This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Geography plays an unfortunately prominent role in health outcomes for people giving birth in Michigan. While pregnant people living in densely populated areas of the Lower Peninsula have access to all that cutting-edge obstetrics and pediatrics have to offer, many of their counterparts in the Upper Peninsula and northern Lower Peninsula encounter "maternity care deserts," areas with a serious lack of resources, facilities, and practitioners for pregnant people, new parents, and infants.

According to Dawn Shanafelt, director of the Michigan Department of Health and Human Services (MDHHS) Division of Maternal and Infant Health, these areas of Michigan lack prenatal care, birthing hospitals, postnatal care, and postpartum care due to three main issues: population density, patient volume, and geographic vastness. Shanafelt notes that there are 23 birthing hospitals in Southeast Michigan alone, compared to eight in the entire U.P. – or nine in the area of the Lower Peninsula north of Alpena and Traverse City.

"As a result, there's a decrease in availability of maternity care services," Shanafelt says. "Patients have to drive further to receive prenatal and postpartum care, as well as labor and delivery services. And that driving distance is compounded by a variety of things — the transportation needs of the family, and then also figure in Michigan weather. We know that babies come when babies want to come."

Michigan is not the only state impacted by maternity deserts, A 2022 March of Dimes report, "Nowhere to Go: Maternity Care Deserts Across the U.S.," found that lack of access to maternity care affects up to 6.9 million people and almost 500,000 births across the country. The report counts 13 Michigan counties as maternity care deserts: Alger, Baraga, Iron, Keweenaw, Luce, Ontonagon, and Schoolcraft in the Upper Peninsula; and Alcona, Antrim, Arenac, Gladwin, Lake, Osceola, Ogemaw, Presque Isle, and Roscommon in the Lower Peninsula. Seventeen other Michigan counties were identified as having low access to maternity care. Counties classified as maternity care deserts have no hospitals providing obstetric care, no birth centers, no OB-GYNs, and no certified nurse midwives. Counties classified as low access had one or less hospital offering OB-GYN service and fewer than 60 OB-GYN providers per 10,000 births.

However, Michigan is making headway on the issue. The state is offering the Michigan Reconnect scholarship program and the State Loan Repayment Program to draw more practitioners to regions lacking maternity services. Home visiting programs like Healthy Futures bring some care to the pregnant patient at home. And, beginning in January, Michigan expanded Medicaid coverage to include doula services and one year of postpartum care, up from 60 days.

"These are all recommendations that entities such as March of Dimes recommend to address maternity care deserts," Shanafelt says. "Also, Michigan's made great strides in addressing bias and the social determinants of health. And Michigan has one of the nation’s oldest maternal mortality review committees. We review every single death that happens in Michigan to try to prevent deaths from happening."

Perinatal Quality Collaboratives aim to address maternity care deserts

In 2015, the MDHHS launched nine Michigan Perinatal Quality Collaboratives across the state to address not only maternity care deserts but also other root causes of maternal and infant deaths and morbidities such as low birth weight and preterm births. The Region 2 and 3 Perinatal Collaborative, which serves the Lower Peninsula’s 21 northernmost, very rural counties, has made maternity care deserts a priority since it began its work in 2010, five years prior to the MDHHS launch.

"We're such a large geographic region. We have 5,000 births a year. And that presents challenges," says Jenifer Murray, a contracted grant coordinator with Munson Healthcare, the agency that supports the work of the Region 2 and 3 Perinatal Collaborative. By comparison, Wayne County had 21,362 live births in 2021. 
Jenifer Murray.
"We want to have OB-GYNs and prenatal care providers in each community," Murray says. "We want our communities to be able to serve moms without them having to travel so far. In a lot of cases, there is no OB-GYN provider in these rural counties. Moms have to go to a county where that OB-GYN provider is. There's a disconnect when they don't live in the actual community that the provider is in."

The 21-county region is served by seven local health departments, nine birthing hospitals, and one neonatal intensive care unit (NICU) in Traverse City. Trained public health nurses in the Healthy Futures program have expanded home visits and reduced the number of appointments that parents and their babies have to travel to. Through focus groups conducted with the region’s physicians, the collaborative determined that substance use disorder (SUD) among pregnant people is a major concern. Thanks to the collaborative, many of the region's OB-GYNs now hand new patients an iPad to complete an online substance use and mental health screening during their initial prenatal visit. Murray says that about 90% of patients complete the screening, and 50% of them screen positive for complicating factors including tobacco, anxiety, and depression.

 "The cool thing is, doctors and their nurse care coordinators are learning of the substance use right at that first visit," she says.

To follow up, every participating OB-GYN office has a list of local recovery resources to share with its patients. In addition, the collaborative is helping physicians become licensed to dispense approved medications – for example, Suboxone – to help parents with SUDs overcome their dependence or addiction. This saves the parent the time and expense of traveling even further to get those prescriptions from another doctor.

Dr. Brendan Conboy, an obstetrician practicing with MyMichigan Medical Center Alpena, is one such physician. He can prescribe Suboxone to pregnant people with SUDs in his care. When their babies are born, they can deliver at MyMichigan Alpena. Because nursery staff have been trained in caring for babies with Suboxone in their systems, babies do not need to travel 130 miles to the NICU in Traverse City or 150 miles to Saginaw.
Dr. Brendan Conboy.
"The babies very, very rarely have to be transferred," Conboy says. "They stay an extra three to five days to transition off the medication and then they go home. It’s been really nice that these folks aren't having to drive all the way to Traverse City or Saginaw for their deliveries and their prenatal care."

To help people avoid those same long drives for specialist care during pregnancy, MyMichigan Alpena is also seeking to reestablish a telemedicine program offering maternal fetal medicine consultations. Pregnant people will be able to come in for their checkup, have an ultrasound, and confer with a specialist via video chat.

"We had really good success with that previously," Conboy says. "It really saves patients more than time. I really worry about patients on the road, especially in the winter."

And, because people are often traveling a long way to come to give birth at MyMichigan Alpena, the maternity floor staff there offer patients reliable birth control before they are discharged.

"That helps patients who find it hard to come in for that postpartum visit because they're busy with the newborn and they live far away. It’s just another way we're trying to help patients," Conboy says. "We will place an IUD before they leave the hospital if they would like. That can be done during C-sections or after a vaginal delivery."

More work to be done

With the United States ranking 33^rd among the 38 Organisation for Economic
Co-operation and Development (OECD) member countries when it comes to infant mortality, the need for universal systemic change in how people here give birth is obvious. That need is even more obvious in Michigan’s maternity care deserts. As more small, local community hospitals vanish and birthing becomes an even higher-tech, higher-cost experience that can only be accessed within huge health systems, more expectant parents will find themselves traveling further to find care.

"If there are any chronic health conditions with mom or emergencies happen, such as a baby coming early, there are a variety of different reasons why an individual would want to get to a hospital quickly. This can impact outcomes, not only maternity outcomes and labor-delivery outcomes, but things such as heart attack or other emergent issues," Shanafelt says. "Thankfully, a variety of efforts have been underway for quite some time, both locally at the state level and at the national level, to help address some of these challenges."
 
Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Jenifer Murray photos by John Russell. All other photos courtesy of the subjects.