The March of Dimes 2023 Report Card released Thursday highlights a fourth straight increase in preterm birth rate in Iowa and continued disparities by race/ethnicity across poor birthing outcomes, all part of a maternal health care decline that Abby Flannagan, doctor of osteopathic medicine at UnityPoint Health – Grinnell, said has been decades in the making.

Between January 2000 and December 2021, 41 of Iowa’s community-level hospitals closed their birthing units, with 33 of those in rural counties, according to data from Iowa’s Integrated Data System for Decision Making (I2D2).

“The fact that we’re surprised that rural maternal care is decreasing here in Iowa is just something that has potentially been overlooked because it has been this way for years, and unfortunately, we’re just starting to see more side effects of it now because more places have had to close their maternity floors because of this,” Flannagan said.

According to the March of Dimes report, Iowa’s preterm birth rate was 10.2 in 2022, up from 10.0 a year prior, but the 2022 rate was much higher for American Indian/Alaska Native birthing people (15.7) and Black birthing people (12.4).

While the state’s infant mortality rate continued its downward trend from the 6.0 mark it reached in 2016 to 4.0 in 2021 – 1.4 points lower than the U.S. rate – the infant mortality rate among babies born to Black birthing people was 11.1 and 6.6 among babies born to Asian/Pacific Islander birthing people,” the report says.

Ebonie Bailey has set out to help try to reverse those trends and improve the well-being and experiences of Black birthing people.

Bailey, who said she started her doula journey in 2015 after having three kids of her own, met with a couple of doulas in 2020 during the height of the COVID-19 pandemic to discuss how they could have the greatest influence, which led to the creation of the Iowa Black Doula Collective.

A doula is a trained professional who provides emotional, physical and informational support to individuals before, during and after childbirth. The support a doula offers is non-medical and focuses on the well-being of the birthing person and their overall experience.

Doulas aim to empower individuals by providing education, advocacy and continuous support during the childbirth process, Bailey said.

In addition to all of those services that doulas provide, the Iowa Black Doula Collective engages in community outreach and educational activities, including community baby showers and Doula Bag Facebook Live events that take place monthly, to raise awareness about the benefits of doula support and promote maternal and infant health within the Black community.

Bailey said the disparities in preterm birth rates and infant mortality rates among different racial and ethnic groups are complex and often influenced by a combination of social, economic and health care factors.

Bailey outlined in an email seven potential factors that could contribute to the disparities highlighted in the March of Dimes report:

• Social determinants of health: “Social and economic factors, such as income, education, employment and adequate housing, can significantly impact health outcomes,” Bailey said. “Communities facing systemic racism and economic inequality may experience higher rates of stress, which can contribute to adverse birth outcomes.”

• Access to prenatal care: Bailey said that limited access to quality prenatal care can lead to disparities in preterm birth rates and infant mortality rates. “Barriers, such as transportation issues, lack of insurance and inadequate health care facilities can prevent individuals from receiving timely and appropriate prenatal care,” she said.  

• Maternal health disparities: “Disparities in maternal health, including pre-existing health conditions, can contribute to adverse birth outcomes,” Bailey said. “Black women may face higher rates of chronic health conditions, such as hypertension and diabetes, which are risk factors for preterm birth and infant mortality.”

• Implicit bias in health care: Bailey said studies have shown that implicit biases among health care providers can impact the quality of care individuals receive. “Black birthing people may face discrimination or receive suboptimal care, leading to poorer outcomes,” she said. A 2021 Iowa Maternal Mortality Review Committee report found that of all pregnancy-associated deaths reviewed, “structural racism and/or discrimination were determined to be a contributing factor in 40% of the cases.”  

• Stress and racism: Bailey said that chronic stress, often exacerbated by experiences of racism and discrimination, can contribute to adverse birth outcomes. The stress associated with racism has been linked to preterm birth and low birth weight.

• Community resources: “Disparities in access to community resources, such as nutritious food, safe neighborhoods and social support, can affect overall health and contribute to adverse birth outcomes,” Bailey said.

• Systemic racism: Bailey said structural and systemic racism can permeate various aspects of society, including health care, leading to unequal treatment and opportunities. “Addressing disparities in preterm birth and infant mortality requires efforts to dismantle systemic racism and promote equity in health care,” she said.

