Child and Maternal Health in WNC - WNC Health Policy Podcast Ep. 1
Katlyn Moss, Region 1 Perinatal Nurse Champion. Photo: Colby Rabon/Carolina Public Press
In WNC, there are fewer than 10 hospitals that provide delivery services and only one Maternal Fetal Medicine (MFM) provider across the 18 counties and Qualla Boundary. This lack of access to vital pre- and postnatal care creates “maternal healthcare deserts,” resulting in high maternal mortality rates, worse health outcomes, and increased healthcare costs. To address this crisis, WNC must explore place-based collaborations and policies to improve Maternal, Infant, and Child Health in the region.
Learn more about the WNC Maternal, Infant and Child healthcare landscape with NC’s Region 1 Perinatal Nurse Champion, Katlyn Moss (BSN. RN).
About the host: Andrew is a trauma-informed systems thinker, educator, linguist, and naturalist with an international worldview. Currently an MPH candidate at the Gillings School of Global Public Health, he is also a mental healthcare worker and longtime community radio producer.
RESOURCE LINKS
The March of Dimes 2022 NC Report Card
NCDHHS Women, Infant, and Community Wellness Section
MAHEC Maternal Health Innovations Grant
Just Us: Before Birth & Beyond Podcast
Sistas Caring 4 Sistas Doula Group
MUSIC
Little Margaret, by Cath and Phil Tyler, is found on the FreeMusicArchive. It is licensed under an Attribution-Noncommercial-Share Alike 3.0 United States License.
Expectations, by Lee Rosevere, found on the FreeMusicArchive under license attribution international CC BY 4.0.
Cobweb Transit, A Catalog of Seasons, Blister Creek, and Night Watch, by the Blue Dot Sessions, found on the FreeMusicArchive under license attribution international CC BY 4.0.
Evening Shade, hummed by Asheville-based Appalachian ballad singer Saro Lynch-Thomason for the HPI Podcast. You can learn more about her work and regional music traditions at https://www.sarosings.com/
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FreeMusicArchive: https://freemusicarchive.org/home
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To learn more about our studio host, AshevilleFM, please visit: https://www.ashevillefm.org/
Transcript
WNC HPI Podcast: Maternal Infant and Child Health with Katlyn Moss
6/14/2023
KM: Katlyn Moss
AR: Andrew Rainey
____________________________________________________________________
KM: Really, the overarching goal is of course, to decrease our maternal morbidity and mortality rates in the state which are not great.
*Music begins
INTRODUCTION
AR: You’re listening to the Western North Carolina (WNC) Health Policy Initiative (HPI) Podcast.
*Car door closes
AR: I’m Andrew Rainey. In each installment, we’ll speak about different public health strategies for improving health and wellbeing in WNC.
Recorded in the studios of Asheville FM, in this first installment: Maternal, infant and Child Health.
(1:07) I have the privilege to speak with 2023 HPI caucus panelist, the Region 1 Perinatal Nurse Champion on MAHEC’s Maternal Health Innovations team, and fellow audio producer, Katlyn Moss, about Maternal, Infant, and Child Health in WNC. Thanks for being here!
KM: Thank you for having me, Andrew, I’m very happy to be here. AR: Could you tell us some about your journey in the field?
Overdub: The neo-natal intensive care unit
KM: So, I am a nurse. I’ve been a nurse for 10 years this summer, actually, summer 2023, and I have practiced mostly in women’s health or NICU nursing…
KM: ...for my entire career, so I’ve done some labor and delivery nursing, some outpatient OBGYN office nursing- always just kind of in that realm of maternal, infant, and child health.
I work for MAHEC OBGYN out of Asheville, but I actually live in Clay County, or Hayesville, is the town name, and it’s about 2 hours west of Asheville so right at the very tip of the state of NC.
My official title is the Region 1 Perinatal Nurse Champion. I was hired into my current position to do maternal outreach in the 16 western-most counties of North Carolina - trying to get the word out about maternal health, make sure we’re promoting equitable and evidence-based practice in relation to maternal health in the state, and really, the overarching goal is of course, to decrease our maternal morbidity and mortality rates in the 16 western-most counties, which are not great.
