Rural Maine Maternity Workforce Needs Assessment

Needs Assessment of the Obstetric Workforce in Maine’s Rural Hospitals

Needs Assessment of the Obstetric Workforce in Maine’s Rural Hospitals

This assessment was contracted by MaineHealth to the Roux Institute at Northeastern University. It was supported by Rural Maternity and Obstetrics Management Strategies (RMOMS) grant number UK9RH46984, through the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Report Authors

Brianna Keefe-Oates PhD, MPH

Katherine Simmonds PhD, MPH, RN, WHNP-BC, FAAN

Louisa H. Smith PhD, MS

Jeni Stolow PhD, MPH

Contact Information

Roux Institute

Dr. Katherine Simmonds

Lead Author

k.simmonds@northeastern.edu

MaineHealth

Dr. Dora Anne Mills

Principal Investigator for RMOMS doraanne.mills@mainehealth.org

The authors of the report wish to thank the staff, providers, stakeholders, and other partners who shared stories, suggestions, and valuable insights for this assessment.

Executive Summary

Obstetric units have been closing throughout the United States in recent decades, especially in rural areas. Closures lead to increased distances that pregnant people must travel to access obstetric care when in labor, when experiencing pregnancy or postpartum complications, or to receive routine prenatal and postpartum care. The Health Resources and Services Administration (HRSA) initiated the Rural Maternity and Obstetrics Management Strategies (RMOMS) program in 2019 to support state initiatives to improve perinatal care for people in rural areas.

In 2022, MaineHealth was awarded an RMOMS grant with the goal of strengthening the system of maternity care in rural Maine, where almost one-third of hospitals have closed their obstetric units over the past 15 years. The RMOMS program contracted a multidisciplinary research team from the Roux Institute at Northeastern University, based in Portland, Maine, to conduct this assessment. The research team comprises four researchers with specialties in epidemiology, reproductive health and medicine, communications, and qualitative methods.

The project aim was to document the needs, strengths, and challenges of the current hospitalbased obstetric workforce in rural Maine. In total, 15 hospitals within the RMOMS network agreed to participate in this study. The research team visited each of the hospitals for an observational site visit, the findings of which were triangulated with 35 key informant interviews and over 40 informational conversations conducted throughout the research period.

The findings underscore a profound commitment by the rural obstetrics workforce to the community and patients, coupled with innovative strategies to facilitate patient access to care within both the hospital and tertiary healthcare settings. However, challenges stemming from declining birth rates and an aging obstetric workforce in rural areas have resulted in a diminished staff and provider pool. This, in turn, has led to challenges in service provision, restricted opportunities for obstetric providers and nurses to enhance skills due to low birth volumes, and nurses being reassigned to other services or units, leading to dissatisfaction. While each hospital addressed these challenges uniquely based on their individual needs and geographic location, the diverse strategies employed provided valuable insights. Consequently, we draw upon these varied approaches to propose recommendations aimed at sustaining the healthcare workforce and ensuring the delivery of safe, high-quality services.

K ey recommendations

Recruit

Establish pathways for aspiring health care providers to join the rural obstetric workforce and mentorship programs to support them in growing into their new roles.

Retain Expand integrated practice models in which every member of the team is supported to realize the full extent of their education, scope of practice, and training.

Support

Create Communities of Practice that connect the rural obstetric workforce across hospitals and to training opportunities at high-volume hospitals.

Celebrate Mount media campaigns to showcase the exceptional work that rural hospitals, staff, and providers do caring for Maine’s pregnant, birthing, and postpartum people and families.

c

ommonly used abbreviations

BMI: Body Mass Index

CAH: Critical Access Hospital

ED: Emergency Department

EMT: Emergency Medical Technician

HRSA: Health Resources and Services Administration

KII: Key Informant Interview

NLH: Northern Light Health

OB: Obstetrics

RMOMS: Rural Maternity and Obstetrics Management Strategies

SUD: Substance Use Disorder

TOLAC: Trial of Labor after Cesarean

commonly used terminology

MaineCare: The state’s Medicaid program, providing free and low-cost health insurance to Mainers who meet certain eligibility requirements based on household composition and income.

MaineHealth: An integrated health system with 15 hospitals, 9 of which provide in-patient obstetric services (8 in Maine, 1 in New Hampshire). MaineHealth's service area covers Western and Southern Maine as well as Carroll County in NH.

Med-surg: Inpatient medical-surgical unit.

Northern Light Health (NLH): An integrated health system that serves southern, central, and northern Maine. It includes 10 hospitals, 6 of which provide in-patient obstetric services (labor and delivery).

Obstetric services (OB services): The diverse array of perinatal (prenatal, labor, delivery, and postnatal) care services, both in-patient and outpatient; this report focuses on in-patient services.

Obstetric unit (OB unit): This term refers to the range of obstetric services provided in hospital settings, including where those services are delivered and the team responsible for them. For consistency in this report, this term will be used in lieu of other common terms such as labor/delivery/ recovery/postpartum (LDRP) unit, hospital-based obstetric care, and obstetric services.

