In rural America, the crisis of disappearing reproductive care steals lives

BANGOR, Maine - All the reasons people in this rural region seek reproductive care - and the barriers they must overcome in accessing it - were on full display from the moment the first patient stepped into this clinic nestled amid towering evergreens.

There was the 32-year-old struggling to pay out of pocket for a medication abortion because her credit card wouldn’t go through. A first-time patient who was referred to the Mabel Wadsworth Center - more than an hour from home - because her provider wasn’t sure how best to treat her disabling premenstrual syndrome. Another woman who developed hypertension while pregnant arrived to have her blood pressure checked. And a couple was there for their first prenatal visit.

The nation is in a maternal mortality and morbidity crisis that grows year after year and is particularly acute in rural communities, where it is normal for the nearest hospital to be a long drive away and poverty is too often prevalent.

Each year, tens of thousands of people experience unexpected pregnancy complications - cardiovascular issues, hypertension, diabetes - and about 700 die, making pregnancy and childbirth among the leading causes of death for teenage girls and women 15 to 44 years old. Black women are three times as likely to die as a result of pregnancy as White women, and Native American women are more than twice as likely to die, disparities that persist regardless of income, education and other socioeconomic factors.

And considerable gaps in death exist based on geography, too, with women who live in rural communities about 60% more likely to die from pregnancy complications than their urban counterparts.

Mabel Wadsworth Center is an island of integrated care in this rural community, where state reports show there is one primary care physician for every 1,300 residents and one psychiatrist for every 14,000. Its mission is to provide full-spectrum reproductive care, telegraphed by the art lining the walls: colorful renderings of uteruses and vaginas and black-and-white images of the bellies of women who have given birth, had miscarriages, abortions and stillbirths.

The ratio of primary care providers to patients in Penobscot County, where the clinic is located, is comparable to statewide figures but worse when it comes to mental health providers, and state officials acknowledge a shortage of health-care providers in this largely rural state.

More and more, people want their reproductive health needs addressed in a primary care setting because of the convenience and the relationship established with their provider.

“Patients actually do better when their care is provided by the clinicians that they have grown to trust,” said Julia McDonald, medical director of abortion services at Mabel Wadsworth Center. “As a full-spectrum family physician, the fact that I can provide contraceptive care, provide prenatal care, catch somebody’s baby, provide abortion care, go on to provide well-children care and annual physical exams, just strengthens the bond.”

Said one patient recently as she waited to be seen: “They have my whole history.” She has been coming to the clinic for more than a decade.

Clinicians and public health experts worry the crisis caused by the pandemic, staffing shortages and increased abortion restrictions will tax an already-strained health-care system, further eroding access to comprehensive reproductive care and putting more people who give birth at risk.

Amid disappearing maternity wards as rural hospitals struggle to stay afloat, some experts view more fully integrating reproductive care into primary medicine as a way to expand care and improve patient outcomes.

Primary care providers deliver a significant share of women’s reproductive and preventive health care in rural settings, but not all providers offer the same services. A 2020 study in the Journal of the American Board of Family Medicine found that just 40% of family medicine doctors who recently graduated from residency programs offered long-acting, removable contraception implantation and about 26% provided maternity care. Roughly 3% terminated pregnancies.

Rural communities in huge swaths of the country don’t have an obstetrician-gynecologist, said Charlotte M. Lee, a resident in the obstetrics and gynecology program at Tufts Medical Center in Boston. As a medical and public health student at Brown University, she researched ways to better integrate abortion services into primary care medicine.

“What I had been told, or what I had seen, was only OB-GYNs or nurse-midwives really provide this type of care, then I went to medical school and my world was totally opened up in realizing that family doctors are providing this care all across the country,” Lee said, stressing that she was speaking from her professional experience and not on behalf of her institution.

As a medical student, Lee said she did a rotation at an abortion clinic, where she met family doctors and asked if they performed the procedure in their practices. Some did. Others did not. Curious about the divergence, she interviewed primary care doctors throughout New England.

What she found, according to the study published in August in the medical journal Contraception, was that a mixture of explicit and implied institutional policies, government regulations, stigma and friction among medical specialties kept primary care doctors from being able to provide patients with full-spectrum reproductive care.

“This is not complicated medicine,” she said.

It is, however, controversial.

Here, at Mabel Wadsworth, they try to bring down the barriers that contribute to the nation’s maternal health crisis and knit together a fractured medical system, with its balkanized patchwork of providers and insurers. Primary care, mental health counseling, Pap smears and abortion services are all provided inside this small clinic sandwiched between an allergist and an oral surgeon.

“It’s absurd that there are not clinics like ours everywhere,” said Abbie Strout-Bentes, Mabel Wadsworth’s director of education and community engagement.

But they’re not.

Mabel Wadsworth is Maine’s only private, independent not-for-profit health center providing full-spectrum reproductive care and just one of a handful nationwide.

The care Mabel Wadsworth provides is controversial because offering full-spectrum reproductive care means performing abortions, along with prenatal and postpartum care. So, despite the center’s founders being given keys to the city, the clinic is not welcomed by all.

A small group of “antis” regularly pickets the clinic, where patients spoke on the condition of anonymity out of concern for their safety. Many of the small-town family medicine doctors who work on “clinic days” when abortions are performed travel from more than 75 miles away and don’t broadcast their work at Mabel Wadsworth in their home communities, which are more conservative than Bangor. Here, storefront window displays in downtown show support for abortion rights.