AR: It sounds like you’re in a strategic role to both have an ear to the ground and a sort of bird’s eye view of maternal health.
KM: I’m in a unique position because we are not attached to a hospital system, and we are a nonprofit organization, so it just makes it easier for, you know, myself and my team to have conversations with all of the key players in women’s health in this part of the state.
TOPIC DEFINITION
AR: (3:25) Before we go any further, I wonder if you could define maternal, infant, and child health. How would you describe that for those who are outside the field?
KM: Sure, so this is an area of health that really focuses on developing and promoting programs that protect the health and wellbeing of infants, birthing women, and children. But I want to emphasize that this is not just the pregnant woman that we’re focusing on, right? Its women and birthing people of childbearing age before they’re pregnant, during their pregnancy, and after the pregnancy, as well as the care of not just the infant, but also the child. You know, paying attention to developmental milestones, making sure that these infants and children have all the resources that they need: access to good education. Really focusing and honing in on those social determinants of health, so transportation, housing, education, food insecurity, you know. It is a public health domain. We’re not just looking at healthcare, we’re looking at all the other factors that affect healthcare. So really focusing on mom, baby, but also on either side of that: before the woman is pregnant and then after she has the baby, making sure she has access to as many resources during that period as she did when she was pregnant. That’s what it means to me.
ASSETS
AR: (4:49) When a region faces negative outcomes, these challenges can often lead to a mischaracterization of both the people and the place where the issue is happening. So, I wonder if you could tell us a little about what you love about working in maternal health here in WNC.
KM: Sure. So I have to say, the first thing is the mountains. I have some pretty deep roots in this part of the state on both sides of my family. My great grandparents, great great grandparents were living in Hayesville, so I feel like this region and its landscape is just sort of in my blood, so I’m very proud to be from the mountains. In regards to this work though, I think that there is a really fantastic sense of community and pride in coming from WNC. We’ve seen labor and delivery units close across this part of the state and every time there was one that closed there was this really great coming together of that community to try and help either stop it or just express their concern about losing a service like this in newspapers, and news outlets, and there was a coming together of community which was really beautiful to see even though the result was, of course, not what we wanted.
AR: I’ve noticed that several friends and acquaintances I have from WNC have a lot of pride in the county or hospital where they were born. I’m curious if that’s true out in Clay County too.
KM: Yes, it definitely is. We are a little unique out that far because a lot of our birthing women actually go across state lines to deliver- they go to Georgia because that’s really where the closest labor and delivery to us is. But yes, it rolls out into sports too, right, like your high school -especially those far far west counties. There’s just very much a sense of pride for our little small towns.
I also think that there is a really good sense of excitement around pregnancy. It’s really amazing to see all the family involvement. We’ll have pregnant patients come to the office and they’re bringing their mom, they’re bringing their mother-in-law. Our dads are often really involved and that’s really a beautiful thing to see. You know, those family values and family involvement is really predominant, really in every demographic across this part of the state, so that’s something that is really beautiful.
AR: (7:15) As a maternal health champion doing outreach in 16 of the states’ western most counties and part of a network of other NC maternal health champions, do you find yourself collaborating with other practitioners and sharing ideas?
KM: Yes.
AR: You hear that kind of thing?
KM: Oh my gosh 100%. We piloted an “I gave birth bracelet” project at one of the hospitals that we’re hoping to get to the rest of the region as well. An OB hemorrhage simulation that we’ve done. I have to say, the other perinatal nurse champions in the state who I’m gonna to call out by name right now: Karen, Jessica, Liz, Tina, Kathleen. I love you. We work so well together- I have never worked with as fantastic a group of women as I am working with right now, and not only do we bounce ideas off of each other, vent with each other, get ideas from each other, but we share projects. So, this “I gave birth bracelet” project that I talked about actually started with Jessica’s region, so that’s something that’s really beautiful.
REGIONAL CHALLENGES
AR: (8:20) What challenges do you encounter in your work?
