Brooke A. Flinders, a double graduate of Frontier Nursing University, will become its next president on Aug. 1

Brooke Flinders

Kentucky Health News

Brooke A. Flinders, who earned her advanced degrees from Frontier Nursing University, has been named the next president of the Versailles institution. 

Flinders has extensive experience as an advanced practice nurse, educator, and college administrator. She will leave her position as a nursing professor and associate provost at Miami University in Ohio and become president of FNU on Aug. 1. She holds a Master of Science in Nursing and a Doctor of Nursing Practice degree from FNU. 

“We are thrilled that Dr. Flinders has accepted the offer to become the next president of Frontier Nursing University,” said FNU Board Chair Michael Carter.  “Dr. Flinders’ wealth of experience as an educator, practitioner, and administrator will be a tremendous asset to our students and to our faculty and staff who support them. We are extremely excited about the future of Frontier under Dr. Flinders’ leadership.”

Flinders will succeed Susan E. Stone, who was with the university for more than 30 years, the last 23 as president. Stone will be president emeritus and chair of midwifery and nursing on FNU's board.

Flinders obtained her Associate Degree of Science in Nursing (1994) and Bachelor of Science in Nursing (2003) degrees from Miami. In addition to acute care and community-based care experience as a registered nurse and full-scope practice as a certified nurse-midwife, Flinders has been a nurse educator, nursing department chair, and associate dean.

“I am proud and honored to accept the position of president of Frontier Nursing University,”  Flinders said. “My connection to Frontier extends nearly two full decades, and I am so proud to be one of its more than 9,000 graduates. . . .  I believe wholeheartedly in Frontier’s mission to provide accessible nurse-midwifery and nurse practitioner education that integrates the principles of diversity, equity, and inclusion, and I am excited to carry it forward.”

Flinders received the 2021 Distinguished Alumni Award from Miami's nurisng department, and in recognition of their service efforts during the Covid- pandemic, she and each of her nursing colleagues received the President’s Service Medallion. Flinders became a fellow of the American College of Nurse-Midwives in 2021, as a recognition of her demonstrated leadership, clinical excellence, scholarship, and professional achievement.

“As a proud graduate of Frontier School of Midwifery and Family Nursing and Frontier Nursing University, I am eager to build upon the amazingly strong foundation that already exists,” Flinders said. “Health-care provider shortages and the maternal mortality crisis plague our country. Frontier has a long history of finding unique solutions to complex problems, and we will continue to be a leader in identifying and implementing solutions by producing highly prepared nurse-midwives and nurse practitioners who have answered the call to serve.”

FNU was founded in 1939 as the Frontier Graduate School of Midwifery by the Frontier Nursing Service, a group of nurses and nurse-midwives who have served rural areas of Kentucky since 1925. Formerly located in Hyden, FNU completed its transition to Versailles in 2022 and is "one of the largest not for profit universities in the United States for advanced nursing and midwifery education, its website says.

Senate sends House bill to have Medicaid cover midwife services

By Sarah Ladd
Kentucky Lantern

Kentucky Medicaid would begin covering licensed certified professional midwife services under a bill the state Senate sent to the House Thursday by a vote of 34-3, after little discussion.

The primary sponsor, Sen. Shelley Funke Frommeyer, R-Alexandria, said the legislation is a chance to “innovate” in Kentucky.

Under her bill, she said, a Medicaid-insured patient with a low-risk pregnancy could have the costs of using a certified professional midwife for a home birth covered by the federal-state program, which already pays for about half of all Kentucky births.

State Sen. Shelley Funke Frommeyer, R-Alexandria

Funke Frommeyer, who is also an advocate for freestanding birth centers in Kentucky, cited previously reported numbers showing the state recorded 177 home births in 1988 and 900 in 2021, said mothers should have “maternity care options,” and gave some:

“We see people doing one of the following: They may forego the care truly desired and plan a hospital birth, which is covered by Medicaid. They may make sacrifices and find a way to pay out of pocket for LCPMs. They may have a home birth without a trained provider — or sometimes without anyone at all.”