Obstetric workforce (OB workforce): The array of trained personnel who participate in the direct care of pregnant and postpartum patients, including but not limited to Anesthesiologists, Certified Nursing Assistants (CNA), Certified Nurse-Midwives (CNM), Certified Registered Nurse Anesthetists (CRNA), Emergency Medical Technicians (EMT), Lactation Consultants (LC), Licensed Practical Nurses (LPN), Licensed Clinical Social Workers (LICSW), MDs/DOs (Anesthesiologists, Family Practice physcicians,

OB-GYNs, Pediatricians, and others including Emergency Medicine, Maternal Fetal Medicine (MFM), and Psychiatric specialists), Nurse Practitioners (NP), Physician Assistants (PA), Registered Nurses (RN), Respiratory Therapists, Ultrasound Technologists, etc.). This report focuses on the hospital-based OB workforce, but it recognizes that other trained and community-based individuals provide essential care to pregnant and postpartum people in the community.

Perinatal: The time period leading up to and after birth, including up to several months prior to pregnancy and a year (or more) after birth.

Pregnant people: All individuals, regardless of gender, who are pregnant.

Rural: In the United States, the term "rural" is defined and used in various ways by different federal agencies (see page 3). The RMOMS scope includes areas designated as rural by the Federal Office of Rural Health Policy. However, when referring to other data sources, such as census estimates or CDC natality data, the definition of rural or metro/urban used by those specific sources applies; this is made explicit in the text and figure captions.

Trial of labor after cesarean section (TOLAC): A current term that is an alternative to the term vaginal birth after cesarean section (VBAC).

Background

Since 2004, the United States has witnessed a significant decrease in hospital obstetric units, a trend that raises critical concerns for maternal healthcare. By 2020, half of all US counties lacked a hospital offering obstetric services (GAO, 2022), indicating a deepening healthcare gap. This decline is particularly acute in rural areas, with 89 rural hospital obstetric units closing between 2015 and 2018 (AHA, 2022).

The reasons behind these closures are multifaceted. Key among them is the financial strain caused by Medicaid reimbursement rates set by states, which fail to cover the total costs of obstetric care. This issue disproportionately affects rural areas, where Medicaid covers half of all births. Additionally, rural hospitals face persistent challenges in recruiting and retaining medical staff, exacerbated by factors such as scheduling, fluctuating patient numbers, and internal hospital dynamics (Kozhimannil et al., 2015; GAO, 2022). Compounding these challenges is the overall decreasing volume of births, leading to hospital closures driven both by financial constraints and concerns over patient safety.

Like the rest of the nation, Maine’s obstetric landscape has experienced a significant transformation in recent decades. The state, which currently has the highest average age (45) and the second-highest proportion (61%) of rural residents in the nation (Census 2020), has seen over a dozen obstetric units close since 1970, with half of those closures occurring in the last decade. This leaves 21 hospitals with delivery services in the state, 16 of which are in rural areas. The trend in Maine reflects the broader national pattern of declining healthcare resources in rural areas.

Recruitment and retention of healthcare professionals in Maine has been persistently difficult, a situation exacerbated by the state’s aging population. Births are at their lowest in over a century, dropping by more than half since 1960 (Figure 1). While the past few years have seen a slight rebound, whether that trend continues is yet to be determined. In any case, the recent increase was limited to the metro counties, which lead the non-metro counties in birth rate (Figure 2), evidence of the demographic differences dividing rural Maine from the rest of the state. Despite falling birth rates, the overall population of the state’s metro areas has grown consistently. Southern Maine, particularly York and Cumberland counties, has experienced a notable influx of young people, even before pandemicinduced migration.

Amidst these demographic shifts and facility closures, Maine has also seen a change in the medical needs of pregnant patients. Increased patient acuity and average age have escalated the demand for

F

1. Births in Maine, 1900-2022. Data from Maine Department of

specialized prenatal, delivery, and postpartum care. For example, the prevalence of chronic hypertension among pregnant individuals increased from 1.2% in 2008 to 8.6% in 2022, while pregnancy-associated hypertension rose from 5.1% to 10.6% over the same period (Figure A1). Furthermore, rural areas are more burdened than metro areas by many of these comorbidities. For example, in 2022, 30.5% of pregnant people from metro areas had obesity, compared to 39.2% of those from rural areas. The pattern is reversed, however, for hypertension, where pregnant people in the metro counties exceed those elsewhere (Figure A1).

Given the changing obstetrical landscape in Maine, particularly its rural areas, it is essential to assess the status of the workforce supporting these vital healthcare services. This research will deepen understanding of the unique obstetric workforce experiences and needs in these communities, and contribute to the development of strategies to sustain obstetric services in rural areas facing a critical decline in maternal healthcare resources.

Research aim

To conduct a workforce needs assessment of the hospitals with obstetric units in rural Maine in order to inform the development of a strategic work plan and recommendations for an implementation plan for the RMOMS program.

Methodology

This rapid workforce needs assessment aimed to identify factors contributing to the sustainability, recruitment, and retention of the obstetric workforce in hospitals in rural Maine. The study team was comprised of four female academic public health professionals, three of whom are Maine residents, with expertise in nursing, midwifery/doula care, epidemiology, qualitative methodologies, maternal child health, and reproductive justice.

s tudy setting

The catchment area for this needs assessment was the 16 hospitals with obstetric units in rural Maine, as designated by the Federal Office of Rural Health Policy. However, one hospital declined to participate in the study, leaving a total of 15 participating hospitals.

d ata collection

Data for this needs assessment was collected between September and December 2023. This mixed-methods needs assessment included two primary data collection strategies: Key informant interviews (KIIs) and healthcare facility observations (“site visits”).