KM: There are a few. Transportation is a huge one. Ubers not a thing. Lyfts not a thing. And there are lots of patients in positions where they don’t have reliable transportation. There are also not a bunch of resources for that. We often have patients who tell us transportation is a problem for them, and then we don’t have anything to connect them to. So that’s one huge thing.
And then, yea, the multiple closures of labor and delivery units. We at MAHEC OBGYN house the only maternal fetal medicine providers in this part of the state. And these are providers who take care of really really high-risk conditions whether it’s in the mom or the growing baby. So, for all 16 western counties, as a provider, you have to refer a patient to an MFM provider the only often is Asheville and that just compounds on that transportation problem. You know, some people can’t get the hours it takes to get to Asheville to see a specialist for prenatal care.
And then also we have multiple healthcare systems in WNC. Like 4 or 5. And there are 7 labor and delivery units. A lot of the labor and delivery units live within different hospital systems and so it’s really hard to figure out ways for these hospitals to share data, which is really important in this part of the state because the way that the landscape is, it’s very possible that you’re gonna have patients who receive care in one hospital system but have to deliver because of an emergency in another hospital system. The electronic health records do not communicate and so that means you could be in one hospital, get a pregnant patient walk through the door in an emergency situation and have no idea how far along she is, what her blood type is, what kind of neonatal or NICU services you’re gonna need, you know med allergies- you just don’t have the access to the information that you need to best take care of this patient because of this differentiation in healthcare systems. So that’s a really huge challenge.
Education. So, you get a 15-minute prenatal visit. I know providers can’t get all the information that a birthing woman should have to her in that period of time. You know, the internet is a blackhole, so having access to clear concise helpful information.
And this is such a vulnerable and intimate thing that is happening to them. It is life-changing. We are not addressing it as such and setting our systems up to address it as such and to give it the sacredness that it deserves.
AR: So, we’ve heard about some of the challenges for women in WNC in getting quality maternal health services. Are there other challenges in this region- for example, that impact providers?
KM: Secondary post-traumatic stress disorder is a thing that happens to healthcare providers who are tasked with caring for people in emergency situations that can sometimes come up in labor and delivery. It’s really really happy most of the time, but when it’s not, it’s really really not. And so, burnout is a thing. And our systems are set up in such a way that it’s easy to not feel like that you have everything you need to take care of your patients truly to the best of your ability. So that’s a huge barrier.
Also, substance use disorder treatment. Opioid use is a huge problem in this part of the state. We don’t have a lot of treatment options. And there is a horrible stigma that comes with being pregnant and having a substance use disorder, so not only is there a challenge to get medical care for these individuals but there’s also a cultural challenge of them even being able to ask for the help. So that’s a huge barrier.
I also have lived experience in the realm of access to maternal care especially in the rural parts of the state. I live in Clay County, which is a very rural part of WNC. I have 2 daughters and for my first pregnancy I was working for a specific healthcare system so had that healthcare system’s insurance which means it was cheaper for me to deliver at one of those facilities, the closest one being 45 minutes away. So, I received my prenatal care and had my first delivery at a hospital 45 minutes from my house which is not super close if there was an emergency situation. I was very, very blessed in the fact that I had a pretty seamless pregnancy a pretty seamless delivery everything went great. And then between my first delivery and my second, that hospital labor and delivery actually closed. I continued to work for that healthcare system so the cheapest for us to do was to deliver at a hospital within my healthcare system that I worked for and the closest one was 2 hours away. I did have actual conversations with my then husband about like “if I do go into labor and there’s an emergency and we deliver on the side of the road this is what we’re gonna do this is what you’re gonna have to do” and this is all because I have knowledge as a former labor and delivery nurse. You know, I can’t imagine our patients who are making this travel with no background or information in regards to the medical part of things like I had.
There was also a really huge snowstorm. So, of course I was due in December. Again, my then husband and I had a genuine conversation, even included our provider in it, about like “do we drive out to Asheville and stay the weekend in case something crazy happens and I do need to deliver and we can’t get you know where we need to because of the weather. . .” And I am a prepared nurse, make decent income, at the time had a very supportive partner, and these were real conversations that we were having in order to safely have our baby. And I can’t imagine the anxiety and the stress that comes along with pregnancy in a rural part of WNC with a lack of the resources that I am so privileged to have.
