Leverage technology to reach women in ‘double deserts’ needing cardio-obstetric care
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- Geographic health disparities are multifactorial and present barriers to optimal cardio-obstetrics care.
- Technology can help reduce geographic disparities in CV care from preconception to postpartum.
Cardio-obstetrics care is often out of reach for women living in underserved rural areas, but there are steps cardiologists and OB/GYNs can take to ensure pregnant people have healthy deliveries despite geographic disparities.
Data show approximately 2.2 million women of childbearing age live in a so-called maternity care desert, defined as an area with no obstetric services, certified nurse midwives or OB/GYNs, including hospitals that provide birth services, Rachel Rodel, MD, FACOG, an assistant professor of maternal-fetal medicine at the University of South Dakota Sanford School of Medicine, said during a presentation at the American College of Cardiology’s virtual Cardio-Obstetrics Essentials interprofessional course. According to data from the 2021 U.S. Health Resources and Services Administration, approximately 1.8 million women in the U.S. are living in areas considered “double deserts” — a county with no birth services and an area that requires at least a 60-minute drive to access abortion services.
“Reproductive health access is critical for patients with underlying medical conditions — in particular, patients with CVD,” Rodel told Healio. “We know that CVD is a leading cause of maternal morbidity and mortality. Therefore, preconception counseling to adequately weigh the risks and benefits of a pregnancy is optimal. Reliable contraception needs to be readily available in order to prevent pregnancy until a desired time at which underlying health can be optimized with their cardiologist. Additionally, pregnancy counseling, including availability of abortion care, is important, especially for patients carrying the highest CV risks during a pregnancy.”
Limitations to reproductive counseling, access to pregnancy and CV specialists, as well as basic prenatal care, create major disparities for all patients, but especially for those with underlying CVD, Rodel said. Such double deserts also lead to more complex cardiac patients entering the delivery timeframe, Rodel said.
“While it is unfavorable to have an unplanned delivery for an otherwise healthy patient in a location without any obstetric services, the lives of both the mother and baby are at even greater risk when underlying CVD is present,” Rodel told Healio.
Contributors to geographic disparities
According to data from the American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women, 75% of the U.S. is considered rural and 25% of women aged 18 or older live in these areas, Rodel said. Hispanic and Asian populations make up the largest growing subgroups in these rural areas, and rural women overall experience poorer health outcomes compared with women living in urban areas.
“Recognizing that geographic health care disparities are multifactorial is important,” Rodel told Healio. “There are many geographic barriers that are present to both rural and urban patients that prevent optimal patient care. Some examples of barriers include baseline health, access to care, transportation, finances, education and technology. Second, patient-centered health care innovation may help reduce some of these disparities, especially for the cardio-obstetric population from preconception to postpartum.”
Patients who live rural areas tend to have poorer health at baseline, Rodel said, in part due to a lack of access to preventive care and subspeciality care. People in rural areas also tend to have more CV risk factors such as smoking, alcohol use and obesity and have higher rates of ischemic heart disease. In a typical rural area, about half of obstetric patients must drive at least 30 minutes to access basic care, Rodel said, complicating access to family planning services like contraception.
“When we think about how far the distance is to care ... some people have to fly or even travel by boat to see a provider,” Rodel said. “Transportation can be expensive, and it takes a lot of time to find childcare [and] to take time off work.”
Financial strain also plays a role in disparities, Rodel said. Many patients from rural areas are of lower socioeconomic status, lack insurance or rely on public insurance such as Medicaid. Access to higher education and technology is also a major limiting factor for these patients, Rodel said.
“Many of these patients do not have access to the internet,” Rodel said. “That is a huge barrier when we talk about how we can implement different methods to reduce these barriers.”
How to reduce impact on health outcomes
A three-pronged approach can help reduce geographic disparities and improve birth outcomes, Rodel said.
The first is perinatal regionalization, by bringing care to large academic centers, where there are subspeciality cardiologists and radiologists with access to advanced imaging. However, Rodel said the reality is many women from rural areas will present to a local hospital without subspecialty care. That is where maternal levels of care are key.
“Prenatally, we want to be able to ‘assign’ these patients and counsel them on accessing care at the appropriate level,” Rodel said.
The ACOG/Society for Maternal-Fetal Medicine Levels of Maternal Care Obstetric Care Consensus defines the required minimal capabilities, physical facilities, and medical and support personnel for levels of maternal care, ranging from level I (basic care), level II (specialty care), level III (subspecialty care) and level IV (regional perinatal health care centers for complex cardiology needs).
The third issue is maternal transport, Rodel said.
“When a patient presents with an acute issue, we have to figure out safe maternal transport,” Rodel said. “For us in the Midwest, that often requires air transport. We have well trained, high-risk perinatal nurses who often team up with an advanced adult critical care nurse.”
Other ways to optimize care involve direct outreach, seeing the patient close to their home or at a centralized rural outreach clinic.
“Even if your patients cannot be seen in those areas, you can hold educational sessions there and build relationships with the team to help keep patients safe and close to home and offer that collaborative care to give complex patients what they need,” Rodel said. “Of course, if you have internet access, most medical records now allow for virtual visits to check in with patients.”
Additionally, three main components of prenatal care can be performed remotely: ambulatory BP monitoring, fetal heart rate monitoring and self-measured fundal height. The results can be interpreted by the woman’s clinician and can be discussed in a real-time telehealth appointment, Rodel said.
“The complexity of cardio-obstetrics cannot be lost to geographic disparities,” Rodel said. “We ask a lot of these patients. The team is large and very complex, and that is a lot of things for a patient to track. If we really want to maximize our virtual care, we can help our patients access many resources via phone, virtual visits and submitting their home monitoring to these people so the visits are not quite as burdensome.”
Future of rural cardio-obstetrics care
Rodel said the future of remote cardio-obstetrics care is bright, with technology in development that allows for home nonstress tests and other forms of virtual monitoring. But even with new tools that expand care, a strong infrastructure with a multidisciplinary team is needed to provide care and co-manage at-home and virtual visits, she said.
“While geographic disparities are multifactorial, optimizing multidisciplinary health care innovation works towards an overarching goal of reducing the burden to the patient while optimizing outcomes,” Rodel told Healio. “For example, using remote patient monitoring or telehealth can assist to reduce barriers such as access to preventative and subspecialty care, time required for transportation, financial burdens of travel and being away from work or family. Another great example of how health care innovation can promptly reduce disparities is the dedication of the ACC to develop an infrastructure for cardio-obstetric education. The extraordinarily informative online course and materials can connect and educate clinicians that are remote from large academic centers.”
Any efforts must also be sustainable, Rodel said, who cautioned providers to advocate for reimbursement, good coding and billing and getting payors to “buy in” so any interventions are in place long term.
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Rodel R. ACC Cardio-Obstetrics Essentials: Team-Based Management of Cardiovascular Disease and Pregnancy; Dec. 15, 2023 (virtual meeting).
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