Rural Maternity and Obstetrics Management Strategies – Dartmouth Health
The Georgia Health Policy Center recently spoke to Daisy Goodman, D.N.P., M.P.H., C.N.M., an associate professor of obstetrics and gynecology at Dartmouth Health and the project director for the North Country Maternity Network, about using the RMOMS grant to build a maternity safety net in the New Hampshire North Country.
To date, what has been the biggest accomplishment or win in your RMOMS program?
In our planning year, we introduced a new concept and role to the North Country, which is the role of a doula combined with a community health worker. There already are some independent doulas who have worked in the area, but they are not very well utilized and sometimes not well-received in hospital settings. Up until now, there has not been a reimbursement pathway, so it has been a pretty small group of people who benefited from their care due to out-of-pocket cost. We are working on a sustainable approach that will offer no-cost doula services to every birthing person that resides in the north country. We will be housing these three doula-community health workers in our community-based partner organizations as part of the North Country Health Consortium. We also hired a high-risk registered nurse care coordinator, who is going to be responsible specifically for the people who are high risk and making sure that they get appropriate care and follow-up, as needed. The hospitals are really enthusiastic about this as they see this role as bridging between health care systems and community resources.
The second thing that I feel like we have done well is our baseline assessment. We are gathering voices of birthing people in the North Country. We also met with emergency department staff and conducted a baseline survey with our clinical sites. As a result, we identified some areas where education about early warning signs and urgent signs for perinatal complications are lacking, specifically in our first responder teams. We developed an approach that will build on some prior work, and we will implement this training in an ongoing way.
What is a tip or early learning that you would share with an organization launching a similar program?
I think one-on-one meetings are really important. We struggled to get people, who are absolutely committed on paper, to come to meetings. We understand they are busy, so we are trying to make sure that everybody is informed if they do not make it to a meeting, including scheduling a one-on-one meeting where we will drive two hours up to a site and have a sit-down conversation.
Even though a tertiary care center is the fiscally responsible agent for this grant, the project is really being driven by the community. Our public health partner in the North Country is a health consortium and we meet with them every week, and all the planning is done in conjunction with them. It is important not to come in from the outside as an academic force, throw our weight around and tell everybody how to design maternity care services. Here. We really listen to the community about what they want and need and then, if we see holes, like a better way to manage hypertension, our role is to say, ‘There is new research out there about this. Let’s talk about how we might implement that approach.’ We recognize that sometimes people who are very busy trying to save lives of the people that they are working with right now might not have time to read that research, so that is where we can be a partner.
How do you see participation in the RMOMS Program as impacting your broader health improvement efforts?
Public health improvement in this area has focused primarily on elder care because it is an aging area and on substance use and mental health conditions, which are huge problems. The area has lost two of our five maternity care units in the past 20 years, plus there are two others that are teetering and that has been hard for people. This influx of attention has been really valuable for the area and makes people feel like somebody does care about pregnant people in this area. We are working hard to build this concept of a north country maternity network that will be a safety net for pregnant and postpartum people and their babies.
What’s next on the horizon for your grant-funded program?
We are focused on the first implementation year. Our high-risk care coordinator will be flagged every time somebody gets a referral to maternal-fetal medicine, for an in-person or telehealth visit our specialty practice at Dartmouth Health. She lives in the North country and will be able to meet people and do nursing education with them like at their house or at one of the clinics where they get prenatal care. She will follow up postpartum to ensure they are adequately cared for and do not face preventable postpartum risks. Our community health worker doulas will meet patients at their prenatal visits, talk to them about what their needs are, and offer them assistance, including linking them to needed community services, and follow up with them appropriately.
We feel like we wrapped our arms around what the problems are, and we have some ideas for fixing it. The great news is that New Hampshire voted in 2023 to extend Medicaid coverage to a full year postpartum, and that includes reimbursement for the doula role, so that means that we are going to be able to think about sustainability in a different way.