Something I always like to mention too is the drive back. And this happens a lot in maternal, infant, and child health is as a whole we focus very very intensely on the pregnancy, and just that period of being pregnant, and once the baby comes out it’s like “ok great, you know, problem solved,” but we actually had to stay in the hospital for an extra couple days and so when we were finally discharged from the hospital, it was 5 o’clock at night, in December, it was getting dark, I was 3 or 4 days post-partum, bleeding, still cramping, breastfeeding, wearing this huge diaper, and this giant pad, and I had to sit in the car for 2 hours to get home in the dark. It was raining, we get home, my driveway is a gravel driveway, I’m like bouncing all over the backseat. It was just very uncomfortable and not the magical ride home with your new baby that you want.
So this is going on 5 days that I have not seen my 3 year old child and that other people have had to take on the childcare. Praise my parents, they’re fantastic, and it was so wonderful to have that, but not everyone has those resources. So it’s not just pregnancy to delivery, it is the postpartum period as well that is just really hard to get the care you need when you live rurally.
AR: Its incredible really. Just the standard transportation making it an almost emergency- sounding situation. .
KM: And we have a car, and we can afford the gas 2 hours one way. Again, there are so many women and birthing people in our rural parts of WNC that don’t have the resources they need to do this effectively and comfortably. Pregnancy is uncomfortable enough to add social factors and other things like that to the table. It’s hard. And it shouldn’t be so hard.
BREAK
AR: Hey everyone, Andrew here on the WNC HPI Podcast, the show that looks at public health strategies to improve health in WNC. Today we’re talking about Maternal, Infant, and Child Health with Katlyn Moss, who is a perinatal champion for WNC. We’ve heard some about her work and challenges facing the region, and now in the second part, we’ll hear her thoughts on interventions and resources for improving Maternal, Infant, and Child Health in WNC.
SOLUTIONS
AR: (18:35) Hearing all of these issues for maternal, infant, and child health in WNC. . . are there any practices or policies that you’d like to see enacted?
KM: This work is hard because of the systemic influence on a lot of the problems. One thing that I am stuck on and can’t let go and don’t know how to make happen is reimbursement rates. So, we have a very large Medicaid pregnant population, so a lot of our pregnant patients have pregnancy Medicaid, and reimbursement rates are such that it is really hard, especially for rural labor and delivery units so with the lower volume, for them to sustain that labor and delivery unit based on the Medicaid reimbursements.
And I know for a fact that C-section deliveries are reimbursed, so hospitals are paid more for C- section deliveries than they are for vaginal deliveries, and it comes down to utilization of resources. You know it takes more supplies, more personnel, etc., to do a C-section. However, the standard of care in pregnancy is a vaginal delivery- that’s always the goal. Its’ not always possible, C-sections are not lesser than vaginal deliveries, it’s just, the goal is to keep the labor and the delivery as natural as possible, which means having a vaginal delivery, and we do two times more vaginal deliveries than C-sections. So, I would like to see Medicaid change the reimbursement rates and just flip-flop them so make vaginal deliveries the standard of care, the evidence-based scientific standard of care, hospitals be reimbursed more for those than their C- sections and because you’re doing more vaginal deliveries than you are C-sections it’s going to offset that extra resource and personnel cost to C-sections, and it’s also telling providers and communities that we value natural, safe, healthy, and low risk deliveries, and we value the opportunity to do those in their home county and closer to home.
Another solution would be, of course, some kind of system for transportation in rural areas. And not just scheduled planned transportation but very much in the sense of like Uber and Lyft. You know we have patients call the office:
“I don’t feel right. I’m having contractions and I don’t think I should be,” You know, etc. and it’s:
“Ok, you know, well, come to the office, and we’ll check you out.”
“Well, I’m at home with my 2-year-old. We only have one car. My husband’s at work. I have no way to get to the office before you close.”
In doing that you’re going to make it easier for rural labor and delivery units closer to these people’s homes to stay open. Its going to make it a more financially sustainable model of care.