Key Informant Interviews

Semi-structured, key informant interviews (KIIs) were conducted with hospital administrators, providers, certified nurse-midwives, nurses, and other key personnel. Of note, many of the interviewees and personnel we spoke with during site visits to the hospitals had roles that included clinical and administrative/leadership responsibilities, such as Director of Women’s Health and obstetrics unit nurse. Recruitment of interviewees was supported by the RMOMS leadership, who provided our study team with a list of point people for each hospital. The indicated point people from all 15 facilities were contacted via email to introduce the study, describe participant rights, and present a list of potential interview questions (i.e., the semistructured interview guide). In some cases, the designated point people referred the research team to other staff who they believed could provide important perspectives. Interviewees who agreed to participate were scheduled for a 30–60-minute Zoom interview. All Zoom interviews were audio-recorded and transcribed with consent from the participants. The research team revised transcripts to ensure accuracy and anonymity. All transcripts were sent to interviewees for verification and the opportunity to redact potentially identifiable or sensitive content. Topics discussed in interviews included:

b ox 1. A selection of defintions of rural used by federal agencies and in this report.

Office of Management and Budget (OMB)

• Defines metropolitan and micropolitan statistical areas based on population, economic, and social patterns.

• In Maine: There are three metropolitan areas (Bangor, Lewiston-Auburn, Portland-South Portland) and one micropolitan area (Augusta-Waterville). Counties with metropolitan areas are labeled “metro”: Penobscot, Androscoggin, Cumberland, York, and Sagadahoc (the latter three containing the Portland-South Portland metropolitan area). Counties with only micropolitan areas or neither are “non-metro.”

National Center for Health Statistics (NCHS)

• Further breaks down metro (large central metro, large fringe metro, medium metro, small metro) and nonmetro (micropolitan, non-core).

• In Maine: Penobscot and Androscoggin Counties are small metro, Cumberland, York, and Sagadahoc Counties are medium metro, Kennebec County is micropolitan, and other counties are non-core.

Federal Office of Rural Health Policy (FORHP)

• Non-metro counties are considered rural. Also, some parts of metro counties are classified as rural, based primarily on USDA’s Rural-Urban Commuting Area codes.

• In Maine: Besides the non-metro counties, rural areas include all of Sagadahoc County as well as one census tract in Androscoggin County (Livermore Falls), eight census tracts in Cumberland County (covering the Bridgton and Brunswick areas), nine census tracts in Penobscot County (primarily the northern and eastern sections of the countyincluding Millinocket and Lincoln), and 12 census tracts in York (the middle section of the county, including Sanford).

U.S. Census Bureau

• Any area not classified as urban is considered rural. Urban areas have high housing or population density and are determined after each census.

• Workforce SWOT (strengths, weaknesses, opportunities, and threats): Workforce assets and needs, facilitators and barriers to workforce sustainability, workforce training needs, educational/training gaps, and opportunities to enhance the experiences of workforces across the state.

• In Maine: Some areas classified as urban by the Census Bureau might be considered rural by other definitions (e.g., Millinocket, Houlton, Sanford, Boothbay Harbor).

• Hospital-based obstetric services (including labor, delivery, prenatal, and postpartum care): Capacity to sustain and/or expand services and facilitators and barriers to service delivery. Interview questions sought to document how patients, administrators, physicians, nurses, and other members of the healthcare team experience the continuum of obstetric care service delivery. Interviewees were asked to describe their “wish lists” for a 5-year workforce and delivery system improvement plan.

Hospital Observations (“Site visits”)

In addition to KIIs, all 15 participating hospitals allowed site visits. The purpose of the site visit was to document the visual characteristics of the facilities, as well as access, availability, quality, patterns, and gaps in physically available resources within and en route to these hospitals. The site visits were conducted to complement qualitative data from the KIIs.

Site visits were coordinated with the hospital point persons. During each site visit, members of the study team were led by an obstetric unit representative to the areas of the hospital where a pregnant or post-partum person may present for care, such as the emergency department, out-patient clinic, labor and delivery rooms, recovery rooms, and family areas. Staff communal and call room areas were also observed. During the site visit, numerous informal informational interviews (hereinafter termed “conversations”) took place with personnel who were available and willing to talk with the observation team. These interviews were neither scheduled nor audio recorded; however, they were highly informative, engaged essential hospital personnel, and sometimes lasted over an hour. Most site visits lasted approximately two hours and included 2-6 conversations each. Site visit observations and conversational data were combined to complete a standardized observational checklist for each hospital.

d ata synthesis

KII and site visit observation data were combined to create “hospital summaries” for each of the 15 locations. These summaries were collectively and iteratively analyzed to deduce similarities, differences, gaps, and opportunities across locations. Several rounds of initial findings were presented to RMOMS representatives as a form of member-checking to ensure the findings were reliable. Individual hospital summaries were also sent to the indicated point person at each hospital for review and correction of any mistakes recorded about the site.

