Maternity Deserts

A couple months ago, a mini documentary was released titled “Maternity Deserts.” I just got around to watching it tonight, and feel it is worthy of discussing here.

I think if you could sum up the documentary with one quote, it would be this appalling statistic which was shared:

Between 2004 and 2014, 179 rural counties (9% of all rural counties) in the United States lost hospital based obstetric services.

Katy Kozhimannil, Associate Professor and Director of Research at University of Minnesota

The film then rightfully proceeded to address issues of institutional racism and health inequities, and shared a few families’ stories along the way. Given my role as a birth worker, I was already very familiar with the themes shared in the film, and felt that little news was added to this story which I have read in numerous articles. Still, it was nicely put together, and the individual stories added some sweetness and depth.

As a white woman, I almost feel I have no right to make any comments beyond this point, but for the sake of truth-seeking, I’m going to risk offering some negative feedback, anyway.

I’ll start, for the sake of context, by sharing my own story. I lived in a rural county in Virginia during my first pregnancy, at age 23, and had no maternity insurance, thanks to the fact that pregnancy was considered a pre-existing condition for which a minimum of 6 months of expensive coverage prior to conception was required (this was in there era before Affordable Care Act had been enacted). My husband and I were forced to shop around for care and pay out of pocket for our earlier-than-planned pregnancy. Guess what we found?

My first appointment at our local, rural obstetrics office had me in the waiting room for 2 hours. I finally met with the doctor, but it was for less than ten minutes, and then we paid over a thousand dollars for some simple blood work. Afterwards, I discovered a group of midwives in more population dense Norfolk, VA (a 1 hour 15 minute drive east of us), who would have done all of that bloodwork, plus my 10 months or so of appointments, plus the birth itself, for under $2,000. The hospital in my small rural city, in contrast, was suggesting my costs would probably be around $5,000 (for a natural birth only — not counting interventions). We kept a mileage log of all of our trips back and forth to Norfolk and were able to deduct the cost using the IRS mileage rate, so even though it sort of felt expensive to drive that far all the time, we at least were given a credit on our taxes. I ended up extremely pleased with the care I received from my midwives! Then, in 2017, the hospital in my rural city closed it’s doors to birthing women, citing low demand as the culprit behind the supposedly financially unsustainable unit.

I know this isn’t the case, but if all the OB clients being served by rural hospitals were like me, then what is the reason for these units closing? Even though the hospitals claim reduced demand for services has driven closures, interviews and caricatures in the film suggested that, there is still a great need for OB care in the areas losing services. Is it because health care consumers like myself — who have the private transportation available to explore a wider market — were choosing better and more affordable options elsewhere, that these rural hospitals did not have enough volume to make ends meet? If that is the case, however, then here are my questions: why was the OB I met with (twice, actually) so extremely busy with her patients that we had to wait for 2 hours to be seen and could only meet for 10 minutes or less? That would seem an indicator that they have plenty of volume, nay?! The other question is this: have any of these rural practice administrators taken an economics class? Because the rate that I was paying for 45 minute long visits with my Norfolk provider (with practically no wait time) was waaay cheaper than the rate for the small town doctor! Usually, per supply and demand logic, if demand is down, then prices are lowered, and if demand is high, then prices are raised. The prices at my rural location, however, were high. So, did the administrators just need to retake high school economics? My high school economics teacher thinks so.

I know this is a bit of an impulsive thing to say based on my personal anecdote (and the similar anecdotes of my neighbors from the rural city we lived in), but I’m calling BULL$#;+. There is much more to the story than is being shared.

If the “maternity deserts” are such a major health problem, then we need to investigate a bit deeper into what the operations were like in the places where closures have happened. Was there poor management? High pay expectations from physicians in spite of the low cost of living for their chosen locations? Maybe a “who moved my cheese?” scenario where obstetrical practices who thought they had a monopoly were unwilling or too slow to make adaptations as young college graduates increasingly flocked to urban centers, rather than return home to their roots? Perhaps it was just the fact that in small towns, everyone knows your business before you do, and for that reason, a single negative birth experience could cause a dearth of patients willing to trust the local OB group. Anyway, I have a feeling the answer is not quite as simple as the film tried to make it out to be.

I do LOVE the midwife from Albany, GA in the film, who stated that she does this work as service, and not to become a millionaire. Implicit in her comment is the idea that purpose — a higher calling — is what drives her to care for her clients in such a warm and generous manner. It begs the question — if medical students did not graduate with such massive debt, and/or if young doctors (and young pre-meds drawn to the medical field) were not expecting great pay for all their years of schooling, would this situation be different? I don’t know how easy it would be to change doctor culture, but for starters, maybe we need to stop telling our children that doctors are wealthy, because research shows they are relatively poor for their level of income (“under accumulators of wealth” is what The Millionaire Next Door calls them, but “poor money managers” would be just as apt). Maybe we need to stop modeling for our kids a lust for luxury vehicles that we see doctors drive, or lust for whatever other material fluff high incomes can purchase. These seemingly innocuous cues we send our children are exactly why people who have material lust desire to go to medical school (though, to be clear, this is a generalization and does not apply universally).

Finally, I’d like to convey that I’m really disappointed by the documentary’s modeling of external locus of control (or victim mindset, basically). This is the predominant locus of control featured in almost every documentary ever, unfortunately, so I can’t completely blame the producers of this film. It’s an industry wide trend. Or maybe whiners just love documentaries. I don’t know. However, it would be wonderful to see more stories featured where someone says, “Things were falling apart around me, and I just got up and walked away, and my life got better.” Taking personal responsibility for one’s well being, even when it requires the inconvenience of moving, or of traveling further to get the care you need, is not such a bad thing, and can lead not only to healthier outcomes, but also a greater sense and ownership and pride in the experiences chosen out of free will.

Have you watched the film Maternity Deserts? If so, what are your thoughts?

Find the film here:

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