Rural Obstetrics Workgroup Meeting MinutesThursday, March 15, 2012
1:30 - 3:30 p.m.
Members/Guests present – Robie Carter (Director of Nursing, Swift County-Benson Hospital), Mary Jo Chippendale (Maternal and Child Health Unit Supervisor, Minnesota Department of Health), Ray Christensen (UMN-Duluth Medical School), Tom Crowley (Administrator, Saint Elizabeth’s Hospital, Wabasha), Jen Harvey (Women’s Health Consultant, Minnesota Department of Health), Scott Johnson (OB/GYN, chief of surgery, Duluth), Sue LaMotte (CNM, Minnesota Board of Nursing), Frank Lawatch (Administrator, Swift County-Benson Hospital), Holly Rudol (RN, Swift County-Benson Hospital), Nicole Wilson (Student, UMN-Duluth Medical School)
MDH staff – Mark Schoenbaum, Kristen Tharaldson
Rural Obstetric Patient Issues
MDH staff presented information on patient issues including access to prenatal care, cesarean deliveries, support for high-risk pregnancies and cultural considerations in rural obstetric settings. Attendees were introduced to a list of prenatal care discussion topics and frequency of topic being discussed with a health care professional. The workgroup members found it interesting that the topics of “how smoking affects fetal development” and “how drinking affects fetal development” were discussed 74% of the time at prenatal visits. The number of women who smoke and drink while pregnant should be noted in the final report.
The top barriers to prenatal care in greater Minnesota were uninsurance and difficulty scheduling appointments. Attendees noted rural obstetric insurance coverage may change with health reform. This is because of the universal health insurance mandate as well as the new rule to allow children to stay on their parent’s policy until age 26. Attendees noted it is relatively easy to enroll eligible women in the state Medical Assistance program, especially if they are pregnant and/or a single mother. However, legislators reduced obstetric related Medicaid reimbursement, so some providers may be reluctant to work with this population.
Rural women are less likely to be offered vaginal birth after cesarean (VBAC). Although medical literature supports VBACs as a safe and appropriate choice for most women, newer evidence suggests this topic is still up for debate. There are distinct guidelines providers must follow in the hospital setting that limit VBACs due to liability and insurance restrictions. The obstetric providers felt the current rules were medically appropriate. If a VBAC is used, women are referred to larger facilities. Primary care physicians and mid-levels can often impact the patient’s decision on elective versus medically necessary cesarean sections.
Two workgroup members who are tribal doulas and a trainer on Ojibwe traditional births met with workgroup staff for a roundtable discussion back in January. Some of the findings about traditional birth and challenges encountered in rural hospital settings were shared with the workgroup. Attendees felt the information was new to them and would be valuable for obstetric health care providers. They suggested adding a recommendation that statewide training be offered on traditional birth from an Ojibwe perspective. The Minnesota Hospital Association’s small rural hospital committee may be a good partner to get this information to rural hospitals and providers. Attendees felt all hospitals doing obstetrics could benefit from this information.
Attendees discussed what could be done to improve access to prenatal care in greater Minnesota. Minnesota does fairly well when compared to other states at providing access to early prenatal care. Some women in their first trimester do not know they are pregnant and will seek care during the second trimester. Local public health can help screen and refer women who smoke or use alcohol during pregnancy.
When it comes to reimbursement issues, it is important to study the issues and present the facts to legislators. The consequences for reducing Medicaid may be unintended, but they are real to rural health care providers. As rural areas encounter more patients dependent on Medicaid, the costs do not equate.
It is really important for clinics, hospitals and local public health to understand the resources of each agency so patients can easily access local services (prenatal care, obstetric options, post-partum care, breastfeeding, etc.). The process of checking in to update this information across the health provider continuum also helps identify gaps at the local level. If agencies do not connect periodically, they may forget what is offered or not know about new programs.
Rural Obstetric Community Issues
MDH staff presented information on community issues including the importance of access to local obstetric services and care coordination across systems and settings. Call coverage and surgical coverage are areas that are important for local collaboration around obstetric services. Local collaboration also helps with training new obstetric staff. It takes time to get new nurses acquainted with providing obstetric services. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) is a strong nursing professional organization that makes obstetric related educational information available to nurses. What kind of volume is needed (at a minimum) to maintain the competencies of a rural obstetric team? Minnesota and the U.S. needs to answer this question and identify models to maintain staff competencies.
Attendees discussed what could be done to foster local support for obstetric services. Physician champions can lead the way with community buy-in work. Patient satisfaction surveys for new moms and sharing the findings is another way to promote services at the local level. Focus groups to study patients who do not seek local services may be interesting. Some women are referred out, but with normal deliveries, most would at least consider local services.
As a rural hospital develops a new obstetric service, they can coordinate information and publicity so there is a sense the local hospital is linked to a larger system and referral OB/GYNs are available. This helps patients understand the “seamless transfer” available locally. The more options given to patients, it is more likely they will stay at rural facilities. Having female providers and midwife provider options are an important consideration. Water births and other common options women seek out are also important. When updating services or remodeling birthing rooms, it is a good time to check in with local birth options and patient preferences.
Attendees were excited about the potential of telemedicine for obstetrics. A shared EMR is helpful for information sharing and is a good starting point. Information can be shared from genetic counseling and prenatal appointments. It is getting more common to see fetal monitor strip/real time charting being observed remotely by providers. Certification is available for fetal monitoring for nurses and physicians, and some have proposed to make it a prerequisite for obstetric providers. Some OB/GYNs have equipment in their homes and can receive electronic information from hospitals, making their work more palatable from an on-call perspective. Attachments can be included with the EMR such as x-ray or ultrasounds, so the capabilities are there depending on the system being used.
Avera e-Care Services are well developed and some remote obstetrics monitoring is done through their e-Emergency Service. Rural hospitals can subscribe to the service and consults are available 24/7. It would be interesting to see how many of their remote consults are obstetric related. The work group may consider a recommendation to pilot a rural obstetrics telehealth model. Development and equipment may be subsidized by the Leona Helmsley Foundation (Helmsley Trust) which already supports a lot of Avera’s telemedicine development work.
Review of Draft Recommendations
MDH staff presented the draft recommendations for the report. Workgroup members worked with staff to worksmith and edit the recommendations. This updated draft will be reviewed by RHAC committee members at their next meeting. A final review of the recommendations by Rural Obstetric Work Group members will occur with review of the report.
An RHAC meeting on March 30th will include review and approval of an initial draft of the Rural Obstetric Work Group recommendations.
The webinar adjourned at 3:20 p.m.