The U.S. has the highest maternal mortality rate among developed countries. Giving birth is particularly dangerous for African American pregnant individuals, those living in rural areas, and those with underlying conditions. North Carolina currently ranks 30th in the country in maternal mortality and 39th in infant mortality. In addition, 12% of women in the state experience postpartum depression.1
The Maternal Outreach Through Telehealth for Rural Sites (MOTHeRS) Project was established in 2020 to increase access to health care and improve health outcomes for mothers and babies in North Carolina. It was developed at a time when fear of COVID-19 and the lack of definitive and timely information caused many patients to not keep clinic appointments, and, as a result not receive the care they needed. Of the 37 North Carolina counties along or east of the I-95 corridor, all but 10 have heart disease mortality rates higher than the national and state averages. At least 22 of those counties also have diabetes mortality rates higher than both the national and state averages. One in four mothers here live in poverty; and one in eight are uninsured. Ninety-four of the 100 counties in North Carolina are designated as mental health provider shortage areas and eastern NC has a disproportionate share of these underserved counties. Socioeconomic factors in the region limit access to transportation, adequate nutrition and basic necessities in the maternal population.
The MOTHeRS Project was established through a $1.2 million grant from the United Health Foundation, the philanthropic foundation of United Health Group, and is offered through ECU Health, formerly East Carolina University (ECU) Physicians. ECU OBGYN, Psychiatry, Family Medicine, and the Center for Telepsychiatry and e-Behavioral Health use a multidisciplinary approach to address barriers and challenges for those facing high-risk pregnancies in eastern North Carolina.
The MOTHeRS Project is based on the idea that where an expectant or new mother lives should not negatively impact her physical or mental wellbeing or that of her child. Individuals who live in rural areas are less likely to have access to health services and challenges to maternal care are even greater. Many hospitals, such as those in rural areas that perform fewer than 240 births per year, are likely to have family physicians and general surgeons attending deliveries because obstetricians and midwives are not available.
Many rural hospitals do not have specialized labor and delivery services or neonatal intensive care units (NICU) to care for high-risk pregnancies or infants. Babies who are born pre-term often need intensive care and have better outcomes if they are born in a hospital with a NICU than if they are moved to one after birth.
In-Person Care, Telehealth and Community Services
The MOTHeRS Project framework was created using the North Carolina Statewide Telepsychiatry Program (NC-STeP), founded in 2013 by ECU’s Dr. Sy Saeed. NC-STeP is the largest telepsychiatry program in the state and one of the largest such programs in the nation. This program launched in October 2013 and, since then, has exceeded its goals, received national and international recognition for its innovative work, and has become a model for telepsychiatry specifically and telehealth in general. ECU’s Center for Telepsychiatry is the home for this statewide program. Today, NC-STeP provides telepsychiatry services in 39 hospitals and 21 outpatient primary care sites across North Carolina.
The MOTHeRS project provides face-to-face care at community-based primary care obstetric clinics, health departments, and other regional clinics. Expectant individuals are also able to access telehealth services at home via tablet, computer, or phone, if clinically indicated.
In the model, the primary care provider remains the driver of the mother’s care with the assistance of these specialists:
- Primary Care Obstetrician
- Maternal Fetal Medicine Specialist
- Certified Diabetes Educator
- Nurse Navigator
- Behavioral Health Manager
- Registered Dietitian/Nutrition Specialist
The MOTHeRS Project also provides for other important needs for pregnant individuals, such as mental health care, food and clothing. Pregnant people are also connected with additional resources in their community as needed.
The association of food insecurity and diet quality with mental health, and with poor outcomes in high-risk pregnancies, has been established. The MOTHeRS Project screens all patients at its clinical sites for food insecurity. The project has developed a medically tailored emergency food bag for high-risk pregnant women identified as food insecure in the clinical setting. Those who screen positive are provided this medically tailored food bag, nutrition education, and links to existing community resources. This approach promotes effective nutrition education and healthy behavior, and has been presented at national meetings.2,3
Eliminating Barriers and Improving Outcomes for Rural Maternity Care
This model helps manage patients in clinics closer to their homes and minimizes travel to the remote specialty clinics for high-risk patients – such as those with diabetes, chronic hypertension, opioid/substance use and/or psychiatric needs. Aside from enhancing access to services, this model helps to reduce geographic health disparities, enhances patient convenience, and improves patient adherence to treatment. Despite high health care spending, the United States has some of the worst maternal outcomes in the industrialized world.4,5,6 The collaborative co-management model developed by the MOTHeRS Project creates a patient-centered team approach to care delivery and results in both improved patient experiences and a positive impact on maternal fetal health.
By bringing specialists to the primary care sites, this model also reduces professional isolation, enhances recruiting and retention of health professionals in underserved areas, and improves coordination of care across the health care system.
The MOTHeRS Project results were strong and have increased access to pregnancy care for rural individuals. Through June of 2022, there were 935 pregnant individuals who received care through the MOTHeRS Project: 106 maternal fetal medicine (MFM) specialist visits and 829 mental health visits with either a psychiatrist or a licensed clinical social worker. The project screened 14,535 patients for food insecurity and distributed 440 medically tailored food bags to those who screened positive. Additionally, the project has saved 16,586 driving miles for patients and their families.
The MOTHeRS project expects to continue to provide care at three initial sites and another clinic, which is being added this year. Through its ongoing work, the MOTHeRS Project expects not only to provide care to those who need it at its clinical sites, but also to generate new knowledge regarding how these barriers can be better addressed to ensure every woman in rural America has a safe and healthy pregnancy, delivery, and post-natal outcome.
- Postpartum Coverage Extended to 12 Months for NC Medicaid Beneficiaries Beginning April 1 Opens in a new window
- Smith B, Kolasa KM, Sastre LR, Craven K. MOTHeRS Project: Acceptability of a medically tailored food bag treating food insecurity in high-risk pregnant patients. Poster presented at: SNEB 2021 Annual Conference; August 9, 2021; Department of Family Medicine, East Carolina University, Greenville, NC. Opens in a new window
- Smith B, Kolasa KM, Craven K. Emergency Food Bag and Patient Education for the MOTHeRS' Project. Presented at: ECU Family Medicine Research Day; June 10, 2021; Department of Family Medicine, East Carolina University, Greenville, NC. Opens in a new window
- Maternal mortality ratio (modeled estimate, per 100,000 live births) -Finland, Venezuela, RB. (n.d.). Opens in a new window
- MacDorman M, Declercq E. The failure of United States maternal mortality reporting and its impact on women’s lives. Published in final edited form as: Birth. 2018 Jun; 45(2): 105–108. Published online 2018 Jan 4.
- Gunja MZ, Tikkanen R, Seervai S, Collins SR on behalf of The Commonwealth Fund. What is the status of women’s health and health care in the U.S. compared to ten other countries? Published December 19, 2018. Opens in a new window