As a nurse I have gone to pick patients up if they couldn’t get to us for whatever reason. And of course, that’s not reimbursed, or part of my job description, or possible every time that it needs to happen, but you know, could we make that reimbursable? Could we set up a system within a doctor’s office if there’s someone there that does some kind of transportation service for the patients? You know, I don’t know, but I do think that transportation is an immediate issue that we should try to fix.
We in WNC are really great at identifying the problem, we’re really great at screening our patients, we’re really great at understanding what some of their health barriers are, but sometimes there’s just not anything to connect them to. So it’s like “yes I understand you’re having trouble with transportation but the only option you have is Medicaid transit through the health department which has to be scheduled 3 to 4 days in advance and you’re only allotted so much time.” You know, sometimes our appointments take a long time, sometimes there’s a wait, sometimes we’ve doubled you up and you’re not only going to see the provider but you’re going to get an ultrasound today or. It doesn’t take into account the same day urgent like “we need to check you out and make sure everything is ok” situations.
We looked at and really explored the option of getting a mobile unit together to do prenatal care and getting out to some of the regions that have absolutely no prenatal care available. The funding wasn’t there. But that was another like “Are you kidding me?”
There are also telehealth visits. So, there are opportunities for rural patients to see our MFM providers either from their home or from their home doctor’s office if transportation or travel is an issue. So that’s another really great thing that’s happening and could help the transportation issue too is access to broadband and utilizing telehealth services. There’s going to have to be an in-person visit, especially for ultrasounds and things like that, but to be able to connect with the MFM provider virtually is sometimes the only option that patients have.
And then, my last and final is that communication between healthcare systems. So, figuring out a way to share data to prevent emergencies if a patient shows up to a hospital outside the healthcare system where they’ve been receiving their prenatal care. Dr. Dixon, who’s my OB champion, has been hoping for something like a pregnancy registry. So, like an independent database for WNC that houses every pregnant patient and their snapshot vital information that someone would need to take care of the patient if they didn’t have access to the full records and then giving it to all of the prenatal care providers, you know password protected. And you know just call it the ‘WNC Prenatal Care Registry’ and we can make this safer for patients. So, it’s a big undertaking but it could be a possible solution.
POTENTIAL POLICY
AR: While many of those issues you mentioned could be translated into policy, is there any current legislation of note that could improve maternal health in WNC?
KM: So, currently summer 2023 Senate bill 175, or The SAVE Act, which is a bill that would give advanced practitioners - so nurse practitioners, PAs, physicians assistants - full practicing authority. So, currently they need overhead by a physician and this bill would make this no longer necessary in these advanced practitioners would have full practice authority and this is gonna get more practitioners to rural parts. Its gonna increase that access because the further west you get the less providers there are and so if you’ve got practitioners who want to go practice in rural areas but there’s not a physician there that will kind of take that oversight, they’re not going to practice there. And so, I actually start grad school in the fall, and I’m going back to be a family nurse practitioner and I am just crossing my fingers that this bill gets passed for that reason. I want to practice in Hayesville. I want to practice where I live. There are some physicians out there but there’s some liability and financial clout that has to be put in from the physician to do that supervision so not all of them are up for it - reasonably so. So, yea, if that bill could be passed vote, this is going to get more practitioners to rural parts. It’s going to increase that access.
RESOURCES
AR: Finally, any resources that you’d recommend to listeners who wanna learn more about maternal, infant, and child health?
KM: Sure, off the top of my head in a real broad range, the CDC has some really great information, especially in regards to data on the nation as a whole. We do not fare well compared to other well-developed countries and the statistics related to maternal mortality and morbidly like not well at all. And so, you can get a lot of that information from the CDC.
The March of Dimes also has some broader national information, but you can also actually drill that down too by state as well so a little but more specific into NC.
And then NCDHHS is always a great place to start. Our state is really putting a lot of effort and focus on maternal, infant, and child health at the moment and really coming up with some great ideas and programs. I mean my grant would be one of them. So that’s another great place to look.
