Lisa Vendeland, an OB-GYN, has witnessed dozens of stillbirths and maternal deaths.
When giving birth to her own child, all she wanted was, “to have a live baby and I don't want to die doing it,” she wrote in an op-ed. Vendeland now heads the new OB-GYN program at Advance Community Health in Raleigh, a clinic that launched Jan. 23.
The federally qualified health center is a nonprofit that provides health care for patients on a sliding fee scale based on what they’re able to pay. Advance primarily serves Wake and Franklin counties.
The OB-GYN program aims to reduce risks of infant and maternal mortality for its patients. If successful, leaders said they hope the model they've applied in this urban setting could be replicated in rural areas that also face barriers to accessing maternal health care.
The OB-GYN program will use a “centering pregnancy” model, where patients have 90-120 minute visits to increase face time with their providers. Patients also take their own health data, such as measuring blood pressure and weight, to gain a sense of autonomy over their health.
Pregnant mothers with similar due dates are placed in groups of eight-to-10 people to foster community and education.
An important part of the approach is teaching women to advocate for themselves, as some medical providers may brush off women’s concerns, Vendeland said.
Overt and implicit bias from health care providers contributes to a higher risk of maternal mortality for Black women when providers ignore symptoms or requests for help, according to Yale Medicine.
"One of the biggest barriers in health care is that health care leadership is not reflective of the people it serves."
Scott McCray, CEO of Advance Community Health, said the model and the center’s diverse providers will hopefully make this clinic more successful than past attempts at addressing maternal and infant mortality.
“One of the biggest barriers in health care is that health care leadership is not reflective of the people it serves,” he said.
Behind pregnancy-related deaths
The rates of maternal mortality increased in North Carolina from 22 to 44 deaths per 100,000 live births from 2019 to 2021, according to data compiled by the investigative news organization MuckRock, NC Health News reported.
That disproportionately affects Black women, who were over two times as likely to die from pregnancy-related deaths as white women in the state from 2017-2021, according to America’s Health Rankings. Over 12 Black babies died before the age of one for every 1,000 live births in the state from 2019-2020, compared to 4.8 white babies.
North Carolina ranked 29 out of 45 states on maternal mortality rates using data from 2017 to 2021.
Vendeland said one of the reasons North Carolina ranks higher is because of its rural areas, where it can be harder for patients to access health care, including OB-GYN care, because of barriers like transportation and distance from a provider.
Poverty is another factor, she said, with challenges to meeting basic needs such as transportation, food and housing.
Mental health conditions are one of the leading underlying causes of maternal deaths nationally, according to the CDC, including deaths to suicide and overdose/poisoning related to substance use disorder.
For Black women, “allostatic load,” or the cumulative physiological effects of chronic stress, can also contribute to an increased risk of maternal mortality, according to a 2020 article in the Journal of Racial Ethnic Health Disparities. Those stressors are often higher in Black women because of historic and current racism, the article said.
Meeting gaps in care
In some rural areas of the state, federally qualified health centers are the only primary care providers in the area, said Brendan Riley, vice president of government affairs and external relations at the North Carolina Community Health Center Association.
Located across the state are 38 FQHC organizations and five similar centers with different funding, many with multiple locations for a total of over 500 sites statewide, Riley said.
But because these centers serve people regardless of their ability to pay, funding is a challenge, Riley said. Prior to the 2023 Medicaid expansion, he said more than a third of center patients were uninsured. The expansion will likely help more of those uninsured patients get coverage, he said.
Much of FQHCs’ federal funding has to be reauthorized every few years through Congress, which means it’s hard to plan to expand services or recruit more providers, Riley said. Federal funding has also remained the same for the last five years.
“It's not keeping pace with inflation, with the cost of doing business, and particularly with the cost of provider salaries that we've seen really explode since the pandemic hit,” Riley said.
OB-GYN care in rural areas
Advance leadership plans to share how their OB-GYN program model goes with other FQHCs in the state, McCray said. It could have even more potential for impact in a rural community, but would likely require strong alliances with rural hospitals and health departments, he said.
Betsy Johnson Hospital in Harnett County closed its labor and delivery unit in 2023, which redirected many OB-GYN patients in the area to the CommWell Health community health center, according to CommWell CEO Pamela Tripp.
CommWell serves Johnston, Sampson, Bladen, Pender, Brunswick and part of Harnett counties. The Johnston County location contracts with obstetricians under the UNC Health system to provide OB-GYN services to expecting mothers, but the providers are only there two days a week, Tripp said.
“They are really seeing a lot of patients," she said. "We're delivering a lot of babies, but we can feel the pressure of the (hospital unit) closing.”
The health center serves a large farmworker community and for migrant mothers, they may come into the clinic in their third trimester without having ever received prenatal care, Tripp said. The health center helps meet that gap in care.
“Without us, they will go to the nearest emergency room and deliver," she said. "That's not the best way and there may be hospitals now like in Harnett County that don't deliver."
In Pender, Bladen and Brunswick counties, Tripp said CommWell has working agreements to refer those OB patients to private OB practices and local hospitals. While it would expand access for rural mothers if CommWell were to have OB services in those counties, there’s just not enough funding to do so, Tripp said.
CommWell has its own way of centering pregnant mothers, such as educational booklets on pregnancy and a maternal nutrition program, she said.
Rural Health Group serves patients in Halifax, Vance, Granville, Warren, Northampton and part of Edgecombe counties. The center provides OB-GYN services and serves many high-risk patients.
Stephanie Pierce, director of women’s health, said transportation is a barrier for her patients, as well as a lack of education, such as not knowing the importance of pap smears to test for cervical cancer.
Pierce said she recognizes that Black women are at a higher risk of maternal mortality, but also that Black women are less likely to die if they’re taken care of by a Black physician, such as herself.
“What I try to express with my patients is … make sure if you have a concern, that somebody’s paying attention to you,’” she said. “Do not allow your concerns to be blown off, because you are at higher risk just by virtue of being a Black woman in America and pregnant.”
"Do not allow your concerns to be blown off, because you are at higher risk just by virtue of being a Black woman in America and pregnant."
Because Pierce and the women’s health practice manager Emily Stacy are natives of the area, their work is more than a job, Pierce said.
“These people are our families,” she said. “So we have a passion to improve the level of care in this area, to improve the level of education.”
The centering pregnancy model is effective and creates a great community, Pierce said, but hasn’t previously been possible for Rural Health Group because of limited resources. The center is considering starting a program under the model in the future, but it depends on funding and whether women would want to take part in it, she said.
But if implemented, the high level of education available in the model could “change the entire community,” she said.