F igure 3. Locations of the 15 rural Maine hospitals visited by the study team.

Findings

This section provides an overview of identified strengths and challenges to sustaining the obstetric workforce among rural hospitals in Maine based on the data collected during site visits and interviews conducted during the study period. First, this section describes some contextual factors in which our findings should be situated; next, the findings have been grouped into four broad categories: 1) Community characteristics and implications for the OB workforce; 2) Recruitment/ filling gaps in the OB workforce; 3) Retention; and 4) Training, programs, and other strategies to support the OB workforce. In each section, we highlight workforce strengths and bring attention to areas of vulnerability with a goal of informing recommendations and future strategies to promote the sustainability of the obstetric workforce and the continued availability of hospital-based obstetric services in rural Maine.

The main findings are presented in a summary SWOT (strength, weakness, opportunity, threat) graphic (Figure 4). This figure aims to show key insights into the major themes from each category. The rest of this section presents more nuanced discussions regarding the needs, assets, challenges, and recommendations documented by the research team. Throughout, findings are classified as strengths (), challenges (), or mixed (±). We also highlight exemplars in boxes, which represent noteworthy examples of a hospital or workforce operationalizing what is discussed in the text.

• Deep commitment to the community and patients

• Strong reciprocal support from community

• Systems for telehealth and transfers between rural and tertiary hospitals

• Reliance on small staff and provider pools

• Inability to provide some services due to provider gaps

• Limited opportunities for obstetric providers and nurses to build skills

• Floating obstetric nurses to deliver non-obstetric care causes job dissatisfaction

• Implement wider range of effective models to cover 24/7 patient care

• Multi-generational employment and engagement with hospitals strengths WeaKnesses staerht seitnutroppo

• Establish training opportunities at higher-volume partner hospitals

• Cross-train other hospital staff in OB care

• Share staff/providers across catchment areas

• Increase visible appreciation for OB staff and providers

• Support professional development

• Declining birth rate in rural areas

• Aging obstetric workforce

• Increased acuity among patient population

• More patient social needs

• High cost of travel nurses and locums

and threats.

F igure 4. Main findings of the report classified as strengths, weaknesses, opportunities,

c ontextual F actors

Several key statewide contextual factors were identified as pertinent to the sustainability of the hospital-based obstetric workforce in rural Maine. These include:

Declining birth rate in rural areas

• Lower birth volume causes financial strain as lower volume yields less revenue. Furthermore, OB units are an expensive asset for hospitals due to high liability/malpractice insurance costs and the need for 24/7 staff/provider coverage.

• Hospitals with fewer births provide limited opportunities for staff/providers to acquire, maintain, or advance their skills and confidence in providing OB care.

Aging health workforce

• A high number of retirements among nurses, nurse midwives, and physicians that were concurrent with the COVID-19 pandemic continues to strain the OB workforce.

• A number of highly experienced RNs, CNMs, and physicians in the OB workforce are currently nearing retirement age or actively planning to retire.

Reliance on a small number of providers

• Several hospitals reported a limited number (1-2) of providers available to attend deliveries, leaving the hospitals highly vulnerable to work disruptors such as illness, medical leave, retirement, relocations, or other life events. In these low-staffed facilities, one physician's departure can lead to diversions, short-term shutdowns, or the closure of a unit altogether.

Increases in poor health among pregnant/postpartum people in rural Maine (including high rates of diabetes, hypertension, high BMI, mental health concerns, substance use) and social needs (poverty, food insecurity, housing instability, lack of transportation) result in complex obstetric care.

 Staff/providers expressed the need for more advanced skills to care for complex OB patients. While many hospitals aim to transfer complex patients, the rural reality is that some pregnant and postpartum people still access their local hospitals for care, especially during labor or other crises.

 Staff are addressing more social needs and coordinating post-discharge services for patients during hospital stays, which can be time-consuming and emotionally challenging.

 Inability to offer patients TOLAC/VBAC at several hospitals because of the lack of 24/7 on-site anesthesia was noted as a barrier to meeting the community’s needs and desires for hospital-based obstetric services.

 At some hospitals, absence of midwifery-provided care was noted as a missed opportunity to meet the needs and desires of the community.

 Members of the OB workforce of all types and across all sites expressed strong support for maintaining obstetric services at their hospital to continue serving the women and families of the community.

 Strong connections between staff/providers and community: successful, sustained partnerships with patients, EMTs, community midwives, and other types of community-based care and services were described frequently.

• Monthly meetings between hospital staff and community midwives to discuss their prenatal patients and those with upcoming expected deliveries.

• Some community midwives use and provide a standardized health record to the hospital when there is a patient transfer from the community, improving communication and care.

• OB staff reported partnering with the local EMT team to check on high-risk postpartum patients after discharge.

• Postpartum patients return to the obstetrics unit for a checkup, lactation support, and newborn assessment 1-2 days after discharge.

 Hospitals frequently reported being a major employer of and with high retention of employees from the community.

๗ I was born in this hospital, my kids were born in this hospital, their kids will be born in this hospital. We're never leaving.

 Multi-generational employment (mother, daughter, etc.) noted at several sites.

๗ We grow our own.

 A variety of staffing models (including a mix of provider types – OB-GYN/Family Practice MDs/CNMs and scheduling arrangements) are acceptable to different communities and hospitals.

