Data to Action Success Story: Minnesota

All Our Babies: Using Minnesota PRAMS Data to Inform Policies and Planning for Improved Rural Birth Outcomes

Problem Overview

Disparities in key indicators of maternal and infant health, such as prenatal care access, have been observed between urban and rural communities. The presentation, All Our Babies: Improving Rural Birth Outcomes in Minnesota, at the Community Health Conference in September 2013, underscored that we need to be concerned about all our babies, whether they are born in rural or metropolitan areas. Lack of prenatal care in rural areas has been associated with higher rates of premature birth, infant mortality, and complications during delivery. Early and regular prenatal care allows prenatal care providers to diagnose, treat, and help prevent problems that may occur during pregnancy.

According to Minnesota PRAMS data from 2009–2010, approximately 1 of 10 mothers in Greater Minnesota (a rural area of the state) reported they did not receive prenatal care as early in their pregnancy as they wanted. Of these women, 44% encountered at least one barrier, 31% encountered 2 barriers, and 19% encountered three or more barriers to getting prenatal care. Considering barriers to timely prenatal care, mothers attributed the delay to not having enough money or insurance to pay for the visit; not knowing they were pregnant; physicians or health plans not starting prenatal care as early as the mother wanted; or an inability to schedule prenatal appointments. In addition, mothers from Greater Minnesota were less likely to report that their health care provider discussed topics such as smoking, alcohol use, illegal drug use, HIV screening, physical abuse, seat belt use, and safe fish eating guidelines related to mercury levels during prenatal care visits. Preconception health, risk factors for smoking tobacco and drinking alcohol during pregnancy, and barriers to prenatal care for mothers in rural areas in Minnesota need to be better understood.

Program Activity Description

In June 2011, the Rural Health Advisory Committee formed a work group to review access to obstetric services among women living in Greater Minnesota and asked Minnesota PRAMS staff to conduct an analysis of PRAMS data collected from mothers in Greater Minnesota. The analysis included assessments of preconception health status, barriers to prenatal care, topics discussed by the health care providers during prenatal care visits, and risk behaviors during pregnancy. The results were included in the "Rural Health Advisory Committee’s Report on Obstetric Services in Rural Minnesota" [PDF 2MB], which was released in November 2013.

The work group indicated that access to local obstetric services is a great challenge in small and isolated rural communities in Minnesota, and that for some health indicators, such as smoking, there are pronounced rural-urban differences. For example, 34% of Greater Minnesota mothers smoked 3 months prior to pregnancy, as compared with 20% of mothers in the metro region. Further, mothers from Greater Minnesota were less likely to report that a health provider talked with them during a prenatal care visit about how smoking during pregnancy could affect their baby (72%) as compared with talking about medicines that are safe to take during pregnancy (90%).

Program Activity Outcomes

Based on the findings highlighted in the report, the Rural Health Advisory Committee work group issued 18 recommendations for improving obstetric services in rural Minnesota, 4 of which were directly related to results from analyses using PRAMS data: (1) address smoking in women of childbearing age who live in rural areas, with a special focus on women who are young, uninsured or publicly insured, and those most likely to have an unintended pregnancy; (2) encourage collaboration between rural obstetric providers and public health nurses to maximize the use of local resources available to pregnant women and new parents; (3) educate rural providers and hospital staff about ways to better serve American Indian women; and (4) educate rural providers and hospital staff about the role of doulas.

The report also recommended that rural hospitals can improve cultural competencies and internal processes to address birth-related disparities in American Indian communities Minnesota PRAMS data on mothers in Greater Minnesota found that American Indian mothers had some of the highest risk factors; for example, nearly half of American Indian mothers living in Greater Minnesota reported smoking during the last 3 months of pregnancy. Because of the large pregnancy- and birth-related disparities in American Indian mothers, the work group invited tribal doulas to discuss their work to restore traditional birth knowledge within their communities. Tribal doulas want to see mothers as soon as possible once a pregnancy is confirmed. Tribal doulas make home visits to educate mothers about the importance of prenatal care. They help pregnant women seek additional services to address addiction, poverty, or social isolation. 

Finally, the PRAMS data included in the report influenced development of state Medicaid policies related to prenatal care. Specifically, in 2013, the Minnesota state legislature passed a bill to provide Medicaid payment for services from a certified doula for low-income pregnant women in Minnesota. When Minnesota revised the Medicaid state plan amendment to include reimbursement for doula services, it was necessary to define doula scope of practice as well as the need for doula services for low-income populations. The use of Minnesota PRAMS data contributed to our understanding of how doula services could be targeted to rural and underserved women, especially American Indian mothers. In addition, a nonprofit organization has been formed to explore ways to improve birth outcomes among American Indian women in rural northwest Minnesota. A doula service, doula training program, and free-standing birth center are among the goals the organization is considering.