Providers of prenatal and postpartum medical care in Arkansas need to better reach the general public and collaborate more with each other, elected officials and medical professionals agreed Wednesday at a roundtable discussion about maternal health at the University of Arkansas for Medical Sciences.

U.S. Sen. John Boozman’s office coordinated the discussion between him, U.S. Rep. French Hill and Gov. Sarah Huckabee Sanders, all Republicans, and four Arkansas doctors with experience in maternal care. Jodiane Tritt, executive vice president of the Arkansas Hospital Association, moderated the panel.

“It’s so important to hear this kind of integrated talk today… about how to streamline [care] and deliver outcomes for our babies, for our moms and for our families,” said Hill, who represents much of Central Arkansas.

Arkansas is one of three states that have not taken advantage of the federal option to extend postpartum Medicaid coverage from 60 days to 12 months after birth. State Rep. Aaron Pilkington, R-Knoxville, sponsored a bill in 2023 that would have extended this coverage, but it did not advance in the Legislature due to cost concerns.

“At this point, I wouldn’t say that that additional level of legislation is needed, but we do need to do a better job of transitioning people after those first 60 days to other coverage options,” Sanders told reporters after the panel discussion. “…We want those moms to have a full year of coverage. It already exists in the state, but we need to do a better job moving forward of educating them on what’s available.”

Arkansas has the nation’s highest maternal mortality rate and the third highest infant mortality rate, according to the Arkansas Center for Health Improvement.

Some of Arkansas’ 75 counties do not have hospitals, while only 35 hospitals in the state have labor and delivery units. Four units have closed since the onset of the COVID-19 pandemic in 2020, said Dr. Nirvana Manning, chair of the Department of Obstetrics and Gynecology and a practicing OB/GYN at UAMS. The Bradley County Medical Center in Warren closed its labor and delivery unit recently due to staffing challenges.

Manning praised two state laws instituted in 2023: one that requires Medicaid to cover postpartum depression screenings, which physicians are now required to offer patients post-delivery, and one requiring Medicaid to cover long-acting reversible contraception if postpartum patients request it.

Arkansas Legislature saw wide range of maternal and reproductive health legislation in 2023

Mothers should receive the best care possible regardless of whether they plan to become pregnant again in the future, Manning said.

“Navigating this postpartum period on top of having a newborn child they’re taking care of… the mom is the unit of all of that, and when she’s falling apart, everything kind of falls apart,” she said. “We need to assess ways that we can wrap [services] around that mom, not only in that immediate postpartum period of 60 days, but in the long trajectory.”

Dr. Sharmila Makhija, a gynecological oncologist, called the postpartum period the “fourth trimester” of pregnancy, emphasizing the need for continued care, especially if patients have pre-existing health issues.

“Another way to approach this is that moms are always going to take care of their children, so teaming up with the pediatrics offices to have a dual visit at the same time [would help] because they’re definitely going to show up to make sure their baby has their visit,” said Makhija, founding dean and CEO of the Alice L. Walton School of Medicine, which will open in 2025 in Bentonville.

Allan Nichols, an Arkansas Rural Health Partnership board member, explained to the panelists and audience why rural hospitals have trouble keeping their labor and delivery units open. Nichols is CEO of Mainline Health Systems, which took over the labor and delivery unit at Drew Memorial Hospital in Monticello in 2022; Baptist Health acquired the hospital in 2023.

Nichols said a fully-staffed labor and delivery unit includes a “critical mass” of four physicians who each do 200 deliveries per year, and 800 deliveries per year at one hospital “can’t happen everywhere.”

“We need this hub-and-spoke program that has delivery areas out in the state that feed up to higher-level care, that’s all coordinated and everybody works together,” Nichols said. “I don’t know how many phone calls and video [conferences] I’ve been in in the last year and half, and everybody has a great plan and none of it is coordinated. They’re duplicating activities all over the place… We’re in a state with very little resources, and we’re going to waste a lot of them.”

‘A PR issue’

Dr. William “Sam” Greenfield said the medical community needs to adopt a widely accepted definition of prenatal health care beyond just regular doctors’ appointments during pregnancy.

“Effective prenatal care is respectful care,” said Greenfield, an OB/GYN and a member of the state’s Maternal Mortality Review Committee. “It’s a process of risk assessment to see where a patient falls on the spectrum in terms of what the risks are for the pregnancy. It’s therapy and intervention… It’s the opportunity to educate on what to expect and what to look for and how to advocate for yourself.”

Dr. Lanita White, a pharmacist on the UAMS faculty, said mental and behavioral health services need to be included under the umbrella of prenatal and postpartum care because the stigma associated with these issues plays a role in maternal mortality.

“You get on the scale, it’s part of the visit [to a doctor],” White said. “We talk about your blood pressure as a part of the visit. We have to normalize those conversations to make it palatable for people to get help when they need it.”

However, rural areas have very fewer doctors in specialized medical disciplines, including pediatrics, and primary care practitioners do the lion’s share of medical care in those areas, the panelists said. Many Arkansas counties had very few full-time primary care physicians per 10,000 residents in 2020, according to ACHI data.

In 2022, Arkansas became the 48th state to join the Alliance for Innovation on Maternal Health (AIM), which creates “patient safety bundles,” or maternal health care plans and best practices, that state health systems distribute to providers. Manning said having information about potential emergency situations during pregnancy and delivery is an important tool for rural maternal health care providers.

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The panelists agreed that Arkansas needs an efficient system of transferring pregnant and delivering patients from rural health care facilities to better-equipped facilities on short notice. Manning said UAMS is working on such a mechanism, in response to comments from Dr. Sherry Turner, a rural emergency room physician and an associate dean at the Arkansas College of Osteopathic Medicine in Fort Smith.

“They come to me in that small ER, I deliver [babies] and it may take me hours to get an ambulance because we may only have one in the county,” Turner said. “…There’s a lot of work outside this structure that needs to be done.”

White said other barriers to care in rural areas include distance, transportation and low-income people’s hesitancy to seek care at all. She is CEO of Community Health Centers of Arkansas, a nonprofit organization that provides health care regardless of patients’ ability to pay, but many Arkansans are not aware of this resource, White said.

“If you have women who don’t have a payer for their care — no Medicaid, no private insurance or what have you — many times they believe health care is not in their reach,” she said. “…That is a PR issue on both sides.”