Limited by consolidation, funds to help improve rural birthing access

As more than one-third of New Hampshire’s hospital-based labor and delivery units have closed in the past two decades, some rural parts of the state have become “maternity deserts,” according to Dr. Timothy Fisher, an obstetrician at Dartmouth-Hitchcock Medical Center.

Following a national trend, most Upper Valley hospitals such as Alice Peck Day Memorial Hospital in Lebanon; Valley Regional Hospital in Claremont; Springfield (Vt.) Hospital, Cottage Hospital in Woodsville; and New London Hospital have all closed their birthing units in recent years. In the Upper Valley, just two hospitals continue to deliver babies, DHMC in Lebanon and Gifford Medical Center in Randolph.

Fisher and his colleagues at the Northern New England Perinatal Quality Improvement Network, a collaboration of organizations involved in perinatal care across the region, and at The Center for Rural Emergency Services and Trauma, a D-H-based collaborative program of small hospitals, came together to talk about what they could do to address the care gaps left behind by the closings.

“People still show up for care (at the) closest place,” Fisher said. Just because birthing facilities have closed “doesn’t mean pregnant people aren’t going to need care.”

Driving distances for labor and delivery services has roughly doubled in the past 20 years, he said. That’s an increase from an average of a 20-minute drive to a hospital to a 40-minute drive, he said. But that increase has been unevenly felt throughout the state and has hit those in New Hampshire’s North Country the hardest. There, mothers may see a trip of 1½ hours to the nearest hospital delivery room, he said. That’s on a day with good weather.

The longer trips are also being felt by New Hampshire emergency service providers, Justin Romanello, Bureau Chief for the New Hampshire Department of Safety Division of Fire Standards and Training & EMS, said. For example, when Lakes Region General Hospital in Laconia dropped their OB/GYN service, ambulances had to transport more patients from that region to Concord, increasing the travel time from 10 minutes to as much as 25 minutes, he said.

The added distance “increases the likelihood of that person (delivering) in the field,” he said.

Now, Fisher and some D-H colleagues are seeking to better prepare rural emergency department clinicians and emergency medical technicians through Simulation Training for Obstetric and Neonatal Emergencies (STONE), a pilot project that is set to receive $192,000 in the $1.5 trillion federal funding package President Joe Biden signed into law this month. The $192,000 was part of some $62.4 million Sen. Jeanne Shaheen, D-N.H., said she brought to projects in the Granite State through the congressionally directed spending process.

“I’m glad to see funding I fought to secure being used in such an important way — to improve prenatal and maternity care,” Shaheen said in a statement.

The STONE project aims to send D-H physicians to rural areas to train emergency department clinicians and EMS providers, and to use telemedicine to handle high risk births and complications in rural hospitals that lack birthing units.

Examples of such complications include shoulder dystocia, when a baby’s shoulder becomes stuck inside the birth canal; and postpartum hemorrhage, when a mother has heavy bleeding after giving birth, Fisher said. Treatment of such conditions, which in some cases can be life threatening, is not necessarily part of the basic training given to emergency room providers or EMTs, he said. Using simulators, the D-H physicians will guide the rural clinicians and emergency responders through hands-on training sessions.

Fisher said he expects that the D-H team will conduct a training session with Lebanon and Hanover emergency medical services this spring. The grant includes support for EMS providers in Grafton, Sullivan, Carroll and Coos counties.

Romanello, at the state’s Division of Fire Standards and Training & EMS, said, “Any training in addition to the baseline (is) always welcome.”

The training sessions will use high fidelity manikins, which allow EMTs to practice delivering babies in a normal fashion or a breech position, when the baby is facing backward.

“It’s pretty phenomenal,” Romanello said.

In addition to bringing D-H doctors out to rural emergency departments and emergency service providers, the project also aims to expand D-H’s TeleICN, which allows hospitals to connect to D-H neonatologists at the push of a button on a tablet such as an iPad that is mounted to a baby’s hospital bed, to rural emergency departments, Fisher said.

Beyond this grant, both Fisher and Romanello also said they’d like to see improved access to prenatal care close to home for pregnant women, in order to prevent avoidable complications.

While there are emergency service providers throughout the state that can help in a crisis, Romanello said, “reduced staff (and) reduced access to services makes it tougher.”

Several other Upper Valley projects also garnered federal money through the recent funding package, including $448,000 to Dartmouth-Hitchcock for a new Center for Advancing Rural Health Equity to address persistent health disparities in rural communities by bringing together researchers, clinicians, public health workers and community members. Families Flourish Northeast, an organization aimed at establishing a treatment center for mothers in recovery and their children in the Upper Valley, is slated to receive $500,000 in federal funding.

Courtney Tanner, Families Flourish’s board chairwoman, said in a news release, “While we have quite a bit of work ahead of us, this funding brings us one step closer to operationalizing a residential treatment program for women who are desperate for an opportunity to get help.”