The University of Arizona College of Nursing Nurse Midwife Program and the Center for Rural Health Team Up to Improve Maternal Health with Labor and Delivery Skills in Rural Arizona

On a chilly January morning, Emergency Department Nurses, EMS and local firefighters – the backbone of rural emergency response  – gathered in a conference room at White Mountain Regional Medical Center (WMRMC) in Springerville, Arizona. They were there to care for Sophie and her Mum. Sophie, a six and a half pound, startingly realistic newborn mannequin, along with her mannequin Mum (crafted in Australia) were there to give hands on simulated training in labor and delivery in a rapid birth situation. Some participants had previous experience caring for a person in active labor when travelling the far 50-plus miles to the nearest birthing hospital, Summit Health in Show Low.

The training program was developed through a collaboration between the Arizona Medicare Rural Hospital Flexibility Program (AzFLEX) at the Arizona Center for Rural Health (AzCRH) and the Nurse Midwife Program at the College of Nursing at the University of Arizona. The goal was to improve maternal healthcare skills in rural Arizona. The training builds skills for providers who practice in maternal health deserts and high need areas where distances to labor and delivery services can be many miles away. 

The need is alarming

The United States has the highest maternal mortality rate of developed countries, defined as maternal death during pregnancy, childbirth or within 42 days after delivery. Arizona’s maternal mortality rate is worse than the national average and has worsened in recent years. Report cards from March of Dimes and the Arizona Department of Health Services Maternal Mortality Review Board illustrate alarming downward trends in maternal health outcomes. Contributing factors to maternal mortality include fewer facilities offering labor and delivery services, inadequate behavioral health services and substance use disorder treatment, shortages of obstetric providers, long drive times to access care, lack of reliable transportation, and other socioeconomic determinants. Training the available rural health workforce and first responders in best practices for precipitous deliveries is one approach to improving care and outcomes.

Simulation-based experiential training delivered at Critical Access Hospitals without labor and delivery units helps to bridge the gap in access to maternal health care. Designed for Emergency Department registered nurses, physicians, EMS, and other care providers - the simulation training teaches skills to attend rapid births, provides hands-on maneuvers, and fosters patient-centered experiences. 

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Erin McMahon, EdD, CNM, FACNM, the founding director of the Nurse-Midwife program at the U of A College of Nursing, is passionate about using simulation as a teaching strategy.  McMahon said, “the opportunity to practice clinical situations that happen infrequently but require clinical skill can optimize outcomes for pregnant women and their newborns.” 

WMRMC was an ideal partner to host the simulation. Located in Apache County, WMRMC serves a community with some of the longest drive times to the nearest birthing hospital (53 miles) in the state. It is a a federally designated Critical Access Hospital (CAH), which means it has less than 25 inpatient beds, is 35 miles or more from another facility, and provides Emergency Department and inpatient services 24-hours a day, 7days per week. WMRMC participates in the AzFLEX program and has a long-standing relationship with AzCRH. Jill Bullock, Associate Director for the Arizona Center for Rural Health, recalls hearing a presentation on maternal health by the medical director of the Federal Office of Rural Health Policy (FORHP). “I found out we could provide training under the Flex program so connected with the new U of A Midwife program to do simulation training at White Mountain Regional Medical Center. We are working on ways to expand the OB simulation training to other Arizona CAHs who do not have labor and delivery services.”

Bringing hands-on, experiential training to health professionals in rural and critical access hospitals can improve access to critical maternal health services and reduce the tragic consequences of maternal and infant mortality during and after birth. 

Designed to facilitate participation and discussion, the trainings provided space for participants to reflect and share how the experience would be impactful for their communities. Nurses, physicians, and EMS providers shared stories illustrating the challenges they face and the importance of having the training and skills to provide high quality care.

By the end of the day EMTs, Firefighters, Paramedics, RNs, an EMT/Paramedic Student, hospital administrators and the Fire Chief participated in 70 safe deliveries for Sophie and her Mum. While everyone was tired from the long day, Sophie seemed unphased. She’s ready to train the next batch of rural health professionals. 

Challenges in Arizona 

Two of Arizona’s 15 counites, Greenlee and La Paz, do not have hospitals offering obstetric labor and delivery care. 

Pregnant women must travel an average of 57.5 miles to a birthing hospital in 3 of Arizona’s 15 counties. 

In the US women living in maternity care deserts travel 5.7x farther than those with full access. 

Arizona ranked 32^nd for Infant Mortality at 6.2 per 1,000 live births; the highest rate since 2012. 

Maternal Vulnerability Index are high or very high in nearly all counties in Arizona, with a Maternal Vulnerability Index of 93.5 out of 100 in Apache County, considered Very High.