Better reimbursement, access and more midwives among maternal health ideas

Policymakers, government agency officials, doctors and medical advocates on Wednesday (May 1) discussed the need for action to improve maternal health in Arkansas, which has the highest maternal mortality rate in the country.

Ross DeVol, CEO of Bentonville-based Heartland Forward, said the U.S. ranks behind Brazil, Mexico and Russia in maternal mortality. He said the primary reason for the Heartland study was to draw more attention to the overall costs of not investing in maternal health.

“Maternal health is an economic issue based on medical and non-medical costs. Maternal health is also closely tied to human capital potential, and in Arkansas, the loss totaled $6.815 billion from 2014 through 2020,” DeVol said while speaking at the NWA Health Summit on Wednesday at the Fayetteville Town Center.

The event focused on improving maternal health by using community health workers, mobile health units, doulas and midwives, working together with traditional healthcare providers to bridge the gap that is likely to worsen.

He said 92% of maternal deaths are preventable, and when a mother dies, the cost to the household and community is exponential. DeVol said more study is needed to assess the economic and social impact on the surviving child and siblings. Removing silos that exist between government agencies, non-profits, healthcare providers and community groups is imperative to addressing the problem.

Dr. Pearl McElfish, director for Community Health Innovation at the University of Arkansas for Medical Sciences (UAMS), said it will take everyone to change maternal and infant health outcomes.

Accèss to care was discussed at length at the day-long event. Among Arkansas’ 75 counties, 35 don’t offer obstetrics care. That creates major gaps in access to care because of long travel distances for appointments, which often means expectant mothers don’t get the early prenatal care they need.

Dr. Nirvana Manning, chair of obstetrics and gynecology at UAMS, said before the pandemic, 39 Arkansas hospitals delivered babies, and now it’s just 35. Factor in that 50% of OB/GYN doctors in the U.S. will be 60 or older by 2030, fewer hospitals accept OBGYN residents in the state and nation, and concern looms about how the pipeline will be filled.

According to healthcare officials, midwives, doulas, personal emotional coaches during pregnancy, and other trained county workers will have to try to bridge the gap.

A steering committee panel moderated by Olivia Walton, founder and CEO of Ingeborg Investments and an outspoken advocate for maternal health, discussed challenges with Medicare reimbursement for maternal health and changes that should be made to improve access. Medicaid covers 50% of the births in Arkansas. Fewer doctors are accepting Medicaid for maternity because of the lack of reimbursement, given the risk.

Janet Mann, deputy secretary of medical services for the Arkansas Department of Health, oversees Medicaid funding. She said the payment is $1,800, which is paid following the delivery. The standard of care for a healthy prenatal care regimen should include at least nine doctor appointments, ultrasound, blood work, anesthesia, labor and delivery.

Mann and six other government officials comprise a steering committee to engage legislators, advocacy groups, health care providers and other stakeholders to provide input and support a statewide plan to address maternal health. The committee is part of Governor Sarah Sanders’ executive order to improve maternal health, support moms and protect babies.

The poor maternal birth outcomes are tied to a lack of prenatal care. Each year nearly 10,000 pregnant women in Arkansas wait until after their first trimester to see a doctor. But 1,100 pregnant women in the state wait until they are in labor to see a doctor. This is nearly one in every 32 births.

Doctors with UAMS, Johnson Regional Medical Center in Clarksville, Baptist Health, Mercy, Washington Regional and Willow Creek Women’s Health confirmed they are often tasked with delivering babies where the mother has not received good prenatal care because of travel distances, lack of transportation or coverage gaps.

Dr. Shannon Case, an OB/GYN, practices in Clarksville and serves a more rural community. She said Johnson Regional offers maternity care, but many people don’t realize that, so they travel to Fort Smith or Conway for care. Too often, expectant mothers present with other health issues that increase their risks, such as diabetes, obesity, and age. They typically need 22 doctor appointments and more ultrasounds, and the pay is still $1,800.

The doctors said it takes three patients with private insurance to cover losses from one Medicaid birth. Another issue that must be addressed is the 56% of unwanted pregnancies that occur each year across the state. Jacob Oliva, secretary of the Arkansas Department of Education, said 600 teens become pregnant each year, the highest in the nation.

Education, access to information and contraception have to become part of the conversation between schools, parents and other stakeholders to address teen pregnancy. Olivia, also on the steering committee, said too often pregnant teens don’t finish school, and that has to change.

Walton said the best way for a mother to care for a child is to care for herself and her education. She said unless teen mothers get an education, they often live in poverty.

Coordination of mobile health units based in central Arkansas, more midwives and better communication between traditional health providers, government agencies and other resources are part of the solution and the low-hanging fruit the steering committee is looking to harvest.

Dr. William Greenfield, a doctor of Obstetrics and Gynecology at UAMS, said certified professional midwives are not nurses, but they are trained in labor and delivery and often practice outside of the hospital in birthing centers and home births. He said they deliver about 300 babies a year in Arkansas. However, certified nurse midwives like SaraBeth Askins often have a master’s degree with post-graduate training in obstetrics and gynecology. Askins is one of two certified nurse midwives at Baptist Health in Fort Smith. She works in the hospital setting.

UAMS in Little Rock is launching a nurse-midwifery program expected to open enrollment in the next 18 months. It will be the first such training site in the state.

Expanding access to care can also be achieved through Telehealth opportunities that are not being fully leveraged, according to Dr. David Deschamps, a maternal-fetal medicine specialist at Mercy Hospital in Rogers. A former Walmart programmer, Deschamps said health organizations could blend online and in-person visits to increase doctor interaction with patients who must travel long distances to see their doctor.