In Florida, 91% of rural hospitals do not have OB-GYN services, the highest percentage in the country.
Over the past two years, more than 50 rural hospitals have ended their labor and delivery services, contributing to the 57% of rural U.S. hospitals without these services, according to a November report from the Center for Healthcare Quality and Payment Reform. Closing OB-GYN programs leaves some patients without care options and with greater access barriers.
Becker’s reached out to systems and hospitals in Florida that still have OB-GYN programs to discuss how they are filling maternal care gaps.
“Florida currently ranks last in the nation for early prenatal care access,” Rizwana Fareeduddin, MD, executive medical director at Orlando, Fla.-based AdventHealth for Women, told Becker’s. “And we know that early prenatal care can help prevent many adverse pregnancy outcomes and long-term health issues.”
Access to OB-GYN services can also reduce maternal mortality.
“I find it astounding that in the United States we are still grappling with maternal mortality and OB-GYN deserts, while countries in Europe and Scandinavia have achieved zero maternal mortality,” Melida Akiti, chief transformation officer at Fort Lauderdale, Fla.-based Broward Health, told Becker’s. “Meanwhile, we’re still in the double digits. Something is fundamentally wrong.”
Across the three systems, leaders told Becker’s they are seeing a number of key challenges and trends in care needs.
1. OB-GYN deserts in rural areas often means women have to travel 30 to 60 minutes or more to reach a provider. But even in larger communities, systems are finding many women do not seek care in their first trimester because of access issues.
“It’s not just about distance, it’s also about appointment availability,” Ms. Akiti said. “Women should not have to take two buses just to reach a prenatal appointment. They shouldn’t be starting care in the second trimester or later. Some women have said, ‘This isn’t my first child. I can manage until I’m six months pregnant.’ That mindset leads to poor outcomes: NICU admissions, maternal deaths, avoidable complications.”
2. Commercially insured women are more likely to delay childbirth to their 30s and 40s, but most of the births at Broward Health are Medicaid-covered. And Medicaid trends for births can help systems detect needs.
“Women will do what they need to for a safe delivery,” Ms. Akiti said. “That’s why you see them traveling, and we see those trends reflected in the Medicaid birth numbers.”
3. AdventHealth is seeing growth in birth rates and maternal care demands, even as birth rates across the nation decline, Kristen Toth, vice president of women’s services at AdventHealth for Women, told Becker’s.
4. Even for large systems in urban communities, finding enough OB-GYNs to meet demand can be difficult.
“So we’re asking: What are the right care models?” Dr. Fareeduddin said. “How do we get women in the door earlier? How do we better educate them to stay healthy during and beyond pregnancy?”
Leaders from AdventHealth, Orlando Health and Broward Health said they are not seeing an increase in rural OB-GYN patients referred to their facilities, but all three are working to make rural access to maternal healthcare easier.
Here is how they are tackling the growing demand and needs for maternal care.
Telehealth
Orlando Health, AdventHealth and Broward Health all utilize telehealth to make rural access to care easier, while also helping patients overcome barriers such as transportation and child care.
“These [rural patients] have been unfairly labeled as ‘non-compliants,’ but we see it as our responsibility to make care more accessible,” Lori Boardman, MD, executive director for the Orlando Health Women’s Center for Maternal Health, told Becker’s.
Orlando Health’s Winnie Palmer Hospital had a maternal morbidity rate of 5.6% in 2022, but after receiving a grant to launch a maternal telehealth nursing team, the morbidity rate dropped to 2.7% in one year.
Increasing access to outpatient care
All three systems have invested in outpatient and ambulatory care models to expand access to maternal health.
Orlando Health expanded local OB-GYN access through 33 ambulator locations staffed by physicians and practitioners. The system has also opened new labor and delivery units at two hospitals surrounded by rural communities and opened a NICU, Anjali Vyas, MD, president of Winnie Palmer Hospital and a senior vice president for Orlando Health, told Becker’s.
Broward Health has focused on collaboration to improve access to maternal health and expand services to rural areas.
AdventHealth routinely receives transfers from rural communities who need higher levels of care and have been “thoughtful” about how they provide routine care to these patients, Dr. Fareeduddin said.
“Rather than requiring women to travel long distances for routine care, we coordinate with their local OB-GYNs and bring them in for delivery or specialized visits, sometimes using telemedicine,” Dr. Fareeduddin said. “When patients do come to our hospital, we have a coordinator who provides a warm handoff to the labor and delivery team. We’re not seeing an increase in rural referrals, but we do maintain that role as a tertiary referral center.”
While patients are at the hospital, Ms. Toth said the system focuses on patient experience.
“Our care doesn’t stop at the hospital door. It extends into the community, thanks to our incredible partners,” she said. “Quality care is non-negotiable, but so is the experience of care.”
More support for mothers
For maternal patients in the hospital, providing better support is a top priority.
At Orlando Health, nearly 98% of hospitals have breastfeeding and lactation consultants; more than 90% allow doulas on the labor and delivery floor; 86% of hospitals support vaginal birth after cesarean; and certified nurse midwives are delivering in about 80% of hospitals, Dr. Boardman said. These, plus telehealth maternity care programs, have helped to improve outcomes and eliminated access barriers for patients.
The system has also improved outcomes by partnering with community organizations to create mobile clinics and train six licensed practical nurses as doulas to provide support to patients who could not otherwise afford the service.
“We’re reaching populations that have historically been overlooked, and making it as easy as possible for them to be healthy when they come to deliver,” Dr. Boardman said. “We even coordinate food delivery through our partners so patients don’t have to leave home.”
AdventHealth’s OB-GYN programs go beyond pregnancy and birth. Its Fourth Trimester program helps women in the first 12 weeks postpartum by providing patients with a postpartum doula to help with scheduling appointments and medication access.
Addressing staff shortages
Physician shortages are especially pressing in obstetrics and gynecology. Even large, urban systems are struggling to hire and retain OB-GYN staff.
The bottom line is not enough residents are choosing the specialty, Ms. Akiti said.
“The work is demanding, high risk and often thankless,” she said. “You’re not dealing with one life — you’re dealing with two, sometimes three. And the hours? Babies don’t come on a schedule.”
But her solution is not to hire more OB-GYNs.
“We know there aren’t enough [people] choosing the field,” Ms. Akiti said. “Even creating a residency program won’t generate enough practitioners. We must focus on collaboration: Identify the gaps, figure out who’s working in those spaces and join forces. Whether the issue is housing, transportation or healthcare access, it needs to be addressed. There’s no magic bullet, but there is collaboration. We can’t keep working in silos.”
