Healthy Babies, Healthy Mothers
Alaska’s vast geography is a wonder to behold for both residents and tourists, but it presents more than a few challenges for women when it comes to pregnancy and childbirth—scenarios which already are inherent with worries and concerns for moms-to-be.
YKHC and Southcentral Foundation provide spectrum of pregnancy care
For example, just the monthly checkup can present a financial and logistical hurdle if a patient isn’t living within driving range of a medical center or healthcare clinic. The trip to a healthcare provider can involve taking a boat or a plane, or both, and then a car ride, and may even entail an overnight stay due to transportation time. And, as with most deliveries in Alaska’s remote and rural areas, weather plays a big element in transport options and transport availability.
Just the monthly [prenatal] checkup can present a financial and logistical hurdle if a patient isn’t living within driving range of a medical center or healthcare clinic. The trip to a healthcare provider can involve taking a boat or a plane, or both, and then a car ride, and may even entail an overnight stay due to transportation time.
That’s because weather, just like a pregnancy, is often unpredictable, explains Janet Froeschle, a certified midwife at Southcentral Foundation, which provides healthcare for residents in the Southcentral region of Alaska. The coverage area includes Anchorage and surrounding villages extending to the Iliamna Lake Region, McGrath, Pribilof Islands, and the Aleutian Chain. Pregnant women in these areas usually deliver at the Alaska Native Medical Center, the referral hospital for the entire state for women with complicated or high-risk pregnancies. These women also come to Anchorage to receive care and deliver their babies.
“Even with close follow up and monitoring, pregnancy is not always predictable, and neither is the weather in rural Alaska, especially in the winter. It can take hours for a medevac plane to reach a village,” Froeschle says, noting weather can prevent flights which then makes boats the best, and sometimes lone, means of transportation to get patients to larger airports.
Prenatal Care Is a Team Effort
Such unpredictability in transport means the community health clinic and staff play a critical role in providing prenatal and pregnancy care—as does communication between regional hospital doctors and rural medical staff.
“Prenatal care for rural women is a team effort,” says Southcentral Foundation physician Dr. Donna Galbreath. “It starts with the remarkable health aides in the rural communities working in those clinics. Some of the larger clinics are also staffed with nurse practitioners or physician assistants. These providers are vital; they are part of the communities and key to getting women in to initiate prenatal care.”
Southcentral Foundation’s OB-GYN department is home to the provider’s Rural Maternal Child Health Program (RMCH), which includes a dedicated certified nurse midwife, RN case manager, and appointment/travel scheduler.
“The key to providing prenatal care to women in rural communities is early initiation of prenatal care, review for risk factors, and coordination of visits in Anchorage for provision of services not available in the villages,” says Froeschle, explaining rural providers shoulder a lot of responsibility with healthcare supervision for the whole village.
“They are trained in prenatal care to verify normal, identify when things are not normal, and have ready access to the RMCH team during clinic hours and on-call OB-GYN providers 24/7 for emergent conditions,” she says, adding the goal is to avoid births occurring in villages.
“Prenatal care is reviewed and monitored, and women come in to Anchorage for visits and testing as indicated. Rural providers report village pregnancies to the RMCH team. Prenatal care is then coordinated with visits and care in the village, including trips in for visits and care in Anchorage. This team reviews the pregnant woman’s medical history and prenatal visits for coordinating and advising prenatal care,” explains Galbreath, adding Southcentral Foundation’s OB-GYN department provides specialist physician consultation and care as needed.
“The key to providing prenatal care to women in rural communities is early initiation of prenatal care, review for risk factors, and coordination of visits in Anchorage for provision of services not available in the villages.”
When a patient can’t get to Anchorage-based medical services, Southcentral Foundation still plays a big role.
“We have had our OB-GYN surgeons on the phone with doctors in rural hospitals, talking them through emergency lifesaving surgery,” says Froeschle. “More experienced healthcare providers may go to nearby villages by snowmachine or boat to provide care until a medevac team can reach them.”
Oftentimes pregnant women in remote locations relocate from their village to Anchorage three to four weeks prior to their due date and stay until delivery.
“While we are not currently able to offer or advise women to stay and deliver in small rural villages, due to safety concerns, we do realize what a hardship it is to be away from home and family for weeks at a time. We support and encourage women with normal pregnancies and regular prenatal care to deliver in the outlying regional hospitals that are closer to home,” says Froeschle.
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Some expectant mothers come to Anchorage early in a pregnancy due to high-risk conditions, according to Galbreath. In response to this scenario, Southcentral has expanded and improved patient housing on the Alaska Native Health Campus to provide a more hotel-like atmosphere. The housing, says Froeschle, makes the delivery experience more family friendly.
“It is a hardship for women to be away from home and family for this period of time, but small rural villages are not equipped to handle the potential complications that can occur with labor and delivery,” she says.
The expanded and improved patient housing reflects Southcentral Foundation’s consistent focus on meeting the needs of its patients
“We continue to adapt and expand as indicated. In the past twenty years, there has been constant growth, expansion, and adaptation at Southcentral Foundation,” says Galbreath.
“We offer care that is current with evidence-based advances in medical care. We adjust to the changes resulting from a growing population and a shift between rural and urban areas. Changes in overall health and socioeconomic conditions are also considered,” she adds.