Sen. Karen Berg (D-Louisville), a physician, asked if a midwife could do an episiotomy if needed, and Funke Frommeyer said the procedure is within the scope of their practice. An episiotomy is an incision in the tissue between the vagina and the anus, which may be necessary if the baby’s shoulder is stuck behind the pelvic bone, among other reasons. Midwives may also suture the incision.

Free-standing birth centers would no longer be subject to 'competitor's veto' under bills awaiting votes in Senate and House

Sen. Shelley Funke Frommeyer

By Melissa Patrick

Kentucky Health News

Bills to exempt free-standing birth centers from Kentucky's certificate-of-need law have cleared committees in the House and Senare and are poised for floor votes, despite opposition from the chair of the House health committee and two legislators in the sponsor's home region of Northern Kentucky.

"It's still important to have hospitals that have great options for giving birth, but consumers are asking for more," Sen. Shelley Funke Frommeyer, R-Alexandria, told the Senate Licensing and Occupations Committee Feb. 21. "Consumers are asking for free-standing birthing centers. . . .  Kentucky is one of only eight states that does not offer free-standing birthing centers." 

Funke Frommeyer, a freshman senator, is the sponsor of Senate Bill 67 and veteran Rep. Jason Nemes, R-Louisville, is the sponsor of House Bill 129, the latest version of legislation he has sponsored in previous sessions. 

Mary Kathryn DeLodder, director of the Kentucky Birth Coalition, told the Senate committee that Kentucky hasn't had a freestanding birthing center since the late 1980s, although it has administrative regulations for licensing them and qualifying them for Medicaid reimbursement. 

But the state's certificate of need law requires a propsoed center to prove that there is an unmet need for its services before it can open, a process that allows providers and hospitals to challenge the would-be competitor's application. DeLodder said the CON law is sometimes called "the competitor's veto," adding, "It is not about safety, but it's about market share." 

Frontier Nursing University said in a letter of support for the bills that it did a feasibility study in 2018 of establishing a free-standing birth center on its campus in Versailles and found the CON law was "the major barrier. . . . The CON process has been lengthy and effective at the goal which appears to be to allow hospitals to block the development of FSBCs regardless of the benefits to the women of Kentucky." 

Christy Peterson, an advanced practice registered nurse and certified nurse midwife, explained to the Senate committee what a freestanding birthing center is: "A freestanding birth center is a health-care facility. It offers a home-like setting where families can receive maternity care and give birth with appropriate levels of intervention. These facilities are not hospitals and they do not perform C-sections or anesthesia. They provide evidence-based care using the midwifery model of care and use informed consent and shared decision-making. One of the key components of the birth center is continuous risk screening. . . . Not everyone is a candidate for birthing at a freestanding birth center. There are mothers who should be in the hospital setting, and so birth centers don't just take on anybody." 

She also pointed to studies that show that care in freestanding birth centers is "safe, cost-effective and leads to excellent outcomes." 

Meredith Strayhorn, a Campbell County resident and senior certified professional midwife student, told the committee that in 2022, 34% of Kentucky births resulted in Caesarean sections, ranking the state in the top 10 for the procedure. She said C-section births have "been associated with maternal mortality and severe maternal morbidities." 

She added, "Research shows that when low-risk women give birth within the midwifery model of care, there are lower rates of Caesarean. That's also decreasing the rates of repeat cesareans and the various complications that follow. This will also save thousands and thousands of dollars for the state."

Sen. Donald Douglas, R-Nicholasville, a physician, voted against the bill, saying, “I don’t see it as a competition issue; I see this as a patient-care issue." Douglas said he was not convinced that birth centers would result in the best care and improved health outcomes. 

The committee approved the bill by a vote of 9-2, with Sen. Chris McDaniel, R-Ryland Heights (Kenton County), casting the other "no" vote. Sen. Damon Thayer, R-Georgetown, said he voted "yes" to get it out of committee, but said Douglas's concerns should be noted. 

Rep. Jason Nemes

The next day, there were no dissenting votes as the House Licensing, Occupations & Administrative Regulations Committee approved Nemes's bill. Nemes told the committee that each year he has been presented the legislation it has been improved. 

"The touchstone for me has been safety," Nemes said. "We want to make sure that this is a safe environment for women to have their babies."

