👋 Welcome to Starting Early. Every other week, we spotlight new reports, useful news, engaging interviews with people doing important work, and interesting takes on maternal health and early childhood development issues.
This week’s issue launches a 3-part series on population health, beginning with rural health. Where we live, what we look like, the languages we speak, and other aspects of our identity have an impact on health and wellbeing. Identities can promote connections and bonds with others. Or they can be used as tools of division – feeding into a mentality of us versus them. Understanding and connecting with others – especially those whose identities we don’t share – can be life-changing.
Our Burke Foundation colleague, Kérène Kabambi, who manages the Starting Early newsletter, reflects, “Growing up in South Dakota, I recognize the challenges of being low-income in rural America. Having reliable transportation, job opportunities, and good healthcare is crucial, yet out of reach for so many. Luckily, small town communities have a lot of love and support to offer, which can help fill the gaps.”
Read the links and go deeper.
1 big thing: Decreased access to rural maternal care
About 1 in 5 people in the US live in rural areas. Rural residents face many challenges in obtaining quality healthcare, which contributes to poor health compared to their urban and suburban counterparts. These challenges are even more pronounced for new and expecting mothers.
In 2014, 54% of rural counties had no hospital obstetric services. Additionally, rural communities are less likely to have access to evidence-based maternal and infant health services, including certified lactation support, midwifery care, and doula support. The lack of options forces rural women to travel long distances for their maternal care and contributes to maternal health disparities in rural communities:
- Rural women are less likely to get prenatal care, more likely to have a preterm birth, and more likely to have an out-of-hospital birth.
The rural maternal workforce: Like other parts of the country, rural communities suffer from a shortage of maternal care providers, resulting in maternity care deserts with little to no access to services. Due to an uneven distribution of OBGYNs, family physicians are the primary maternal care provider in rural hospitals and attend two-thirds of rural hospital births. Midwives also provide care to rural populations, attending about 30% of rural hospital births.
Growing diversity: Those communities are home to a growing number of residents identifying as LGBTQ+, people of color, or immigrants. Too often, they are left out of discussions about rural health.
- 24% of rural Americans are people of color
Technology helps: Even prior to the pandemic, telehealth proved to be a useful tool to connect rural residents to healthcare providers. Initiatives such as the Maternal Telehealth Access Project use telehealth to provide services to at-risk populations, including women of color and women living in rural and frontier communities.
2. Bringing healthcare to school communities and beyond
We sat down with Amanda Martin North, executive director of the Center for Rural Health Innovation, a nonprofit improving healthcare access in rural North Carolina. At the Center, Amanda helped start Health-e-Schools, which offers comprehensive telehealth services at public schools in 7 rural counties. Since its launch in September 2011, the program has expanded to 77 schools and inspired the Center’s other programs, Health-e-Corrections and Health-e-Neighbors. Here are highlights from our conversation.
Why are school-based health programs important?
The value, to me, is that we catch kids who would otherwise fall through the cracks. We’re there for those kids who really don’t have anywhere else to go. The idea is to bring things to one central place. We don’t have a bus system. We don’t have Uber. We have no public transportation except for the yellow school bus. So if we want to make sure we have even a half a chance at equitably providing service, it needs to be through the school system.
Do participating schools face nursing shortages?
There’s always turnover in school nursing because it doesn’t pay as well as the next job you could get as an RN. And, also, in the pandemic, school nurses got slammed. They went from being an afterthought or, “Oh, I’m sure we have a nurse somewhere,” to the center of the response. And we burned through some very, very good people because we as communities – and I’ll own my part in that because I live here too – put too much on them. We gave them a ton of responsibility with no additional support.
How has telehealth technology changed since the launch of Health-e-Schools?
The equipment we put in place in 2011 cost about $25,000 per site and we also had several hundred thousand dollars’ worth of servers in a closet somewhere at the school system. Today, I can bring another school on for a $2,000 investment – a 90% decrease in the cost per site. Also, the equipment now is so small that it fits in a lunchbox. So what ends up happening is we don’t even need one per school because if we have a school nurse who takes care of the elementary school and the middle school, she can take that kit with her. So we can actually bring two schools on for $2,000. It’s crazy how the price has gone down, but that also means that we’ve had to change over time, learn new systems.
How does the program help students?
Last spring, a school nurse called us a month before school was going to be out, saying this boy needs to come to school. He was walking through a river and hurt his foot and he was limping a lot. His family took him to the emergency room where he was given a very expensive antibiotic and a bill they couldn’t pay. The antibiotic didn’t work so they sure weren’t going to go back to the emergency room. But at this point his foot hurt so much he wasn’t coming to school because he couldn’t walk on it. The school nurse asked for help and we were able to diagnose his staph infection and get the right medicine. He was able to finish the semester and progress to the next grade. That’s the value in our partnership. My coordinator was also able to connect his family to a church that supplied towels, socks, and food, and make sure that whoever had missed work to go to the hospital could still buy groceries and pay the electric bill.
3. Better maternal data needed for Native Americans
Many Native Americans live in rural communities and suffer from one of the highest rates of maternal mortality. But 93% of Native American maternal deaths are preventable, according to a CDC analysis of 2017 to 2019 data. Mental health conditions and hemorrhage were the most common underlying causes of death. Multiple factors contribute to high maternal mortality for Native Americans.
- On average, Native Americans have higher rates of heart disease and diabetes, are less likely to be insured, and have lower life expectancy than the overall US population.
Lack of data is a barrier to addressing Native American maternal deaths. The National Congress of American Indians refers to Native populations as the “Asterisk Nation” because “an asterisk, instead of data point, is often used in data displays when reporting racial and ethnic data.”
- Native populations and other racial minorities tend to be undercounted in Census data, which can limit access to federal funds for public health, transportation, and other services.
Data-based decision-making: To better understand and address maternal mortality in Native communities, New York physician Dr. Brian Thompson is creating the first national tribal Maternal Mortality Review Committee, a multidisciplinary group to review Native American maternal deaths across the country.
- Dr. Thompson, a Navajo and Oneida OB-GYN at Upstate University Hospital, shares “Because of the unique sovereignty of Native communities there is a strong desire for Native people to look at themselves and see what the commonalities are, what the root causes are, but more importantly how can we prevent each and every one of these from ever occurring again.”
4. The roundup
Learn about upcoming events, new funding opportunities, and jobs in maternal and infant health and early childhood:
- Save the date: Register to attend the first annual New Jersey Rural Health Conference, November 10. The conference will cover rural health topics including maternal and child health, healthcare workforce development, and access to mental health.
- Midwives increase access to maternal care: After 2 rural hospitals closed their maternity units, the University of Iowa launched a pilot project mobilizing a group of 11 certified nurse midwives to provide maternal care to rural communities in the state.
- Strengthening community health systems: The Community Health Acceleration Project (CHAP) seeks a program manager to support maternal and community health initiatives. Apply here to join their team.