“Abortion has been sort of siloed in the sexual and reproductive health world, which is not helpful,” McDonald said.

Research shows in an ideal maternal health system, women would have access to comprehensive and seamless medical care - and not just when they show up pregnant but before, during and after pregnancy. That often doesn’t happen in the United States, which among high-income nations is the worst place to give birth, especially for Black, Native American and rural women.

In the decade starting in 2010, at least 90 rural hospitals closed in the United States, according to a 2019 report from the Federal Reserve Bank of Boston. And while the study said New England was largely spared the brunt of those closings, population loss and financial pressures have resulted in maternity wards shuttering at hospitals. As of 2019, 22 of the 75 hospitals across Maine, New Hampshire and Vermont lacked a maternity ward, the report found.

The study said rural communities with more African American and low-income families have suffered more rapid loss of maternity wards than have other rural communities. More than half of the nation’s Black population lives in the South, which experienced a disproportionate share of hospital closures, federal reports show, while upper New England remains overwhelmingly White.

The consequence of closing maternity wards and rural hospitals: Patients must travel farther for care, which is more than a matter of convenience. Community health suffers as prenatal care, preventive care and maintenance of chronic conditions becomes increasingly challenging.

More than 60,000 women in northern New England live farther than 15 miles from a maternity ward, and in a large swath of Maine, which is as big as the five other New England states put together, the nearest maternity ward is more than 25 miles away, the Federal Reserve report said.

About one-third of Mabel Wadsworth patients travel from outside the county to receive care.

The hospital where one patient, a 42-year-old mother of four, delivered her babies no longer offers obstetric services. She had driven an hour south to Mabel Wadsworth after being referred by her primary care provider. She’d seen multiple doctors, begging for them to take seriously her extreme mood swings, heavy bleeding and severe pain associated with her period.

“If you’re going to be treating women and doing gynecological care, you can’t dismiss women,” she said, describing her struggles while waiting to be seen. The high school graduate who works two jobs said one doctor told her, “’You’re just not managing your anxiety.’ "

“Mind you,” the woman said, “I’m on three different anxiety medications. I live in this body. I know when something’s not right.”

When she finally was diagnosed with premenstrual dysphoric disorder and referred to Mabel Wadsworth, “I just cried,” she said.

Here, she figured she would at least be believed - and she was.

“Honestly, the importance of the work that we do has been amplified through the past couple of years,” Strout-Bentes said. At Mabel Wadsworth, affordable care is provided regardless of cost or insurance status, with private insurance and Medicaid accepted and a sliding scale for patients who must pay out of pocket.

“We’re a very small organization, and we can’t always meet all the demand there is. That’s been something the pandemic has shown us,” Strout-Bentes said, noting the clinic cared for 2,782 people last year and that there is a waiting list for primary care services.

Sitting in the lobby, before the nurse-midwife called her back to an exam room about 9:25 a.m. on a recent Wednesday, a 34-year-old said she has been a Mabel Wadsworth patient through various life phases.

The mother of two said she started seeking care at Mabel Wadsworth as a college student needing emergency contraception and has received gynecological, prenatal and postnatal care here since. On this day, she had come just to have her blood pressure checked - or so she thought. She developed hypertension while pregnant with her son, who’s about 1 1/2 years old, and is still being screened for it.

The 30-minute appointment included updating her medical history and a conversation about her wedding officiating.

“Symptoms of menopause?” - hot flashes or insomnia - Melissa Libby, the nurse-midwife, asked before moving on to the next question after being told no.

“You’re young for it, but I like to ask,” Libby said. “Any symptoms of anxiety or depression?”

This time, the answer was yes - and scrolling through social media wasn’t helping. The woman took Libby up on her offer for help when she mentioned a therapist on staff sees patients through telehealth.

“You can put me on her waitlist,” the 34-year-old said. “Maybe I’ll need it when it comes up.”

After the questions and answers, the provider decided to do a more comprehensive exam. She listened to the patient’s heart and lungs, palpated her abdomen and thyroid, did a breast exam - and checked her blood pressure.

When it comes to figuring out why the nation is in a worsening maternal morbidity and mortality crisis, experts acknowledge they need to better understand how a constellation of life events that start long before pregnancy - racism, housing policy, policing, climate change, pollution - affects expectant mothers.

And they point to something else: the stigma and shame associated with sex, which can lead to mistreatment, misunderstandings and mistrust.

A 31-year-old, who sat in the lobby reading parenting magazines with her husband as they waited for their first prenatal appointment, said she encountered only “compassion” and care “without judgment” since first coming to Mabel Wadsworth more than a decade ago. She started out getting gynecological exams, testing for sexually transmitted infections and then, about six years ago, counseling for an unplanned pregnancy.

The couple’s living and financial situation at the time “would not support a child,” she said by email after the appointment. She considered having an abortion but miscarried, saying the situation “scared us into going back to school.”

Afterward, she had an intrauterine device inserted as a form of birth control but said her body rejected it. So, she had a different type of long-acting reversible contraception implanted in her arm with the help of the clinic’s sliding-scale payment plan.

Now, she said, the couple is married and in a “beautiful and intentional place in our lives.” Something, she said, that wouldn’t have happened without the “education, access and support” they received.