• No single model fits all communities.

r ecruitment / F illing gaps in the ob W or KF orce

The ability to recruit new providers and staff into the rural obstetric care health workforce is essential to sustainability and safe practice. Identified challenges and strengths in recruitment in rural Maine include:

 Salary: Inability to compete with larger tertiary care and more urban hospitals hinders recruitment. Higher pay for travelers or locums: During COVID-19, across hospitals, many providers and nurses left their roles to pursue traveler or locum work as pay was higher for the same work (or, in some cases, it entailed less responsibility).

 Lack of training/mentorship (nurses/providers) prevents some who are newer to the profession/ early in their career from accepting offers at some hospitals.

 Terms of employment are unappealing, including demanding call schedule, lack of backup for illness, vacations, family leave, or professional development time.

 Combination of hospital workforce shortages, high acuity of OB population, and high coverage needs create overly burdensome responsibility for potential new staff and providers.

Recruitment efforts specifically for providers to work in rural sites are not well-targeted or supported within the larger health systems.

 Lack of available affordable housing within a 20-30 minute radius of the hospital.

 Limited job opportunities or community resources (culture, education, etc.) for applicants’ partner/ spouse/family members.

• Several reports of employment offers being turned down due to a spouse’s unwillingness to relocate to the area.

 Sharing personnel (specifically providers and nurses) across hospitals within the same system.

 Cross-training of nurses from med-surg, ED, and other departments to provide obstetric care (primarily routine postpartum and neonatal care).

 Use of advanced practice providers (CNMs, CRNAs) as a strategy to fill gaps with MD/DO providers.

• Successful initiatives that alleviate burden on physicians include CNMs taking first call, while physician providers are called in only “as needed” (i.e., if case becomes complex or requires operative delivery).

 Establishing backup pool for OB providers that includes 1st and 2nd call models to reduce overwork/ burnout or reduce unappealing shift schedules.

 Hires include new grads, med-surg nurses (internal to hospital), travelers converting to permanent staff, and return of former employees.

 Partnering/formalizing relationships with area technical schools, community colleges, universities, medical schools, and residency programs to increase hospital workforce recruitment, including for OB.

• Several hospitals mentioned partnerships with area nursing programs, including one that is involved in the development of a program at a nearby community college.

± Traveling nurses and locums (physicians) to cover staffing gaps.

• Expensive, disruptive to the workforce and patient continuity. Some are not invested in building relationships with patients or care team.

• Some travelers were described as highly skilled and willing to help train new hires, discuss strategies to innovate/enhance the unit, and work nights/weekends.

• Many hospitals noted that travelers decided to return or stay on as permanent staff.

• Some units reported a decrease in travelers due to recent successful hires.

r etention

In addition to recruiting for the obstetric workforce, rural hospitals face challenges retaining those hired. In Maine, some of the specific challenges and strengths with retention noted include:

 Investment of time and resources to train new OB nurse hires is significant: Many rural hospitals reported that because of low birth volume, new nurses typically need a minimum of 9 months to a year before they can care for laboring patients without extensive supervision.

 Floating (nurses) to other units (e.g., med-surg) contributes to job dissatisfaction.

• Reports of nurses stating, “This isn’t what I want or was trained to do,” and tension/lack of collegiality between staff across units.

• When floating is required, the model of “helping hands” seems to work better than actual patient assignments.

 Some concerns expressed about the risk for burnout among providers not able to “turn off” when off-duty because they live in the community where they work.

 Great pride associated with identity as member of OB care team.

 Many staff and providers expressed that the care they provide was rewarding because it was more tailored to the individual, patient-centered, and holistic compared with high-volume (urban) sites.

๗ I am really able to practice midwifery care here.

 Strong “can do” culture: Flexibility and willingness to take on roles, tasks, and responsibilities within and outside obstetric unit, do “whatever it takes” to keep service open for community.

• Staff willingness to provide care across units and participate in OB skills-building trainings and simulations was noted at several sites.

 Careful screening of applicants for fit with actual job (with transparency about range of responsibilities, such as floating and schedule) and rural location rather than skill set leads to better retention.

๗ You can train them in skills, you can’t make them like the town.

 Strong interprofessional care teams make OB workforces feel more connected, supported, and functional.

• Obstetric teams characterized as having effective communication and respect among staff and providers across roles and levels also were described as having greater willingness to cover shifts, come in when not scheduled to attend births, and work together, as well as confidence in their ability to handle unplanned or complicated births.

 Create/designate a CNA role as a member of the care team to support overburdened nursing staff.

• CNAs complete birth certificates, answer unit doors and phones, and handle clerical scheduling tasks.

 Use all staff and providers (e.g., CRNAs) to full extent of licensure/training to increase job satisfaction and balance burden of care across workforce and increase efficiency.

• CRNAs provide epidurals in some hospitals.

• Family practice doctors trained and credentialed to perform c-sections, ensuring the hospital can maintain obstetric services.

 Create and support opportunities for professional growth.

• Allocate specific roles (e.g., follow-up with postpartum patients, newborn screenings, etc.) to specific nurses, including related administrative tasks, to increase a sense of unique value and contribution to the team.

