For women in rural areas, having a baby comes with greater risk.

But training in emergency obstetrics at rural hospitals could improve the odds, according to a new policy brief from the University of Minnesota’s Rural Health Research Center. The study found that hospital administrators and nurse managers want more training to decrease the risk for mothers and their babies. 

Maternal mortality across the country has been rising over the past 30 years. According to the Centers for Disease Control and Prevent, maternal mortality rates increased 143% between 1987 and 2017. In the late 1980s, the maternal mortality rate stood at a little over 7 maternal deaths per every 100,000 live births. In 2017, the maternal mortality rate was 17.3 deaths per every live birth. 

Around the world, however, maternal mortality rates are steadily dropping. In the United Kingdom, maternal mortality rates have fallen to 9 deaths per every 100,000 live births, while in Italy, Denmark, and Finland, maternal mortality is 4.2 or lower. 

In America’s rural states, the rates are much worse. In 2018, Georgia’s maternal mortality rate was 46.2 deaths per 100,00 live births. In Louisiana, it was 44.8, and in Arkansas – 34.8. 

In those areas, non-Hispanic Black women, American Indians and Alaska natives face higher maternal mortality, as do low-income women. 

And according to the CDC, more than 60%of those deaths are preventable. 

In a report from nine states’ maternal mortality committees, researchers found that while some deaths could be attributed to patient or family factors, such as lacking the knowledge of when to seek help, others could be linked specifically to healthcare providers giving misdiagnosis or ineffective treatments. 

“While the Nine Committees most commonly identified patient factors, the patient factors identified are often dependent on providers and systems of care…The following were the most common recommendation themes that the Nine Committees also estimated to have the largest potential for population-level impact if implemented: adopting levels of maternal care, improving policies regarding prevention initiatives, enforcing policies and procedures related to obstetric hemorrhage, and improving policies related to patient management,” the committees wrote in their policy paper.

Authors of the Rural Health Research Center’s paper say lack of access to facilities may be a contributing factor as well. 

“In 2014, 54% of rural counties nationwide did not have hospital-based obstetric units. This trend of loss has continued; between 2014-2018, approximately three percent lost hospital-based obstetric units. Hospitals that remain open after obstetric services close may encounter challenges providing emergency births or managing other obstetric complications,” the group wrote. 

To combat that, rural healthcare providers need training in emergency obstetrics. By surveying hospitals in rural areas across the country, researchers found that what healthcare providers say they need is hands-on simulations of different obstetrics services like labor and delivery, cesarean sections, and neonatal resuscitation training. 

“Many respondents indicated that emergency obstetric situations arise infrequently, and in that event, clinicians rely on past experiences with childbirth. Newer clinicians may not have this experience, and simulation training and basic childbirth skills were cited as beneficial for these instances. Respondents also cited emergency situations, such as supporting delivery in a parking lot or inside a car as reason for needing hands-on simulation training,” Mary Gilbertson, the brief’s lead author, said.

That training, Gilbertson said, could save lives. 

While nearly 70 of the respondents said there was training available for emergency obstetric care, nearly 80 percent said that more training and resources are needed to handle emergency situations. According to the brief, that could include simulations, which in turn requires equipment such as mannequins and means of sharing resources with other facilities. 

Researchers found that while training is available to hospitals, the survey’s respondents said that training was either only offered virtually, inconsistently, or too infrequently, or that the hospitals didn’t have the dedicated funds or time to commit to the offered training. 

But the brief’s authors point out the fact that some of those respondents put down that any training would be good to have. 

“It is worth noting that a substantial number of rural hospitals answered that “any obstetric training” or “basic childbirth skills” would better prepare them to provide emergency obstetric services, showing the need for an increase in basic obstetric training generally,” the report said. 

“Altogether, the responses suggest that rural hospitals are in need of more frequent and accessible obstetric training to better handle emergency obstetric situations. This is especially critical given the continued trend of hospital-based obstetric unit closures in rural communities nationwide.”  

Gilbertson said their research also found that rural facilities sometimes lack the surgical capacity to handle an emergency birth. 

“One of the troubling elements of the survey was the limited surgical capacity in rural facilities, where surgical intervention during childbirth is sometimes a necessity. Our study was based on (World Health Organization) Guidelines for emergency obstetric situations, and only 11% of our respondents met basic standards of the WHO guidelines to appropriately manage emergency birth situations,” Gilbertson said. 

For rural residents facing pregnancy, the training could mean life over death.

“To ensure pregnant residents, regardless of geography or demographics, are able to experience a safe and healthy birth, rural hospitals without obstetric units need access to training that supports clinicians to safely provide these services,” the brief stated.