Sixteen counties in Nebraska average fewer than 50 births a year, according to the U.S. government.
If a hospital only sees a handful of births a year, it’s tough for staff to confidently offer obstetric care, said Mariana Tuttle, research fellow at the University of Minnesota’s Rural Health Research Center.
Low birth rates also make funding labor and delivery services difficult, especially in rural regions where half the births are funded by Medicaid – which reimburses at half the rate of private insurers, Tuttle said.
She said it’s a compelling reason to expand Medicaid in states like Nebraska.
In the 2022 Legislature, Sen. Anna Wishart introduced a bill that would extend Medicaid coverage for new parents. That bill died in committee, said Sara Howard, a former state senator who’s now a policy advisor for First Five Nebraska.
“I think there was a reluctance to invest additional dollars beyond what’s already being invested,” Howard said.
Small-town moms have a substantially greater risk of severe maternal morbidity than big-city moms, Tuttle said.
“People deserve to be able to live in these beautiful rural spaces and still have safe and healthy outcomes and labor and birth,” Tuttle said.
The dangers of giving birth in a rural area increase for parents of color, said Christian Minter, the Maternal and Infant Health Manager in Nebraska for March of Dimes. Black and Native infants die at twice the rate of white infants.
“Many Native American moms do live in some of these rural counties and so looking at their access to health care is important as well,” Minter said.
Maintaining a birthing unit might simply not be possible in some of Nebraska’s smallest counties. Arthur County, for example, averaged only 11 births a year from 2017 to 2019.
Where it might not be feasible to keep a delivery unit open, family medicine physicians can increase prenatal care access at clinics and help transfer their patients to larger hospitals when the time comes, Tuttle said.
But it’s not just delivery hospitals disappearing in rural Nebraska.
The state has lost 56 family medicine physicians in the past five years.
Ninety-one of the state’s counties – every county except Douglas and Lancaster – are now designated as a “shortage area” for at least one type of primary care doctor. Fourteen rural Nebraska counties lack both a family medicine physician and obstetrician, according to a 2022 report by the University of Nebraska Medical Center’s Rural Health Initiatives.
Without intervention, it will get worse. In the coming decade, a large portion of rural Nebraska’s doctors of all types are expected to retire, said Nicole Carritt, director of UNMC’s Rural Health Initiatives.
Recruiting certified nurse midwives is one cost-effective way of improving pregnancy care in rural areas where recruiting doctors may prove impossible, Minter said. And the number of those midwives is growing slightly in Nebraska even as the number of small-town doctors plummets.
But Nebraska is one of only three states where certified nurse midwives have to practice under the supervision of a licensed physician, according to the American College of Nurse Midwives.
That regulation presents a challenge for certified nurse midwives trying to practice in small Nebraska towns that don’t have a doctor, Minter said.
So hour-long drives, like the one from Franklin to Kearney, remain the norm in small-town Nebraska. They make stories like Gutschow’s wild ambulance ride more likely.
On that morning a few days before Thanksgiving, the ambulance made it only 10 miles before she gave birth to her son, Raiden.
The ambulance now carrying mother, newborn and relieved Hildreth EMTs stopped at the nearest hospital in Minden. But that hospital didn’t have the necessary equipment to care for Gutschow’s brand-new son.
Hours into his life, Raiden was put on another ambulance so he could finally arrive in Kearney.
“Normally right after you have birth at the hospital, the baby’s right there with you in the room and you start that bonding time,” Gutschow said. “We didn’t get that until at least four hours afterwards, and I barely got to see him since he was so premature.”
Raiden’s father missed the entirety of the birth. Instead of her fiancee holding her hand, an EMT – a complete stranger – squeezed Gutschow’s hand through delivery.
“[Gutschow] was just so incredibly brave,” Burki said.
Today, Burki regularly receives photo updates of Raiden, who is mastering his crawl alongside his brother. He has already made multiple visits to the EMTs who delivered him.
“We all became aunts and uncles,” Burki said.
The now 9-month-old Raiden owns a one-of-a-kind birth certificate, which lists his place of birth as “Mile Marker 32.”
Delivering Raiden is one of Burki’s best memories as an EMT. She also never wants her ambulance to become a delivery room again.
“Not every outcome is gonna be smooth as that one was,” Burki said. “What happened that day is probably more likely to happen again with how things in rural America, not just in Nebraska, are going.”
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