On a more local and specific level I do encourage you to go to the MAHEC website. We actually created a map of WNC that has every single office providing prenatal care plotted on the map so you can get like a real visual of where the gaps are, where there’s a concentration of healthcare providers, as well as seeing all of the champions for each of the different regions. So maybe if you’re listening outside of WNC, I’m excited to let you know that you do have versions of me (perinatal champions) in your part of the state too and you can jump on over to the MAHEC website and figure out who your champions are. And I actually have an OB champion, a family medicine champion, and a pediatric champion. All providers who I also work with and we actually all four have counterparts in the other 5 regions of the state.
You also have the opportunity to actually click on the county, and you’ll get a little popup that comes up and lists all the offices and address, phone number, website. So it’s a really good resource for patients too if they’re actually looking for prenatal care providers. And you know, check-in with your local health department and see where they’re referring patients who come in and are pregnant. It’s also a really good place to ask about programming and things that are happening locally. Those are kind of my recommendations.
AR: One recommendation I have to add, while you’re here, uh for our listeners, is that you are also a host of the MAHEC “Just Us: Before Birth and Beyond” podcast.
KM: Yea! Thanks! So, we originally uh when the grant started just to give a little background, did a needs assessment, and asked the prenatal care providers what they needed. Education around certain topics was one of the big things that they asked for, so we did a webinar series and got pretty low engagement. So, we pivoted to a podcast format to do some of our education because it’s a little shorter, a little easier to access, you don’t have to be live, you can listen to it in the car, you know that kind of thing. Yea, so we started “Just Us: Before Birth and Beyond Podcast” again with that emphasis on before pregnancy, during pregnancy, and beyond, after pregnancy. And one of the things that I love most about our podcast is one of the filters we put on every single episode we do is “does it apply to WNC?” So, we feature people from all over the state but whatever they’re coming to talk about is available or does affect or impact WNC specifically. So we’re featuring programs like the nurse family partnership. We are doing some didactic episodes so talking about the newest most equitable and evidence-based information on OB hemorrhage, for example. We have an episode coming out on anemia as well. Nurse family partnership is one. And then “Sistas Caring 4 Sistas” is a doula group actually here in Buncombe County and they produced some of our podcast episodes as well. They got some community members that they’ve interviewed. We’ve got an episode from them on education equity which was just fantastic. And I feel like social determinants of health that we’re always talking about, one we don’t often talk about is education. And so, that was one of my favorite episodes we did. This podcast is really geared towards providers and anyone in the healthcare space in regards to maternal health. It’s been really fun and a great way to connect with people.
AR: I guess as evidenced just by our conversation, you’re also a great resource, and I wonder if policy makers were interested in reaching out, or folks who were interested in exploring pilots or other programs for WNC, are you available to reach?
KM: Yes. Please. Do not hesitate to send me an email: katlyn.moss@mahec.net. Like whoever is in charge of Medicaid, please call me, I want to figure out how to switch reimbursement rates on C-sections and vaginal deliveries.
AR: Perinatal champion in WNC, Katyln Moss, thanks so much for talking with me.
KM: Thank you.
OUTRO
AR: You've been listening to the WNC Health Policy Initiative Podcast through the NC Center for Health and Wellness at UNCA. To listen again or learn more about maternal health in WNC, check out the website @ wnchealthpolicy.org. To find some of the resources mentioned in the show you can also find those on the show notes page.
Music included in the podcast includes old ballad, Little Margaret, performed on banjo by Cath and Phil Tyler. Found on the Free music Archives, it is licensed under an Attribution- Noncommercial-Share Alike 3.0 United States License.
Additional music includes the track Expectations by Lee Rosevere, Cobweb Transit, A Catalog of Seasons, Blister Creek, and Night Watch by the Blue Dot Sessions. These tracks are found on the FreeMusicArchive under license attribution international CC BY 4.0.
A big thanks to Asheville-based Appalachian ballad singer Saro Lynch-Thomason for humming the old shape note styled ballad Evening Shade. You can learn more about her work and regional music traditions at sarosings.com.
Additional thanks to the AshevilleFM Studios where this installment was recorded.
Be sure to check the website for more HPI podcast episodes and other resources @ wnchealthpolicy.org. Thanks for listening.