He said in Kentucky mothers can have babies in a hospital or at home, and he thinks many who are choosing home births would choose a birthing center if it were available, "which I believe are safer for those individuals." He noted that the American College of Obstetricians and Gynecologists supports free standing birth centers. 

The maternity mortality rate in Kentucky is "alarmingly high," especially among women of color, said Kazia Bryant, executive director of Mama to Mama, a Louisville nonprofit support group for mothers.

"The more and more that Black women and women of color learn about the climate and rate of maternal deaths that plague our community, the more and more we are searching for alternatives to birth our babies," she told the committee.

While no House committee member voted against the bill, Rep. Kim Moser, R-Taylor Mill, passed, along with Rep. Mike Clines, R-Alexandria.

Moser is chair of the House Health Services Committee. She agreed that Nemes had improved the legislation, but she noted her work as a neonatal intensive-care nurse and said, "I am concerned about safety." She asked if there was a geographic requirement for transfer agreements to hospitals, and was told that there is not one that is related to distance between the facilities. 

Nemes said he considers birth centers safe and secure because their licensing requirements are strict, women are making a choice to have their babies there, and the centers constantly screen their patients to make sure they have low-risk pregnancies.

Both bills would also require the state Cabinet for Health and Human Services to update and modernize its regulations, including requiring accreditation by the Commission for the Accreditation of Birth Centers, compliance with the American Association of Birth Centers standards, and consistent plans for transfer and safe transport to a hospital as needed.

If passed, the legislation would be called the Mary Carol Akers Birth Centers Act, after a certified nurse midwife who wanted to open a birthing center in Elizabethtown and was thwarted by the cabinet and the state Court of Appeals. She exhausted her resources and left the state, Birth Monopoly reports.

Too many pregnant Kentuckians and babies in 'maternity deserts' and Ky. has no birthing centers; midwives say they could help

Laura Browning, an Eastern Kentucky doula and midwife student, with her four children in a selfie.

By Sarah Ladd
Kentucky Lantern

During three of her four pregnancies, Laura Browning drove three hours round-trip past hospitals to get prenatal care from midwives in Lexington, the only place that offered what she needed.

She even made the trip while in labor with her first baby, feeling that “the care that I was receiving” from midwives “was worth that risk” of birthing in her car.

As deaths from pregnancy rise in the United States, Browning and other advocates say Kentucky could fill gaps in prenatal care by educating and certifying more midwives, attracting more to the doula profession and encouraging the creation of freestanding birth centers in the state.

The shortage of care for pregnant people is documented in a recent March of Dimes report, “Nowhere To Go: Maternity Care Deserts Across the U.S.”

More than 2 million Americans, most of them rural, live in “maternity care deserts,” defined in the report as having “no hospitals providing obstetric care, no birth centers, no obstetrician/gynecologist and no certified nurse midwives.”

In 2021, 14.2 percent of mothers received inadequate prenatal care, says the March of Dimes, which gave Kentucky an F on its annual report card this year, making it one of just nine states (plus Puerto Rico) to get a failing rating.

Almost half of Kentucky’s 120 counties — 48% — are maternity-care deserts, according to the March of Dimes study.

Prenatal care provided by midwives has been shown to prevent costly complications in mothers and babies, including cesarean deliveries and low birth weights. The March of Dimes reports that “midwifery care has been associated with an increased chance of having a low-intervention birth and lower cost of care due to significantly lower odds of medical intervention.”

Yet only about 8% of births in the U.S. are attended by midwives. In Kentucky, 700 to 800 babies are born every year outside hospitals, and are usually delivered with midwives present. There were 51,688 live births in Kentucky in 2020.

Certified nurse-midwives and certified midwives are accredited by the Accreditation Commission for Midwifery Education and pass national exams after graduate-level studies, according to the American College of Nurse Midwives.

The midwives and midwifery students who spoke with the Kentucky Lantern expressed passion for serving their communities and reported low rates of transfer to hospitals, easing the burden of hospital staff shortages.

Mary Harman

Also, midwives can provide important inclusive services to people who are “beyond the binary,” said Mary Harman, the only midwife within a two-hour drive from Pike County who travels that far for clients.

“Not every person needs an OB-GYN,” Harman said, but they cannot accept insurance or Medicaid, which is another barrier to their practice, Canary Nest Midwifery.

