By Kristi Birch

When Eleanor Hawes went into labor with her second son 67 years ago, it took two hours to drive 24 miles in a blizzard to the hospital in Dodge City, Kansas, following the township maintainer, who plowed snow off the dirt road.

“We were very lucky that we had a hospital 24 miles away,” remembered Hawes, who will be 92 in May. “Many of our friends had to drive for a couple of hours.”

Unfortunately, despite advances in medicine, not enough has changed since then in terms of access to obstetrical care in rural Kansas. Over the last 10 years, many rural hospitals across the country have closed, including eight in Kansas — or have stopped offering maternity care altogether. The reasons for these shutdowns include shortages of specialized providers such as obstetricians and sonographers and the financial stress of maintaining a costly labor and delivery unit combined with insufficient reimbursement and a relatively small number of births.

In Kansas, 46% of women live in a maternal care desert, according to a report released in September 2024 by the March of Dimes. This term refers to a county, often rural, with no hospitals or birthing centers offering obstetric care and no providers trained in obstetrics. Kansas is second only to Texas in the number of counties that are rural.

Geography matters. Hospital closures are associated with more babies being born early, more infants admitted to neonatal intensive care units and more women dying as a result of pregnancy or giving birth. Access to quality perinatal care, which includes care during pregnancy and after the birth, is critical to the health of newborn babies and their mothers.

Meanwhile, the rural Kansas hospitals and providers that still offer obstetrical services are under pressure to care for more people. That includes women with high-risk pregnancies, most of whom live more than 30 miles from the nearest facility that offers high-risk care. Hawes said her great-granddaughters were delivered at Children’s Mercy in Kansas City, more than 300 miles away from home, because of their health issues.

The University of Kansas School of Nursing is working to do something about it. In 2024, KU Medical Center was awarded a four-year, nearly $4 million grant from the Health Resources and Services Administration (HRSA) to improve pregnancy and birth outcomes in rural Kansas. The grant is part of HRSA’s Rural Maternity and Obstetrics Management Strategies (RMOMS) program, which was created to increase access to quality maternal and obstetrics care in rural parts of the United States.

“The overall outcome that we’re trying to effect with RMOMS is a decrease in maternal mortality and morbidity through aggregated, coordinated and sustained risk-appropriate care,” said Karen Weis, Ph.D., RNC-OB, FAAN, interim dean for the Salina campus of the School of Nursing, Christine A. Hartley Rural Health Nursing professor and research director at the Kansas Center for Rural Health and the principal investigator on the HRSA grant. “And this is by building a system to provide the best obstetrical care we can in a rural environment.”

Knowledge is power

The HRSA grant will be used to create a sustainable model of quality obstetrical services and care. This model will be piloted at three hospitals in central and northwest Kansas that are part of the Sunflower Health Network: Gove County Medical Center in Quinter, Mitchell County Hospital Health Systems in Beloit and Smith County Memorial Hospital and Rural Family Practice in Smith Center.

A number of other facilities in the Sunflower Health Network, which comprises 27 hospitals, have closed their obstetric services, noted executive director Heather Fuller.

“And these hospitals that are still doing obstetrics, their patients have about doubled in volume, so they’re trying to keep up,” she said.

Weis is quick to point out that the grant is not an indictment of the care rural hospitals currently provide; the mission is to support them.

“These hospitals are providing wonderful care and doing an outstanding job at what they do,” she said. “But people don’t realize the immense requirements that exist with providing obstetrical services.”

Those requirements include having two providers capable of providing obstetrics at all times, surgical capabilities, anesthesia and two nurses qualified to provide obstetric care. And it is a challenge to train staff in obstetrics, and keep them practiced, at a hospital that might deliver one or two babies a month.

“In rural care, you need to keep that access for the community and surrounding communities, but it’s hard to get your staff trained and make sure they’re staying up to date so they can provide high-quality care,” said Nikki Cleveland, MSN, chief nursing officer at Mitchell County Hospital, which draws patients from a 60-mile radius for maternity services.

Cleveland is looking forward to the education that the HRSA grant will provide for physicians, nurses and first responders. This education includes the Advanced Life Support in Obstetrics training course in how to handle obstetric emergencies, offered through the Smoky Mountain Family Medicine Residency program in Salina.

Weis said there will also be an immersion program for nurses from these rural hospitals, in which they will take three days of classes and simulation at KU School of Nursing-Salina and learn about fetal monitoring and high-risk situations. They will then work two 12-hour shifts at Salina Regional Health Center, which has over 390 beds and serves a 14-county area.

