Rural Health: "Being jolted around in an ambulance on rural roads, in full-blown labor, is not fun."

Sep 6, 2017

All year long, the Alabama Public Radio news team has been investigating rural healthcare in the state. Studies often list Alabama as having the worst infant mortality rate in the nation. One factor is the lack of maternity units in rural hospitals in Alabama. This can lead to premature births or delayed care, which are often blamed for early infant death. APR’s Pat Duggins has more on a hospital business model that could help, but possible changes to the Affordable Care Act might make matters worse…

“It’s hard for us to support each other, because we’re kind of just surviving," says Kendal Gilchrest.

We met her during our story on getting smaller hospitals in rural communities. We spoke to Kendal and her husband Eric at their home in Perry County. That’s one of seven rural counties in Alabama with no hospital. Eric summed their situation up this way…

“My son falls out of bed, middle of the night, it’s two o’clock in the morning, and he wakes me up and he has blood rushing down his face," Eric says. "He had gashed his, the corner of his eye open, and there’s blood all over his face. It’s two o’clock in rural Alabama, what do you do?”

The Gilchrest’s prefer the medical specialists they can get in Birmingham—that’s a three hour round trip from Perry County. Their son was okay—but the story doesn’t end there. The Gilchrests have three children. Kendal recalls the pregnancy that might have made it four…

“Early on, I got sick. And, I thought it was just a stomach bug. I’m playing phone tag with this practice that I barely know ninety miles away, talking to on-call physicians, trying to weigh is it worth driving a hundred and eighty miles round trip just be told that I have a stomach bug. I end up choosing not to go in because I have two other children at home. Then, about five weeks later when I go to my monthly appointment, I find the baby had died."

“Labor’s not fun anyway, but being jolted around in an ambulance on a rural roads is worse. It is painful,” says Ashley King. 

If there’s anyone who can sympathize with Kendal Gilchrest, it’s King. She’s had her own problems with rural healthcare during childbirth. King lives in Hale County southwest of Birmingham. And, how many hours in an ambulance are we talking about?

“It was two and a half…to three.”

More on King’s story in a moment.

A four month old is getting a checkup at University of Medical Center in Tuscaloosa. This hospital in west central Alabama attracts pregnant women from rural counties up to ninety miles away. That’s roughly twenty four counties.

“Well, the average patient either does not have a job, or works in a fast food restaurant, a gas station," says Dr. Catherine Skinner, who directs the Obstetrical Unit at the center. She says many of her patients from rural Alabama tell a similar story when the baby comes…

“They will need transportation, so they’ll have to get their friend to drive them. That friend will probably miss work the next day so they lose that income. They need gas money to get here. And, child care if they have other children.”

That includes one out of every five pregnancies That Dr. Skinner handles.

If you go by the numbers, Alabama has fifty four rural counties. Seven of these counties have no hospital at all. Of those that are left, only a fraction delivery babies…

“Today, only sixteen,” says Dale Quinney. He’s executive director of the Alabama Rural Health Association. Quinney says it often boils down to the cost…

“You have to have the specially trained staff, and of course your specially trained family medicine physicians, or OBGYNS. You have to have the labs, the incubators, special equipment. Those cost money. And you have to have that whether you have ten births or a thousand.”

And, the financial burden isn’t just because of staff and equipment…

“With obstetrics, there are huge liabilities as well," says Joseph Marchant. He’s CEO of Bibb Medical Center in the rural town of Centerville south of Birmingham. We met him during our story about smaller hospitals for rural communities. Marchant’s hospital stopped delivering babies in the year 2000.

“There’s a lot of risk. And when you have risk that certainly means there could be substantial costs or problems if you have a bad outcome," he says.

And, to hear Ashley King tell it, her case appears to fall into that category. She first became pregnant when she was just sixteen years old. Then, roughly twelve weeks before she was due…this happened

“I started having chest pains, labor pains, migraines, I was blacking out…driving down the road in Dallas County,” she recalls.  Dallas County is about an hour east of where King lives. Just heading home wasn’t an option because Hale County only has a small clinic… “They can do stitches, and broken bones. Other than that, everything else goes to Tuscaloosa or Birmingham," she says.

King and her baby needed specialized care at UAB Hospital in Birmingham. That’s two and a half to three hours away. “I remember bits and pieces of the ambulance ride," she recalls. "I remember first getting in the ambulance and how bad it hurt to be jolted around in full blown labor. It’s not fun.”

And King isn’t alone. Women in Bibb County faced similar challenges finding obstetrical help when Bibb Medical Center stopped delivering babies in the year 2000.  Joseph Marchant was in grade school when that decision was made. When he took the job of CEO at Bibb, he felt something was missing…

“We had people who were delivered here in the 1960’s and 70’s and will come back and say how the campus has changed," he says. Two years ago, that led Marchant to pose a question to the hospital’s board and its staff members… “What would re-opening obstetrics mean to the other parts of the system?”

In 2015, after juggling the budget at Bibb Medical Center, they did…

The newly opened maternity unit has four delivery rooms and a small waiting room. Bibb celebrated its one hundredth birth since deliveries started again in 2015, and financially it’s breaking even. But, all may not be well. How the system works that could be its greatest weakness. Marchant says the doctors that handle births at hospital don’t technically work for him…

“The group that’s covering the labor and delivery that isn’t employed by the hospital. They actually operate a medical practice here in Centreville. And they’re an independent that work out of a federal qualified health center.”

That federally qualified health center is paid for by a grant through the Affordable Care Act, or Obamacare. And, all the talk in Congress about repealing and replacing the Affordable Care Act has Marchant wondering how long the unit can stay open…

“We look at what’s working, we look at what’s not working. We try to effect the things that don’t work positively, and we try to enhance the things that do work. It seems, in Congress that’s not the way they do things.”

Back at University Medical Center, a rural mother to be is getting a check-up after driving forty five minutes. Or more specifically, her grandfather drove her and her husband to the appointment. If Bibb County loses federal funding, and its labor and deliver unit closes, it could mean more than just extra work for the doctors in Tuscaloosa.

“We know that when labor and delivery units close, the infant mortality rate in that county rises," says Dr. Catherine Skinner. And, that could lead to more examples of what she calls her nightmare patient scenario.

“She knew she was having contractions. She knew it was time. And, she arrived too late to be able to stop labor and the baby was born prematurely.”

And, studies indicate Alabama already has one of the highest infant mortality rates in the nation.