Research also suggests that freestanding birth centers, which are staffed by midwives and offer holistic birthing options for people who qualify, reduce the cost of care while producing higher patient satisfaction.

Kentucky is in the minority of states that have no freestanding birth centers. The American Association of Birthing Centers reports that more than 384 freestanding birthing centers are operating in 37 states and the District of Columbia, a 97 % increase since 2010.

Advocates attribute the lack of birthing centers to the difficulty of obtaining the state-required certificate of need in the face of opposition from hospitals that can mount costly legal battles, such as the one waged by three hospitals against a retired Army officer who tried to open a birthing center in Elizabethtown.

She prevailed in Franklin Circuit Court, which overturned a hearing officer’s denial of a certificate of need, but was forced to give up in 2017 when the hospitals won on appeal.

Rep. Jason Nemes, R-Louisville, has sponsored legislation in the past to remove the certificate-of-need requirement for birthing centers and will continue to support them. He has called the law mandating the certificate “very cumbersome.”

In 2019, the legislature did take action aimed at licensing more certified professional midwives, after the Kentucky Hospital Association and Kentucky Medical Association dropped their years of opposition.

The results have been underwhelming. In the almost four years since the law was enacted, the number of certified nurse-midwives and certified midwives in Kentucky has increased by only 12 — to 131 providers, reports the American Midwifery Certification Board.

Some hospitals have doula and midwife programs, such as the University of Kentucky’s midwife clinic and Norton Healthcare’s doula program.

Among the barriers to increasing midwifery care in Kentucky is the $1,000 cost of renewing a Certified Professional Midwife license. Compare that with $110 in Tennessee, $200 in California or $322 in New York.

Earlier this year, Kentucky took advantage of an opportunity in the American Rescue Act Plan to put in place one of the March of Dimes recommendations by increasing postpartum care under Medicaid from 60 days to 12 months. The change will allow an estimated 10,000 Kentucky mothers to maintain their health coverage for one year after giving birth.

Stark racial disparities in maternal mortality

The March of Dimes reports that deaths from pregnancy are increasing in the United States, which already has one of the highest maternal death rates among high-income countries.

About 900 women in the U.S. died from pregnancy-related issues in 2020, up 14% from 2019 and up a whopping 30% from 2018. Sixty-three percent of pregnancy-related fatalities are preventable, says the report. In Kentucky, preterm births increased in 2021 to 12%, up from 11% in 2020.

Pregnancy is especially dangerous for Black Americans, who are three times more likely to die from pregnancy than their white counterparts. Conversely, white women are more likely to have access to good prenatal care than Native, Black, Pacific Islander, Asian and Hispanic women. 

Those stark disparities are not lost on the expectant mothers who turn to doulas to guide them through their pregnancies and births. Doulas provide moral, physical or other support to pregnant people throughout pregnancy, delivery and postpartum.

Meka Kpoh, a doula in Louisville, founded the nonprofit Black Birth Justice to help mothers and babies get off to a healthy start all the way through the critical postpartum period. She has been in birth work long enough that the March of Dimes report wasn’t news to her.

She said these gaps in care should be taken seriously.

“The maternity care deserts aren’t going to just erase themselves,” said Kpoh, who is also in training to be a midwife. “It’s not going to be like next year there’s going to be a new hospital and every community has a hospital at least 30 to 40 minutes away. That’s not going to happen, at least not anytime soon. So it’s really important for there to be options for families like licensed certified home birth midwives.”

Kpoh said many of the clients she sees are driving hours from rural areas. “It’s really insane to me,” she said, “that we are their only option.”

In addition to more doulas and midwives, she said Kentucky needs freestanding birthing centers.

“Pregnant people are driving three hours just to get prenatal care, just to give birth, just to have postpartum appointments,” she said. “It’s ridiculous.”

To get the kind of care they want, Kpoh said many pregnant people end up facing a difficult choice: “Either they drive three hours to a hospital or they catch their baby by (themselves),” she said, adding: “I don’t recommend that for anyone.” 

Renee Basham, a doula, founded the nonprofit community doula program Hope’s Embrace to help pregnant people who are often cut off from help. Basham and her 30 doulas serve those who are unhoused and those with drug addictions.

