Getting prenatal care for her first child was a relative breeze, Cheianne Pogline said: the hospital where she would deliver the baby was only about seven minutes from her house.
The process got significantly harder with the next three. She and her husband moved from Craig to Parachute in 2019, and the closest options for obstetrical care were an hour away, in Glenwood Springs or Grand Junction. When they moved back to Craig in 2022, they found Memorial Regional Health had stopped offering maternity care, meaning the closest option was in Steamboat Springs.
Women in two out of five Colorado counties face the same challenge because their communities don’t have a place to give birth or providers who specialize in pregnancy care. They’re more likely to skip prenatal care and have less healthy babies than those who don’t have to go so far. Reopening hospital birthing units isn’t a viable solution in many places, though, so communities have to get creative.
Pogline was able to get some care through a UCHealth outreach program where obstetricians who normally work in Steamboat Springs visit Craig, but still had to take an hour-long trip for her 20-week ultrasound and to meet with the doctor who would perform her cesarean delivery. They scheduled the birth, but she and her husband worry labor will start early.
“With babies, you never know when they’re going to come,” she said. “You kind of do always have that worry in your mind of, what happens if I deliver now?”
Twenty-five of Colorado’s 64 counties are “maternity care deserts,” meaning they don’t have a hospital performing deliveries or a birthing center, and also lack an obstetrician or midwife, according to March of Dimes.
A higher percentage of Colorado’s counties are maternity care deserts than the national average of about one-third, said Rebecca Alderfer, CEO of the Colorado Perinatal Care Quality Collaborative. The group hasn’t studied health outcomes in those counties, but the state’s most recent maternal mortality report found that mothers in the least-populous parts of the state, which often are care deserts, have four times the risk of dying in pregnancy or the postpartum period as urban-dwelling mothers. About 2.2 urban women die per 10,000 births, compared to 8.2 women in the most remote counties.
While the drive to the hospital is the most dramatic moment, the loss of access to routine care is the bigger problem because conditions go untreated, Alderfer said. The collaborative and others are working together to increase remote monitoring of patients, bring midwives into rural areas and train local doctors to handle pregnant and postpartum patients’ physical and mental health, she said. Suicide and overdoses are the top causes of maternal mortality in Colorado.
“It’s not just labor and delivery,” she said. “It’s prenatal care and postpartum care, it’s home visiting. Especially, it’s behavioral health care.”
With a few exceptions, pregnant women living in maternity care deserts were more likely to report they started prenatal care five months into the pregnancy or later, according to a study from Colorado State University’s Regional Economic Development Institute that examined the same counties as the March of Dimes report. They also generally have higher rates of premature birth and infant mortality.
Not all communities will be able to support a hospital labor and delivery unit or a birthing center, but they do need a provider offering prenatal care at least once a week and transportation options to help families access care that’s not available locally, said Dr. Laurie LeBleu, an obstetrician-gynecologist with UCHealth who is based in Steamboat Springs but regularly sees patients in Craig.
In an uncomplicated pregnancy, the birthing parent sees a doctor every four weeks for the first 28 weeks of pregnancy, every two weeks through week 36 and once a week until week 40. Women who go past their due dates may need more frequent monitoring.
Memorial Regional Health in Craig stopped delivering babies about four years ago. When the hospital still had an obstetrics department, UCHealth had a provider from its Steamboat Springs location drive out once or twice a week to meet extra demand in the area, said Ryan Larson, director of clinic operations at UCHealth Yampa Valley Medical Center. Since then, they increased their “outreach” presence to four times a week, he said.
Pregnant patients still need to travel to Steamboat Springs at least twice, LeBleu said. Women with complicated pregnancies may need to make the drive more often so they can have additional monitoring, though the system is working on installing a machine that would allow more of that to happen in Moffat County, she said.
“Right now, they can end up driving twice a week,” she said.
Caring for rural patients means being proactive, and sometimes taking steps providers wouldn’t in urban areas, such as scheduling an induction before the due date if a patient might not make it to the hospital in time, LeBleu said. Even so, roadside births are an occasional reality. About a month ago, she talked a father through the basics while the family waited for an ambulance.
Some rural hospitals have shown interest in bringing labor and delivery, or at least prenatal care, back to their communities, said Denise Smith, project director for the Colorado Rural Midwifery Workforce Expansion program. University of Colorado’s College of Nursing received a $2 million, four-year grant to fund scholarships for aspiring nurse-midwives who agree to work in rural areas.
In Colorado, certified nurse-midwives can prescribe medications and practice without a doctor’s supervision. They can attend births in hospitals or elsewhere, though they can’t perform cesarean deliveries.
“Our goal is a midwife for every community,” she said.
The odds of recruiting obstetricians to rural areas are slim, but hospitals could restart their birthing programs with a combination of midwives, general practitioners with obstetrics training and an on-call general surgeon to perform cesarean births, Smith said. Ultimately, though, the most important factor is that hospitals are financially stable and get enough reimbursement for births that they at least don’t lose money, she said. Commercial insurers pay an average of $9,700 for an uncomplicated vaginal birth, and Medicaid, which covers 40% of births in the state, pays $3,200.
Colorado’s limits on the growth of state spending prevent it from significantly raising Medicaid rates for births, which saves taxpayers money, Smith said. But when services go away, families bear the costs of paying for gas, lost work time and possibly missed care, she said.
“With the cost savings, it costs somebody something,” she said.
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