“There are enough deliveries there that they will get a chance to watch and to participate,” said Weis.

Better imaging

A key part of the program is creating a referral system to provide virtual consultations with maternal-fetal medicine specialists. These physicians are obstetricians who have completed an additional three years of training to manage
high-risk pregnancies.

Smith County Memorial Hospital, which does not have such a specialist on staff, currently refers many of these cases to an OB-GYN physician in Hastings, Nebraska, who drives an hour to Smith Center once a month to see these patients.

“All of our providers are family practice physicians,” said Sarah Ragsdale, MBA, BSN, chief executive officer at Smith County Memorial Hospital. “That’s one thing RMOMS is going to provide for us: a referral pattern with maternal-fetal
medicine doctors.”

These referrals will utilize telemedicine and teleradiology, the transmission of images such as ultrasounds, CT scans and X-rays from one location to another. Teleradiology enables these specialists to review images and cases referred to them by rural hospitals remotely.

Brian Brost, M.D., and Marc Parrish, D.O., both professors of obstetrics and gynecology at KU School of Medicine with fellowship training in maternal-fetal medicine, are leading this effort. They are co-investigators on the grant.

Teleradiology will also be used to boost rural hospitals’ ability to perform obstetric sonography. Also known as prenatal ultrasound, obstetric sonography is challenging because it requires a number of different measurements, and babies grow and change positions in the uterus. Yet sonography training typically includes just a couple of months focused on obstetrics.

Using a simulator known as a ScanTrainer, rural sonographers can train and practice from their own hospital at their own pace. Brost and Parrish can then review these practice images and offer feedback from Kansas City.

“This training is important because if we get good images, if we get early identification of a fetal problem, we can get the patient to a higher level of care,” said Brost.

Creating collaboration

The grant also will be used hire a nurse navigator to help ensure a continuum of care and coordinate care between the rural hospitals and the referral hospitals; develop system-wide review of high-risk patients; create standardized protocols and policies for care and for maternal transports, blood sharing and staff sharing; and develop the capability for long-term data management and sharing
among hospitals.

The success of the project will be measured by early and consistent prenatal care, reductions in the rate of low-birth weight babies and preterm births and fewer maternal morbidities and decreased infant and maternal deaths. If the project is successful, the goal is to include all rural hospitals in Kansas offering obstetrical services.

For providers like Cleveland, the task is personal as well as professional. When she was pregnant with her second son, she planned to deliver in Salina, about an hour and 15 minutes from her home. But then she went into labor five weeks early, and she knew she wasn’t going to make to Salina. Instead, she came to Mitchell County Hospital, where she now works.

“And I got amazing care. If this hospital hadn’t been here, I’d have delivered on the side of the highway,” she remembered. “It’s so important for us to have rural obstetric care. I’m passionate about us keeping that service.”

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HRSA: Healthy Communities, Healthy People

The grant funding the work Weis and her colleagues are doing to improve pregnancy and birth outcomes in rural Kansas was awarded by the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services. HRSA works to achieve health equity and improve public health for geographically isolated and economically or medically vulnerable people.

To that end, HRSA supports programs that care for communities with a high need, including rural populations, low-income people, pregnant people, children and parents, transplant patients, people with HIV and the health care workforce. During the COVID-19 pandemic, HRSA reimbursed providers for vaccinating people without insurance and accepted claims for testing and treatment for the insured.

HRSA grants are more focused on providing health care and services to people in need, rather than on enabling research, noted Weis.

“Generally speaking, HRSA funds programs and projects that are going to help communities,” she said. “The project may have a research component, but the focus is putting programs into place and working with communities.”

Below are other projects and programs at KU School of Nursing currently funded by HSRA:

• Advanced Nursing Education Workforce (ANEW): $2.5 million over four years to educate advanced practice nursing students specializing in primary rural care.
• Clinical Fellowship for APRNs: $2.2 million to educate nurse practitioners wishing to specialize in rural care.
• Geriatric Workforce Education Program (GWEP): $5 million over 5 years to improve health outcomes for older adults by developing a health care workforce that maximizes patient and family engagement.
• Interprofessional COVID Academic Network (I-CAN): $1.54 million over three years to educate respiratory therapists and nursing students and staff in rural Kansas to support patients with long COVID and chronic respiratory disease.
• MIDWIVES KAN: $1.5 million over four years to support an education program on maternity care in rural Kansas.