation with practical measures. They collaborated on a 2021 paper that addressed the challenges of providing perinatal care in rural areas. The paper suggested opportunities to improve care, including – among others – providing telehealth services; increasing the numbers of certified nurse-midwives, physician assistants and other advanced care providers; and bolstering statewide networks that develop evidence-based initiatives to improve pregnancy outcomes.
Anderson is also a member of an American College of Nurse Midwives task force that focuses on meeting the needs of midwives who serve rural areas.
COVID opens the door to remote health care
An inspiration for bridging care gaps for people in rural and other underserved communities – including those facing transportation issues, economic challenges and language barriers – came from an unlikely source: the COVID-19 pandemic.
“One positive effect of the pandemic is we began focusing on providing virtual health care for our patients,” Anderson said.
The new emphasis led to an initiative to help women get vital prenatal care through virtual appointments and equipment to monitor their health at home, as well as clinic visits. Certified nurse-midwives – registered nurses who complete master’s-level midwife education programs approved by the national Accreditation Commission for Midwifery Education – lead the effort, which is slated to begin this spring. Participants will be recruited from the University Nurse-Midwives – Center for Midwifery-Anschutz Medical campus practices and from the CU Center for Midwifery – Longmont clinic.
A rural-urban divide for maternity care
Too often, access to maternal and perinatal care is determined by where a person lives. Anderson noted that women have access to services from certified nurse-midwives at a variety of sites along the Front Range. The options have grown. For example, the UCHealth Center for Midwifery Lone Tree – Highlands Ranch Hospital, which opened in 2020, has grown impressively, with birth volume increasing, the number of clinic days doubling and the hiring of a fourth midwife now underway.
But that success only highlights the shortfall of birth services in rural areas and the need for more options like the telehealth pilot, Anderson said.
“We know that patients will still have to drive to some appointments,” Anderson said, “but having to make only a few is more palatable than 13 trips. Hopefully, this program will help reduce the barriers that people face accessing perinatal care.”
Improving health care in rural areas starts with its residents
CU Nursing also aims to help communities lacking health care options cultivate their own resources. The overarching goal: build a workforce that not only provides women’s health services but also reflects the communities they serve. Barton called it a “grow your own approach” to removing barriers to care.
“It’s easier to develop providers locally as opposed to convincing someone from an urban area to move to a rural one,” she said. “You really want people who are engaged in and committed to their communities.”
Among the seeds of that strategy is a satellite pre-nursing program set to launch this fall at Fort Lewis College in Durango, with the first nursing class planned for 2025, Barton said. The southwestern Colorado town of roughly 20,000 people sits in the middle of sprawling La Plata County, which covers nearly 1,700 square miles.
In addition, CU Nursing is working toward building a more diverse workforce. According to the American College of Nurse Midwives, Blacks make up just 7% of all nurse midwives in the United States. In response, CU Nursing created the Nursing Midwifery Diversity Scholarship to attract more students from various underrepresented communities. Anderson said the Nurse Midwifery program has thus far awarded two scholarships.
The scholarships attempt to change the face of health care in towns and neighborhoods where resources are few and careers in medicine a remote goal at best, Barton said.
“Students from marginalized and underserved populations often don’t see themselves in the role of health care provider,” she said. “Patients are more comfortable with providers who look like them and speak their language. That can help to overcome an inherent lack of trust.”
Anderson added that, more broadly, the mission of CU Nursing is to educate nurses who will “infiltrate all areas that have access needs. We are training students who want to go back to their communities and serve.”
From rural America to the urban classroom
One of those was Carole Nighswander, who earned a master’s degree in nurse-midwifery in 2021 from CU Nursing. The degree capped a long quest that deepened the roots she long ago sank in the soil of southwestern Colorado.
Originally from suburban Chicago, Nighswander left home at 17 to attend Fort Lewis College in Durango. She studied French and anthropology but maintained “a longstanding desire to be in reproductive health. I wanted to be a midwife when I was 16 years old.”
Nighswander met that aspiration in the late 1990s after she gave birth to her first child. She earned a degree from the National College of Midwifery and worked in Durango as a community midwife for 18 years. At that point, with her third child grown and about to leave home, Nighswander decided to “start over” – not by abandoning midwifery but by extending her commitment to it with additional education at CU.
It was not an easy path. Nighswander’s nearly two decades of experience as a community midwife didn’t translate to any credits in the university system. She earned her associate’s and bachelor’s degrees in nursing while continuing to work delivering babies. She finally put that part of her life on temporary hold with her decision to pursue her graduate degree at CU.
“I had to be available to come to Denver for my clinical rotations,” Nighswander said. “And I wanted to give it my all.”
Rural residents return with new skills for improving care
She took advantage of opportunities for remote learning that the program offered but said she found the greatest satisfaction in working clinical rotations in an urban environment and an academic setting.
“It was incredible working with the Center for Midwifery and University Nurse-Midwives,” Nighswander said. “It gave me a stellar example of collaboration to care for women.”
Nighswander earned her master’s degree two-and-a-half years after she started. Valuable as her experience in the Denver metro area had been, there was no question that she would resume her career as a newly certified nurse-midwife in Durango. She currently works with Southwest Midwives, providing care for people through pregnancy, childbirth and after delivery, as well as an array of women’s health services.
“Durango is the community that raised me,” Nighswander said. “Babies that I delivered are now having their own babies. It’s a gift for me personally to work here, but also for my families.”
Nighswander said nurse-midwifery offers communities “a lifetime of benefits” that include care that is “accessible, relatable and affordable,” producing strong outcomes. And is integrated into the lives of women and families.
“Our goal is to be there for them during pregnancy, birth, puberty and menopause,” she said. “We recognize that these are impactful times that are also incredibly vulnerable. We want to partner with women and when needed, collaborate with our physician colleagues to achieve the optimal health outcomes all women deserve.”
A wider range of services than just maternal and obstetric care
As a certified nurse-midwife, Nighswander also has a much wider scope of practice and thus can attend even more closely to her patients’ physical, social and emotional needs. That’s critical in Durango, with its large geographic area served by an 82-bed hospital that has a birth center and handles a host of specialty care services. Nighswander and her colleagues play an essential role in working with obstetricians while also helping to address the needs of a community confronting teen pregnancies, substance use disorders, mental health issues and chronic disease.
“We can serve some individuals with long-term conditions,” Nighswander said. “Our accessibility is critical in order to care for women while recognizing their needs and potential barriers to health.” She added that she wants to help “level disparities” of care among American Indian and Alaska Native women, who make up about 7% of Durango’s population.
“It’s important for me to bridge those worlds and represent where I came from in community midwifery and nurse-midwifery,” Nighswander said. The chance to split her time between Durango and the Denver metro area while pursuing her graduate degree was essential to her continuing evolution, she added.
“The program at CU was priceless,” Nighswander said. “With three kids, it [wouldn’t have worked] to go away from Durango for two-and-a-half years. It would have been an opportunity lost.”