“You’re not necessarily treated well if you are by yourself,” said Basham. “And so having people … vouch for you, or speak up for you or remind you to speak up for yourself … all of that … contributes to better outcomes.”

 
The stigma of going against the norm

Anihhya Trumbo, a doula who serves the Lexington area, said there remains a stigma about birth outside a hospital.

“Kentucky is a state where it’s always been preached that doctors know best,” she said. “It’s a bit of a taboo if you go outside of what is … considered the norm here.” 

Doula and midwife-assisted birth isn’t a new thing, either, she said.

“This is something that’s been going around since the beginning of time,” said Trumbo, who is also a military veteran. “We just got Western medicine and that’s what changed the norm but home birth and having the natural birth — that’s how we got here.”

Browning was so committed to midwifery care for herself that from six weeks gestation to birth, she drove three hours for her prenatal appointments. She’s now living in Laurel County but lived in Estill at the time of that first pregnancy.

Already a doula, Browning told the Kentucky Lantern that she is in midwifery school herself now “because women should not have to drive that far for care.”

“It’s definitely a need that we have here.”

Bill to certify Ky. midwives OKd after years of effort, and changes that got doctors and hospitals to end longstanding opposition

By Melissa Patrick
Kentucky Health News

Loud clapping and shouts of joy filled the state House chamber March 13 when a bill to give certified midwives professional recognition in Kentucky passed after many years of work by lawmakers and advocates.

Midwives and their advocates gathered for a photo after the March 6 House
Licensing, Occupations &Administrative Regulations Committee meeting.
Photo: Mhari Shaw, photojournalism student, Western Kentucky University

“This is not a bill about whether or not to allow home births; those are going to happen. This is a bill about making sure families who choose home birth have access to safe and competent care providers,” said Rep. Russell Webber, R-Shepherdsville, who presented Senate Bill 84 in the House.

The bill was the fourth attempt by Sen. Tom Buford, R-Nicholasville, to certify midwives. Several others had tried before him, but until this year they were met with strong opposition from the Kentucky Hospital Association and the doctors' lobby, the Kentucky Medical Association.

But both those groups, and the American College of Obstetricians and Gynecologists, went neutral on the bill after the House changed this year's version to require collaboration between midwives and health providers, rules for handling medium- and high-risk births, and an advisory council to recommend regulations to the Kentucky Board of Nursing.

Some of the council's recommendations will include guidelines for use of medications, ordering of medical tests, and policies for transfer to hospitals when necessary, Webber said.

As the bill went to the House committee, Weber told Kentucky Health News that midwives and consumers had been persistent in their efforts to educate legislators about what they do. "I almost liken this effort to a David versus Goliath situation," he said.

Rep. Chad McCoy, a Republican lawyer from Bardstown, added an amendment that would assure that no health-care provider would pick up any liability because of a midwife, and that each person involved in the care of a patient would be responsible for his or her own negligence.

Upon final passage of the bill, Sen. John Schickel, R-Union, chair of the Senate Licensing, Occupations and Administrative Regulations Committee, noted that the panel had often heard such bills. He said passage was the result of a long effort that had been contentious at times, though everyone involved continued to work toward the best outcome.

"This is really a historic day I think for health care, for the midwives, for a new day, [and] for the children of Kentucky," he said.

The changes the House made to the bill even allowed Republican Sen. Ralph Alvarado, a doctor from Winchester, to vote yes, after being one of its loudest opponents in prior years and voting no on the original version.

The bill passed on a vote of 96-1 in the House, with only Rep. Kim King, R-Harrodsburg, voting against it. The Senate concurred with the changes the next day on a 35-1 vote, with only Sen. Stan Humphries, R-Cadiz, voting against it. The original Senate vote on Feb. 21 was 32-4. The bill now moves to Gov. Matt Bevin for his signature or veto.

Buford said when presenting the bill to the Senate in February, “This is a personal choice made by these families for various reasons. We must ensure the families who choose this option have access to quality care through … the licensing of midwives.”

As it stands, Kentucky has no rules or regulations for midwives. When presenting the bill on March 6 in the House committee, Buford said, "Believe it or not, I could be a midwife today, and I know nothing about it."

