HELENA, Mont. -- Maternity health specialists are getting together to overcome the daunting size of Big Sky Country and its impact on their profession.

The Montana Obstetrics and Maternal Support or MOMS program at the Billings Clinic is connecting providers in urban and rural areas to tackle a troubling trend: the state has the sixth-highest maternal mortality rate in the country.

Tersh McCracken, medical director the MOMS program and a practicing OB-GYN said Montana's remoteness is a hazard for some expecting mothers.

"I have patients who are pregnant who drive from more than two hours away to get their obstetrical care," McCracken explained. "So our biggest challenge is distance."

Fifty-two of Montana's 56 counties have at least one medically-underserved area, and the U.S. is one of the only countries in the world where maternal mortality is rising.

MOMS is funded by the federal Health Resources and Services Administration and is finishing its first year of a five-year program.

MOMS also is facilitating Project ECHO, a bimonthly teleconference session connecting doctors, nurses and health care administrators across the state.

Started in June, the hour-long meetings include lectures and case reviews.

Stephanie Fitch, MOMS grant coordinator at the Billings Clinic, said 25 to 35 specialists regularly attend the meetings.

She added many maternal deaths are preventable and distance is doctors' first concern.

"Lack of access to mental health and substance abuse treatment were the next highest issues that were identified by rural providers," Fitch observed.

MOMS also partners with the Rural Institute, and the Center for Children Families and Workforce Development at the University of Montana.

Annie Glover, research director at the University of Montana, evaluates the MOMS grant and said in urban areas, doctors might have colleagues down the hall they can speak to about a case.

"But in a place like Montana, there might be one or two providers and then not another colleague for 100 or 200 miles," Glover described. "And so through Project ECHO, these providers are getting together and creating that community so they have that support and that co-management of these complex patients."

McCracken added Project ECHO is eliminating the isolation some maternal health professionals feel.

"We're a big state but we're a small community and there's no reason that we shouldn't all work together," McCracken concluded.

Some emergency medical services, or EMS, are consolidating or closing across Wyoming, while the need for services is increasing. In 2021, Wyoming EMS agencies received about 89,000 calls for service, that's a roughly 27% increase in five years. The law doesn't require EMS services be funded in a community, but a recent AARP survey shows many people think communities should chip in funding.

Tom Lacock, associate state director for communications and state advocacy with AARP Wyoming, said 16 EMS providers have folded or consolidated over the last decade.

"And when you tell folks that you know, EMS is not an essential service, it's not required to be there, they kind of do a double take. " he explained.

73% of Wyomingites think that communities should fund EMS in the same way as police and fire departments, according to the survey. A 2022 Wyoming Department of Health report shows roughly half of EMS nationwide are delivered through fire departments. Others come via a combination of municipal and county governments, private providers and hospital systems.

After listening sessions, the department's potential recommendations for supporting emergency medical services include creating EMS districts, designating EMS as an essential service, regionalization, education and licensing requirements. Lacock says what he calls the "patchwork" of funding could be strengthened, too.

"The question becomes - what can we do to make perhaps a mix of funding? - Not only to pay for this, you know, as Wyomingites, but also to capture some revenue from folks who come through the state?" he said.

The state doesn't currently contribute to EMS funding. Recent attempts to get grant money and American Rescue Plan funding approved by state legislators and Gov. Mark Gordon both failed.

Hundreds of thousands of older Californians will see huge savings on prescription drugs starting in January, according to a new report from AARP.

The Biden administration's Inflation Reduction Act caps prescription drug costs at $2,000 per year for people on Medicare, starting in 2025.

Nina Weiler-Harwell, associate director of advocacy and community engagement for AARP California, said an estimated 271,000 people in the Golden State will hit the out-of-pocket maximum next year.

"Medicare drug plan enrollees nationwide who reach the new out-of-pocket cap will see an average savings of roughly $1,500," said Weiler-Harwell, "or 56% in 2025 for new prescription drugs."

On average, 40% of people on Medicare who reach the cap will save at $1,000 a year. And 12% will see savings of more than $3,000.

Every year from 2025 to 2029, between 3 and 4 million Part D plan enrollees are estimated to benefit from the new out-of-pocket cap.

