June 29, 2020
Significant disparities in health care access and quality exist between women living in rural areas and those in urban areas, especially regarding prenatal care, birth outcomes, and maternal morbidity and mortality. Rural women, especially racial and ethnic minorities, are dealing with a lack of access to comprehensive services and support during pregnancy and the postpartum period due to hospital closures, limited obstetric providers and social services, transportation barriers, and socioeconomic disparities, among several other systemic problems, and now they are also facing a parallel crisis—the opioid epidemic—which is hitting rural America particularly hard.
The opioid crisis in the United States is pervasive, and its impact on women, especially pregnant women and new mothers, has been striking. Between 1999 and 2015, prescription opioid overdoses increased 471 percent among women (compared to 218 percent among men), and opioid use disorder more than quadrupled among pregnant women at the time of delivery. The increase of substance use disorders (SUDs) in pregnancy and, more specifically, the use of opioids, has led to a surge in the number of infants born with neonatal abstinence syndrome (NAS), and rural areas have been hit disproportionality hard. From 2004–2013, the incidence of NAS per 1,000 births rose from 1.2 to 7.5 in rural areas (compared to 1.4 to 4.8 per 1,000 births in urban areas).
SUDs during pregnancy are associated with higher risk of fetal growth restriction, fetal death, and preterm labor. And, SUDs also pose substantial risks for the woman herself, including respiratory complications, bleeding, mortality in the third trimester, and postpartum overdose. In fact, substance use is now a leading cause of maternal death. These issues are all compounded for rural perinatal women, where many women must drive 30 minutes or more to access obstetric services.
To better understand the needs of rural, perinatal women struggling with SUDs, Altarum conducted qualitative focus groups in Charleston and Huntington, West Virginia, a state with the highest rates of death due to opioid overdose and a neonatal opioid withdrawal syndrome rate of 51.2 cases per 1,000 hospital births (as of 2017). Our findings showed limited known community resources available and accessible for new moms and for those who are low income. In addition to provider bias and lack of resources, women talked at length about the isolation they felt, their need for confidentiality and fear of punishment, and the challenges of cost and transportation. The women also experienced stigma, shame, and judgment.
Ensuring providers are adequately trained to screen and address SUDs (while providing person-centered care) for pregnant and postpartum women, and that patients living in rural areas have sufficient access to care and support is a challenge, but one that, if creatively addressed, can have a significant impact on the prenatal, birth, and postpartum outcomes of rural women and their children. Our strategies include:
Coordinated and Integrated Care Delivery: Pregnancy and childbirth create a unique opportunity to reach and support women with SUDs as they engage with the healthcare system. Coordinated and integrated care delivery can improve quality of care and reduce costs for pregnant and postpartum women with SUD and their infants, as well as expand access, service-delivery capacity, and infrastructure based on state-specific needs. In 2017, Altarum led an initiative to improve postpartum access and outcomes for low-income and underserved women in Central Texas by addressing post-partum opioid misuse through an integrated approach. The program successfully introduced a new universal screening tool for opioid use disorder (OUD) that was merged into the Electronic Medical Record, standardizing the process across the system and increasing referral placements.
Leverage a Diverse Set of Providers and Paraprofessionals: In areas hard hit by hospital closures and provider deserts, partnerships with providers across a variety of services can improve access and care for women. For example, in the Central Texas project mentioned above, we trained WIC breast-feeding paraprofessionals to recognize and refer potential substance use concerns among the mothers they see. Participants reported increased knowledge, comfort in addressing SUDs, and understanding of referral sources.
Provider Training and Technical Assistance: Meaningful and effective training goes beyond providing opportunities to increase knowledge and develop skills. It also includes ensuring that providers have the tools and infrastructure they need to meet the needs of the target population. We believe that there is also a need to ensure that providers can offer family-centered, trauma-informed treatment and recovery approaches that include integrated and coordinated support to truly meet the needs of rural, perinatal women with SUDs.
Tailored Telehealth and Virtual Healthcare Services: Telehealth increases provider capacity to meet patient needs and reduces transportation/mobility limitations for those living in rural, underserved populations. The women participating in our West Virginia focus groups told us that accessing support services and resources through multiple avenues (such as text, phone calls, and video) is desirable. We believe there are opportunities to improve and expand telehealth in rural areas that combine these various options and preferences. Perinatal women, especially those with SUDs, are often in need of virtual support because of challenges in getting to a provider while caring for a newborn. Virtual services related to lactation support, post-partum mental health, contraceptive care, and SUDs are critical, especially in rural areas. Because rural communities are not monolithic, we believe that evaluation research is key to ensuring that virtual healthcare services are tailored to meet the needs of pregnant and parenting women (with and without SUDs) in rural areas.
Overall, meeting the complex needs of perinatal women with SUDs, especially those living in rural areas will require a multi-pronged approach from a host of stakeholders. But with some innovative thinking, we can make huge strides in addressing the complex healthcare needs of these women and their children.
Vice President, Population HealthAreas of Expertise
Tara Fowler leads Altarum's population health work, including in the areas of women's health, military health, behavioral health, and eldercare. She has led a variety of multifaceted quantitative and qualitative research projects that deliver insights to leaders of government health agencies, from the Defense Health Agency to the Health Resources and Services Administration. Her recent work includes an evaluation of a HRSA-funded program implemented in 16 states to improve oral health of low-income pregnant women and infants. Tara holds a PhD in public health from the University of South Florida.