Mary Katherine DeLodder, a leader of the Kentucky Home Birth Coalition, told the committee that the bill is about legitimizing midwifery, since right now you don't know what you are getting when you hire a midwife and communications about them are typically shared via social media. "It's like you have to know the secret handshake sometimes to find your midwife," she said.

She said Kentucky has about 700 home deliveries a year, and 33 states already have certified professional midwife programs. A letter on the coalition's website about the bill's passage says Kentucky has about 20 certified professional midwives.

Elizabeth Regan, president of the Kentucky Chapter of National Association of Certified Professional Midwives, told Kentucky Health News that SB 84 was about access to midwifery care: "This is what we know makes home births safe, integration into the larger health care system and building collaborative relationships."

Bill to certify professional midwives passes Senate, but no time remains to pass it through the House by normal means

By Melissa Patrick and Al Cross
Kentucky Health News

FRANKFORT, Ky. -- A bill to give midwives professional recognition in Kentucky made it out of the Senate March 27 on a 29-8 vote, over opposition from doctors. It is all but dead, with only two days left in the legislative session, though the bill's sponsor refused to declare it so.

Sen. Tom Buford

"It's not too late, but as one might say, we are at the finish line and it will be close if it does," Sen. Tom Buford said in a telephone interview. "The General Assembly always has their barrels loaded until the last day after the veto session." Legislators' final day, Saturday, April 14, is scheduled to reconsider any legislation Gov. Matt Bevin may veto.

Since the legislature postponed its last pre-veto session day to Monday, April 2, it only has that day and the veto-override day left, and the constitution requires a bill to be read in a chamber on three separate days before passage. The House would have to add the bill's contents to a Senate bill pending in the House, pass it and return it to the Senate for final approval.

Kentucky has no rules or regulations for midwives. Buford's Senate Bill 134 would create a Certified Professional Midwife Advisory Council under the Kentucky Board of Nursing, which would be responsible for setting care standards for midwives to follow and issue permits to those who qualify.

Buford said Kentucky needs a law on midwifery "because you and I, believe it or not, we could go and be midwives tonight without any training or anything. That's a scary thought."

The Nicholasville Republican said opposition to the bill comes from the Kentucky Hospital Association and the doctors' lobby, the Kentucky Medical Association, even though he has tried to accommodate them with several changes to it. He said the groups voice safety concerns, but their opposition is more likely a "turf battle," adding that "it's usually about the money."

"Remember that a midwife might perform a home-birth delivery for free, or she might charge $3,000 to $6,000 -- and at a hospital, if everything goes right, it's $20,000 if you are in and out in two to three days with no complications," Buford said.

Mary Kathryn DeLodder, a leader of the Kentucky Home Birth Coalition, told the Senate Health and Welfare Committee March 19 that the coalition has been seeking the legislation since 2012. She said Kentucky has more than 700 home deliveries a year, and 33 states already have certified professional midwife programs.

"This bill is about increasing access to the only category of care providers who are clinically trained to attend births in the home settings, and that is the certified professional midwife," she said. She later added, "Families don't rely on Facebook groups to verify if their dentist or their pediatrician is legitimate, and they shouldn't have to do that for their midwife either. . . . Opposing this bill doesn't make anyone safer."

Buford told the Senate that his bill isn't about whether or not Kentucky will have home births, "because we are," he said. "This is a question of whether you want those home births to be safe. To be a somewhat certified individual that comes into that house, knows what they are doing."

Republican Sen. Ralph Alvarado, a Winchester physician who spoke strongly against the bill during the committee meeting, filed a floor amendment with a long list of conditions that would prohibit a certified midwife from attending a home birth, prohibit midwives from performing abortions and require them to have a transfer agreement with hospitals that deliver babies. Any violation of the law would result in a Class D felony.

Alvarado's amendment got 18 votes, all from Republicans, except Senate Democratic Leader Ray Jones of Pikeville; 19 senators, half the Senate, supported it. Democratic Sen. Perry Clark of Louisville did not vote. (See roll call here.)

Buford said afterward that if the legislation becomes law, the advisory council could add some of the same requirements in the "crushing amendment," but he would prefer to leave these decisions to the Board of Nursing and not allow "men to make the decision on how a woman will have a baby."