“Prenatal care for rural women is a team effort. It starts with the remarkable health aides in the rural communities working in those clinics. Some of the larger clinics are also staffed with nurse practitioners or physician assistants. These providers are vital; they are part of the communities and key to getting women in to initiate prenatal care.”
Prenatal and Delivery Complications
Providing quality prenatal care is essential for a mother’s well being and a healthy delivery; a lack of such services, or inadequate prenatal care, is often associated with low birth weight and pre-term birth, as well as mothers facing increased risks and complications, according to the Alaska Maternal and Child Health Data Book 2011. The data book research is a collaboration of the Alaska Department of Health and Social Services, Division of Public Health, the Alaska Native Tribal Health Consortium, and Alaska Native Epidemiology Center.
The percentage of women delivering live births across the state in 2016 who did not receive prenatal care in the first trimester ranged from a low of 8.3 percent in Juneau to a high of 31.1 percent in the Yukon-Kuskokwim Delta region, according to the Alaska Department of Health and Social Services.
The state’s most recent Pregnancy-Related Mortality in Alaska study, covering pregnancy-related deaths between 2000 and 2011, identified 13 pregnancy-related deaths, an average of 10 per 100,000 live births. The study, which was conducted by the Alaska Maternal-Infant Mortality Review committee, noted that factors “probably or definitely” associated with one or more of the deaths included alcohol abuse, methamphetamine use, problems with access to care, and inadequate medical care.
In its recommendations the committee noted prevention of similar death requires more timely access to medical care and addressing social and behavioral health issues prior to pregnancy.
A state report from the Alaska Native Epidemiology Center reveals that in 2013 just over half (54.5 percent) of mothers of Alaska Native infants had documented adequate prenatal care. That figure was 43 percent in 2008. Between 2009 and 2013, the number of mothers receiving documented adequate prenatal care varied significantly by tribal health region, ranging from 30.7 percent to 80.5 percent, according to the report.
Pre- and Post-Pregnancy
The Yukon Kuskokwim Health Corporation (YKHC), a tribal organization providing healthcare to fifty-eight communities, is committed to reducing risks and eliminating deadly outcomes for pregnant women and newborns living in rural regions.
YKHC, based in Bethel, is the primary healthcare provider in Alaska’s Yukon-Kuskokwim Delta region and operates a fifty-bed regional hospital featuring a pediatric and an obstetric ward, community clinics, behavioral health services, health promotion, and disease prevention programs, as well as dental services and environmental health services. Remote healthcare services are provided by five primary care clinics in the Yukon-Kuskokwim Delta Region, and YKHC’s Community Health Aide Program provides village-based primary healthcare in forty-seven village clinics.
The biggest challenge in delivering prenatal and pregnancy care, according to Ellen Hodges, MD, chief of staff at YKHC for ten years, is the remote location of pregnant patients and getting them needed and necessary care in Bethel.
Much of prenatal and pre pregnancy care is provided by the hospital’s Community Health Aide Program, initiated in the 1950s and 1960s, which taps local residents to be trained as practitioners. They attend to patients during normal clinic hours and also are on-call service after hours. They are also trained in emergency childbirth, but YKHC makes every effort to ensure mothers-to-be get to Bethel, or Anchorage if needed, for delivery, says Hodges.
“Our community health aides can provide basic prenatal care in our villages, but for ultrasounds and blood tests, our moms travel in to Bethel for care,” Hodges explains. “We have dedicated providers in Bethel who provide the needed prenatal care and we have outstanding case managers who coordinate their care. Once women have been identified as needing prenatal care, we track them throughout their pregnancy to ensure the healthiest possible outcome for mom and baby.”
About 620 women deliver in YKHC’s care region annually, and the organization provides all pregnancy care from preconception counseling through post-partum care and beyond.
“We educate our moms on the importance of early prenatal care and what to do if they notice problems with the pregnancy,” says Hodges.
“We have dedicated providers in Bethel who provide the needed prenatal care and we have outstanding case managers who coordinate their care. Once women have been identified as needing prenatal care, we track them throughout their pregnancy to ensure the healthiest possible outcome for mom and baby.”
About 400 women deliver in Bethel and the rest deliver in Anchorage, mostly due to high-risk conditions, says Hodges.
“If our moms need specialized testing, including specialized ultrasounds and consultation with a maternal fetal medicine specialist, they travel in to Anchorage for this care,” she says, noting YKHC has a well-staffed and equipped labor and delivery unit in Bethel.
“We have a physician and a nurse anesthetist available 24 hours a day for emergency C-sections if needed. We have an OB/GYN doctor who lives in Bethel part-time and Anchorage part-time for consultation, and if he isn’t available we have the ability to obtain phone consultation with OB/GYN doctors in Anchorage.”
Similar to Southcentral Foundation, YKHC offers a pre-delivery home to mothers as they are required to arrive in Bethel one month prior to their due date.
“If a patient does go into early labor, we make efforts to get them to Bethel via our air medevac service, LifeMed. This isn’t always possible, which is why our community health aides are trained in emergency childbirth,” says Hodges.
Citing healthcare privacy laws and regulations, Hodges can’t share specific delivery experiences, but she says there are many stories of the heroes who have played a life-saving role for moms and newborns.
“Healthcare providers in our communities have always gone above and beyond to care for our moms and babies. The community health aides deserve special recognition for their dedication and service.”
Judy Mottl writes about important issues country-wide with an affinity for Alaska.
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