• Support nurses in pursuing new roles by gaining lactation skills, developing childbirth education classes, or seeking other credentialing.

t raining , programs , and other strategies to support the ob W or KF orce

Building and maintaining skills, encouraging professional growth, and providing other types of professional support are essential for the successful recruitment and retention of the obstetric workforce. Further, these are imperative drivers to providing timely, safe, high-quality obstetric care.

Among rural hospitals in Maine, specific challenges and strengths noted in training, program offerings, and other strategies to professionally support the obstetric workforce included:

Access to and quality of opportunities for new obstetric nurses to complete immersive training (several weeks/months) at hospitals with high-volume OB services are not available to all rural hospitals.

• Even for those hospitals that do offer such training opportunities for new hires, concerns were voiced about the excessive cost and lack of hands-on experience provided as well as the risk of loss of trainees to the high-volume training sites.

 Lack of guidance/training/support on appropriate evidence-based care of marijuana use among pregnant patients expressed as emerging need.

 Some confusion among hospital staff about what different statewide programs exist for OB care providers and patients.

 Difficulty arranging transport of mother to join neonate due to shortages with ambulance services or lack of bed space at receiving hospital.

 High engagement in in-service, team-based educational activities/simulations for OB providers and staff, including in Neonatal Resuscitation (NRP), postpartum hemorrhage (PPH), and shoulder dystocia management. Some hospitals reported successful programs across units (ED, OB), and some across hospitals within the same system.

 Opportunities for professional growth within hospitals demonstrated by high numbers of employees assuming new positions (clinical roles, management/administration).

 Statewide programs support training, professional growth, quality care.

• Many noted the valuable training resources and programs available to support the OB workforce in caring for pregnant/postpartum patients.

• Perinatal Outreach and Education program; Eat, Sleep, Console program; Maine Ongoing Outreach Simulation Education (MOOSE)

 Strong communication and coordination of care of pregnant patients reported across units (e.g., EDOB, ambulatory-inpatient OB services).

• Collaboration between ED and OB units to establish protocols for pregnant/ postpartum patients who present to ED

 Responsive/reliable Emergency Medical Services described in many areas, including transfers/ transport for neonatal emergencies.

• LifeFlight, Eastern Maine Medical Center (EMMC) and Maine Medical Center’s (MMC) Barbara Bush neonatal transport teams.

 Responsive tertiary care hospitals (EMMC and MMC) provide reliable backup in emergencies, complex cases.

๗ They always pick up the phone when you call.

± Inconsistent access to provider-provider telehealth programs and dedicated telehealth equipment across hospitals.

• Where available, well-received.

• Noted as especially helpful with neonatal, and “sick baby” support while waiting for transfer.

• Equipment ranged from secure cellphones, iPads, to single-button push full telehealth setup.

• In some sites, set up of telehealth equipment is an additional task that falls to nurses.

• Telnet, maternal-fetal medicine consultations, psych/mental health consults.

Recommendations

The following recommendations are based on the data and findings outlined in this report. They include a range of multilevel solutions to inform future strategic, partnered decision-making and resource allocation aimed at sustaining the rural obstetric workforce in delivering high quality patient care. A summary of recommendations seeking to impact recruitment, retention, and/or professional development at the state, regional, health system, hospital, and unit levels is in Figure 5. Of note, some recommendations could be implemented at more than one level (e.g., hospital or health system; unit or hospital), but for brevity are listed only in a single level category in this report.

a t the state level

For policymakers, state government agencies (Department of Health and Human Services) and programs, and state professional organizations

• Incentivize rural clinical practice through increased salary, loan repayment, and other financial incentives (e.g., housing, tuition remission, funds for professional development and credentialing, etc.).

• Restructure the MaineCare reimbursement model to better financially sustain rural service delivery.

s tate l evel

Incentivize rural practice

Restructure MaineCare reimbursement

Support community-based programs

Dedicated OB telehealth support

Coordination across state providers

State representatives visits to rural hospitals

Regional perinatal clinical educators

Immersion training programs

egional and h ealth s ystem l evel u nit l evel

h ospital l evel r

Support coordination of rural hospitals

Establish communities of practice

Establish/ expand residency programs

Support training of family medicine providers

Provide formal mentorship program for clinicians

Develop strategies for sharing staff across locations

Develop sitespecific staffing model to maximize strengths

Cross-train nurses to support lateral movement

Partner with nearby educational programs to increase recruitment potential

Expand remote telemonitoring programs for highrisk patients

Support skill maintenance programs for all personnel

Establish pool of regular locums/per diems

Integrate CNMs into service

Establish OB nursing residency programs

Welcoming culture for travelers

Utilize nursing strengths for training and retention

Integrate more family physicians

Relationships with community midwives

On-site teambased education

Demonstrate staff appreciation

Recommendations for multi-level solutions.

• Increase support for community-based programs (e.g., community health centers, home visiting programs, community health workers, community paramedicine, doula services, etc.) that provide care and services for prenatal and postpartum patients, including the identification and monitoring of high-risk pregnancies/postpartum individuals, facilitating access to social services (food, housing, fuel assistance, transportation, mental health and SUD treatment, etc.).

• Provide dedicated OB telehealth equipment and maintenance/IT support for all in-patient OB hospital units across the state and support for programs that connect rural hospitals to specialists for consultation.