“Efforts to address these disparities require a multifaceted approach that includes improvements in health care access, addressing social determinants of health, reducing implicit bias and promoting policies that support maternal and infant health equity,” Bailey said. “Addressing the disparities in preterm birth rates and infant mortality rates requires a comprehensive and multifaceted approach involving health care, social services and community initiatives.”

More than one of these factors can occur at the same time, creating a complex web of influences on health outcomes.

Two of the challenges regarding maternal health care that Flannagan, who specializes in women’s health in Grinnell, has seen are lack of access and lower workforce numbers.

“We’re down manpower, for sure, so there’s actually only two of us here in town that do [cesarean] sections, so we’re trying to cover every day of every month in order to keep our [obstetrics] floor open,” Flannagan said. “We do need to have somebody available on call to do a C-section in an emergency, so the two of us are kind of balancing trying to cover 30 days a month and still balance families and things like that.”

With the rising number of rural labor and delivery unit closures within the past two decades, Flannagan said that UnityPoint – Grinnell is now only one of a couple hospitals providing services between Des Moines and Iowa City.

“When you think of only having a couple places to stop in a two-and-a-half hour drive, it can be very nerve-wracking, I think, for our patients who live more rurally to know that they’re going to make it to the hospital in time,” Flannagan said.

Increasing staffing has been a growing need for UnityPoint – Grinnell as the number of new patients continues to tick up, driven by surrounding OB units shutting down.

“We just see our numbers grow and grow from a patient standpoint,” Flannagan said. “We’re up almost 40 or 50 deliveries from last year, which in a hospital like ours, is a pretty significant number of growth. Ideally, between the two surgeons and our midwife, who’s fantastic, there’s three of us doing deliveries now. We are looking to add one more partner to our team.”

While workforce gaps have been widening in rural areas across the state, Flannagan is one of three physicians who have transferred recently to the Grinnell clinic.

“I think we’re getting really good support from a staff hiring standpoint,” Flannagan said. “Unfortunately there are just not as many people going into health care as there used to be, but I think they support us really well in knowing what our needs are here. Between me joining and our two family medicine physicians, three of us have now come from Des Moines in the last two years, knowing that hopefully we can make Grinnell an excellent stop along the way and help relieve some of the pressure that the bigger cities are seeing as well. UnityPoint is doing a very good job with that.

“We did open up an outreach center in Marshalltown, which has allowed us to bring women’s health back to that area that was so desperately in need since they lost their providers a couple of years ago.”

And while several labor and delivery units across the state have shut down, Floyd Valley Healthcare in Le Mars is planning a renovation and expansion of its maternal care department.

“It’s a multiphased construction project,” Tara Geddes, chief nursing officer at Floyd Valley, said. “The first phase will be our OB renovations. We expect that to be completed by spring of 2025, so about a year project for that renovation, give or take a few months, and then we’ll be moving from that into a renovation and expansion of our lab services as well.”

The update will include larger rooms where birthing people will be able to labor, deliver and receive postpartum care all in the same location without having to move to another room.

“We have had phenomenal OB care throughout the years in our labor and delivery department,” Geddes said. “We have great physicians and nursing staff. Our existing unit, though, was just quite small. Our current rooms are about 200 square feet each, and so they’ve just really not been able from a square footage and space perspective, been able to keep up with the technology and the demands from our community. By moving into this new space, we were able to double the size of our rooms, and we’re moving from one delivery room into a [labor, delivery, recovery and postpartum] room, where moms will be able to labor and deliver and then have postpartum care right there.”

Geddes said they expect the project to cost about $5 million and have received donations from community businesses and community partners.

“Donors have really stepped up to the plate,” she said. “We’re doing a capital campaign to continue raising funds for that project, and then additionally we will cash flow the difference between the donations and the final sum.”

Updates could be coming to UnityPoint – Grinnell, as well.

“We’re looking at hopefully remodeling and adding some more labor rooms because we’re outgrowing our facility quickly with the amount of counties that we’re covering right now,” Flannagan said. “We’ve gotten good support from all of our donors and things here in Grinnell have been fantastic, too, on helping us to remodel, make things a little bit more comfortable and hopefully get us a few more rooms, so that we’re not ever at a point where we’re just simply full and can’t take more patients.”