Frontier Nursing University in Hyden helps bring better family health care to rural America with distance learning

Midwives and nurse practitioners who recently graduated from Frontier Nursing University in Hyden address the unique challenges of rural areas, including shortages of health care providers, by bringing local health care to rural communities across the country. FNU was featured in a recent report from the Robert Wood Johnson Foundation.

FNU, a graduate program that offers distance education to nurses with an interest in nurse-midwifery and family nurse practitioner and women’s health specialties, aims to build a pipeline of highly educated nurses serving in rural or underserved areas, reports RWJF, one of its funders.  Many scholars and grantees sponsored by RWJF go on to spearhead projects to improve access to high quality nursing care in remote areas, the foundation says.

“We’re trying to introduce primary care providers into rural areas in such a way that they can provide high quality care and preventive services too,” says Suzan Ulrich, associate dean of midwifery and women’s health at FNU and an RWJF executive nurse fellow.

Demand for health care is rising nationwide because of an aging population that is living longer, but sicker, with multiple chronic conditions. The need for health care providers will intensify next year, when millions of new patients will become eligible for health insurance under the health-reform law.

Rural parts of the country face unique challenges and shortages of health providers, including nurses, can be particularly acute in rural areas, said Alan Morgan, CEO of the National Rural Health Association. These nurses and other providers have less access to education programs, which tend to be located in more densely populated areas. Programs that offer advanced degrees, from the baccalaureate to the doctorate, can be especially difficult to access for students living in rural areas, according to RWJF.

Identifying and educating nurses from rural areas is a key goal of FNU, which offers distance education programs that enable students to remain in their home communities and a “bridge” program that allows nurses with associate’s degrees to move more easily into master’s and doctorate programs. “These students really love where they live,” Ulrich said. “If we can educate them to stay within their communities, then those communities are going to have a provider who’s going to be there a long time." (Read more)

Fewer maternity wards, fewer options for rural Kentucky women

The closing of the maternity ward at Mary Breckinridge Hospital in Hyden last year is part of a larger trend, leading to fewer options for women living in rural areas of the state, contends an op-ed piece in the Daily Yonder, the national online rural journal.

"There's a big dose of irony here," writes Kelli Haywood, a Lamaze certified childbirth educator. "Mary Breckinridge Hospital, located in Appalachian Kentucky, is named for a pioneer in maternal and infant health who brought the nurse midwifery model of care to the United States."

"With the closing of this facility, women of the entire southeastern Kentucky region lost an important and rare option for birth, as well as the expertise of the hospitals' midwives, most of whom either moved to other parts of the state or left Kentucky altogether," Haywood continues.

Similar closures are happening in other states as well, including Virginia, Ohio and Alabama, which has "lost 26 options for maternity care since 1980," Kaywood states. The reason for the closures has to do with numbers and reimbursements. Mary Breckinridge Hospital averaged just 12 births monthly, but in order to break even financially needed to attend more than twice that. In some cases, an aging population is leading to fewer births, but some rural areas are still underserved when it comes to maternity care.

The consequences means rural women will have to travel further, and incur related expenses, to receive maternity care. That will put pressure on other rural hospitals, which will in turn have consequences. Studies show medical interventions, such as cesarean sections, are more common in rural hospitals where "care providers are feeling the pressure of a high patient load," Haywood writes. But these procedures carry risks — a Mayo Clinic study showed the risk of death to the mother was four times greater when she delivered via caesearean section rather than vaginally — and are more costly. An uncomplicated vaginal birth costs between $3,000 and $6,000, while a c-section birth can be between $10,000 and $40,000, Haywood contends.

Haywood points to midwifery and free-standing birth centers as possible solutions, but admits there is no easy answer. However, a solution is needed. "In a healthcare system where maternity care providers are facing the highest malpractice premiums of any physicians, and as obstetricians become fewer in number, it is not surprising that we are seeing closures of maternity services in rural hospitals and increases in the rates of medical interventions. Rather than fighting to keep a system that is not benefitting rural women, healthcare providers, or state governments, we need new models of care and ways in which that care can be obtained safely, close to home." (Read more)