• Continue to support and expand coordination between perinatal care providers across the state, including by:

• Increasing the visibility, organization, and promotion of statewide and region-specific offerings focused on providing training and support for the perinatal workforce and the populations they care for. As one example, distribute an electronic and paper “cheat sheet” with essential information about all statewide perinatal programs (contact info, program focus) to OB units and others who care for pregnant/postpartum patients across state. Update and redistribute regularly.

• Conducting regular visits to rural hospitals from personnel who represent various statewide perinatal health programs to increase familiarity with rural practice reality, uptake of programs, support implementation, and reduce burden on hospital staff.

• Expanding investment in regional perinatal clinical educators to further support the work of coordinating, developing, and implementing comprehensive interdisciplinary trainings, including team-based simulation training, for obstetrical and emergency unit staff and providers.

a t the regional and health systems level

For hospitals serving within the same region of the state and/or within integrated health systems

• Establish/expand residency programs for OB-GYNs, pediatricians, and/or family medicine physicians with rural health focus/track.

• Support training of family medicine and general surgery physicians (including residents) in c-section and other OB/reproductive health skills (e.g., management of ectopic pregnancy, ovarian torsion, GYN care, etc.).

• Extend rural hospital provider/nurse-to-specialist telehealth support (via phone, video-conferencing consultations) to all rural hospitals with obstetric services.

• Provide formal mentorship for new providers and nurses including through collaboration between hospitals.

• Develop strategies for sharing obstetric providers/clinicians and obstetric nurses across hospitals.

• Support the development and offering of hands-on immersion programs at high volume birth sites for new obstetrics nurses and experienced nurses seeking to refresh obstetrics skills for all rural hospitals.

• Establish Communities of Practice

• Host virtual meetings/events and at least one annual in-person event to build communities of practice among obstetric-care providing hospitals so they can share successes, explore potential collaborations, and devise creative solutions to shared challenges with one another.

a t the hospital level

For hospital leadership, workforces, and community stakeholders

• Develop site-specific staffing models that maximize patient safety/quality/satisfaction and decrease provider/staff burnout by using all team members to the full extent of their licensure/scope of practice. Several examples from hospitals that have successfully implemented the following strategies include:

• Allowing CRNAs to provide epidurals.

• Integrating family practice physicians who are trained and credentialed to perform c-sections. (Note: This does not obviate the need for the presence of a second provider to focus on the care of the neonate in accordance with recommended standards of practice.)

• Cross-train nurses and/or support lateral moves of nursing staff from other units within hospital to provide care on the obstetric unit.

• Partner with nearby educational programs to establish teaching/pipeline programs in nursing and other health professions that include rotations in obstetric unit.

• Expand remote telemonitoring and telehealth programs to support care of high-risk pregnant and postpartum patients (e.g., blood pressure, diabetes, mental health) in rural populations.

• Support/incentivize staff and provider professional development and additional credentialing including in lactation counseling, c-section (family practice physicians), and other areas.

• Provide compensation and support to attend trainings outside of regular work hours (e.g., overtime pay, funds for travel, registration fees, etc.).

• Support professional development and skill maintenance programs in obstetrics across the hospital workforce and, where relevant, among community providers (e.g., EMTs, visiting nurses, community midwives, doulas, social workers, community health workers, etc.).

• Establish pool of consistent locums/per diems to cover vacations and weekend call to sustain existing providers and nurses.

• Establish consistency in workflows, protocols, equipment, and other aspects of the physical environment across hospital OB units to facilitate easier transitions between sites where OB care is provided.

a t the unit level

For OB unit leaders and workforce

• Identify existing successful models to inform plans for integrating CNMs into service (in hospitals where not already part of provider team).

• Establish obstetric nurse residency programs for new hires.

• Promote welcoming culture/integration of traveling nurses into unit to motivate accepting permanent employment.

• Utilize skilled/experienced travelers to help train new OB hires.

• Build/strengthen relationships with community midwives to encourage consultations, coordination of care, and transfers when warranted.

• Continue to provide regular on-site, team-based educational activities/simulations to support maintenance and acquisition of OB skills.

• Demonstrate appreciation for the work of obstetric staff and providers through public displays such as walls of appreciation, media stories, or other visible acts to acknowledge exemplary and demanding work.

• Bring med-surg patients to obstetric units for in-hospital care rather than having OB nurses float to other units.

These initial recommendations are based on our discussions with hospital nurses, providers, and administrators, and observations of the hospitals and units where they work. Additional research would further advance understanding of how to support these rural hospitals and the obstetric health workforce. Future research could include interviews with patients, community midwives, social workers, community members, staff and providers from obstetrics units that have recently closed, and staff and providers at tertiary care facilities that receive patients from rural areas.

l imitations

This study highlights crucial insights into how to best support the obstetric workforce in rural Maine. While rigorous, it is not without limitations. We interviewed and conversed with more nurses than providers or administrators. While this may be interpreted as a sampling bias, we note it also reflects the proportions of each role within the hospital obstetric workforce. Furthermore, few providers were interviewed or spoken with as it was difficult to schedule as their time seemed to be highly

protected by administrative staff, and few were available on the unit during site visits. Only one CNM was formally interviewed. It is recognized that the tight timeframe and gaps in interviewee roles may suggest a gap in perspectives.

While the partnership with RMOMS proved to be crucial to setting up successful conditions for conducting this rapid needs assessment, several of the interviewees were noted to be active members of the RMOMS network which may have biased their participation. In addition, though we conveyed our established structure to ensure anonymity, it is possible interviewees felt unable to speak as freely as they would at a larger hospital or from a larger community. Furthermore, it is possible interviewees may have felt the need to protect the hospital’s reputation and were therefore less forthcoming in conveying needs, challenges, or problems within their unit. Finally, this study also did not engage with patients or community members as this was outside of its scope; however, absence of these voices is recognized as an important limitation to the study.

Conclusion

The main takeaway from this assessment is that while there are many needs across the obstetric workforce in rural Maine, there is much to celebrate. The dedication and high-quality, individualized care provided by interprofessional care teams is exceptional. Clearly there is great interest among stakeholders at all levels across the state to keep these rural obstetric units open and to support the health of the communities they serve. To achieve this, it is essential to build on the growing momentum and further the work of prioritizing multi-level, tailored interventions to address each hospital and unit’s unique needs. To this end, a recommended first step includes sharing this report broadly across the RMOMS network, the larger Maine obstetric workforce, and the communities they serve to lay the groundwork for a participatory design process for implementation of future interventions.

References

American Hospital Association. “Obstetrics | US Rural Hospitals,” 2022. https://www.aha.org/system/ files/media/file/2022/04/Infographic-rural-health-obstetrics-15ap22.pdf .

Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Natality on CDC WONDER Online Database. Data are from the Natality Records 1995-2022, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.

Government Accountability Office. “Report to Congressional Committees: Maternal Health, Availability of Hospital-Based Obstetric Care in Rural Areas.” United States Government Accountability Office, October 2022. https://www.gao.gov/assets/gao-23-105515.pdf.

Kozhimannil, Katy B., Michelle M. Casey, Peiyin Hung, Xinxin Han, Shailendra Prasad, and Ira S. Moscovice. “The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities.” The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association 31, no. 4 (2015): 365–72.

U.S. Census Bureau. “‘AGE AND SEX.’ American Community Survey, ACS 5-Year Estimates Subject Tables, Table S0101,” 2020. https://data.census.gov/table/ACSST5Y2020.S0101 .

US Census Bureau. “‘URBAN AND RURAL.’ Decennial Census, DEC Demographic and Housing Characteristics, Table P2,” 2020. https://data.census.gov/table/DECENNIALDHC2020.P2.

Appendix

e xamples o F interventions in the literature

CMS. “Improving Access to Maternal Health Care in Rural Communities.” Accessed January 23, 2024. https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/ruralhealth/09032019-Maternal-Health-Care-in-Rural-Communities.pdf.

HRSA. “Improving Rural Maternal Care through Network Models: The RMOMS Program,” October 2021. https://www.hrsa.gov/sites/default/files/hrsa/rural-health/rmoms-fy19-program-summary.pdf.

HRSA. “Improving Rural Maternal Health Care through Network Models: Summary of the RMOMS Program 2021 Cohort,” September 2022. https://www.hrsa.gov/sites/default/files/hrsa/rural-health/grants/ rmoms2-program-summary.pdf.

Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press (US), 2011. http://www.ncbi.nlm.nih.gov/books/ NBK209880/.

Kozhimannil, Katy B., Carrie Henning-Smith, Peiyin Hung, Michelle M. Casey, and Shailendra Prasad. “Ensuring Access to High-Quality Maternity Care in Rural America.” Women’s Health Issues 26, no. 3 (May 1, 2016): 247–50. https://doi.org/10.1016/j.whi.2016.02.001.

The University of Minnesota Rural Health Research Center. “Making It Work: Models of Success in Rural Maternity Care,” February 20, 2015. https://rhrc.umn.edu/project/making-it-work-models-ofsuccess-in-rural-maternity-care/.

Rural Health Information Hub. “Rural Health Models and Innovations,” 2024. https://www. ruralhealthinfo.org/project-examples.

Woolcock, S, E Fredrickson, DV Evans, CHA Adrilla, LA Garberson, and DG Patterson. “Understanding and Overcoming Barriers to Rural Training in Family Medicine Obstetrics Fellowships.” Policy Brief. WWAMI Rural Health Research Center, University of Washington, June 2023. https://familymedicine. uw.edu/rhrc/wp-content/uploads/sites/4/2023/06/RHRC_PBJUN2023-Woolcock.pdf.

t able a 1. Locations and characteristics of hospitals participating in the RMOMS workforce needs assessment.

*Critical Access Hospital

a Regularly used beds + extra including overflow, doubling up, not generally used

b OB: obstetrician; FM: family medicine physician; CNM: certified nurse midwife

c Steady, increasing, decreasing, fluctuating

Metro counties

Non−metro counties

F igure a 1. Changes in health status of pregnant people in Maine. Data from CDC Wonder. Metro/ non-metro counties defined according to OMB.

This assessment was contracted by MaineHealth to the Roux Institute at Northeastern University. It was supported by Rural Maternity and Obstetrics Management Strategies (RMOMS) grant number UK9RH46984, through the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.