Weiler-Harwell said the Inflation Reduction Act introduced a number of new policies to cut costs for Americans on Medicare.

"Copays for insulin capped at $35 a month," said Weiler-Harwell. "Vaccines such as shingles and pneumonia are free. The Inflation Reduction Act did allow Medicare to negotiate the price of high-cost prescription drugs. But we won't really start to see that until 2026."

Also thanks to the IRA, drug companies will have to pay a penalty if they raise their prices higher than inflation.

By Kylie Marsh for the Charlotte Post, with support from the Pulitzer Center on Crisis Reporting.
Broadcast version by Shanteya Hudson for North Carolina News Service reporting for the Charlotte Post-Public News Service Collaboration.

Amirah McCree planned to deliver her second child, Yara, at a hospital in Pineville. She immediately felt rushed by the all-white nursing staff.

Because delivery required an induction, McCree, a Charlotte paralegal, did her research. She knew she did not want to take pain medication, because it would make labor harder and faster. She was able to convince the nurses to go with a different induction method, but "they still felt it wasn't going fast enough."

There is growing awareness of the medical racism Black women like McCree have faced during pregnancy.

"[The nurse] literally said, 'we're here to have a baby,'" McCree said. "It scared me a little...even though I tried to advocate for myself, it still went nowhere. It was really scary because you're in a hospital bed and you can't say, 'I don't like this, I want to leave.'"

The nurses then asked McCree's family to leave the delivery room.

"When they left, it was just me, the nurses and the midwife," McCree said. The nurse then informed McCree that she'd check her cervix, and proceeded to perform an amniotomy, which is manually breaking the amniotic membrane.

"I know what a cervix check feels like. She went further," McCree said. "She swiped my fluid, and when I tried to stop her, the nurses held my hands. It was completely traumatic."

McCree never returned to the hospital, and has trouble recollecting what followed due to blocking out the memory.

In the U.S., Black women are far more likely than white women to report that health care providers scolded, threatened, or shouted at them during childbirth, research shows.

In April, the Charlotte-based nonprofit Care Ring hosted a panel discussion during Black Maternal Health Week, a national initiative geared toward tackling the high rates of death for Black mothers and their babies. There, healthcare professionals Jonisha Brown and Keyona Oni shared their stories about receiving sub-par medical care.

A 2016 survey of medical students and residents found that half held false beliefs about biological differences between Black and white people, including that Black people feel less pain. That belief is just one factor that can cause bias and lead to inaccurate treatment recommendations or clear medical neglect in patients of color.

"We recognize that there is a trust breach that has occurred in healthcare. That trust breach is present, that there is implicit bias, and certain things we took as dogma," said Noellee Clarke MD, a OB-GYN at Novant Health who is Black. "During my residency, they'd talk about the number one risk factor for preterm labor and preterm delivery, and by de facto, it was Black maternal risk.

"It was no more risk factors. The only other would have been prior history of what the condition is, but back then it was, there's a race-based system."

Implicit bias is just one piece of the larger Black maternal and infant mortality puzzle. In addition to lifelong trauma and generational distrust of the medical community, a history of neglect and malpractice are significantly more deadly for women of color.

According to the federal Centers for Disease Control and Prevention, the maternal mortality rate for non-Hispanic Black women in 2021 was 69.9 deaths per 100,000 live births, 2.6 times the rate for white women.

Rates for Black women were significantly higher than rates for their white and Hispanic peers. The increases from 2020 to 2021 for all race and Hispanic-origin groups were significant.

In North Carolina, the maternal death rate is higher than the U.S. average. In 2021, the state's maternal mortality rate was 44 deaths per 100,000 births, according to CDC data compiled and analyzed by the investigative news organization MuckRock.

North Carolina's Maternal Mortality Review Committee's report on North Carolina reported that more than 85% of those deaths were preventable, and discrimination was the leading probable contributing factor in nearly 70% of cases.

Bias and discrimination went beyond race or ethnicity, and included weight, geography, substance use, history of incarceration, and other factors.

Panelists at Care Ring's Black Maternal Health Conference in Charlotte addressed issues relating to maternal and infant mortality in addition to implicit bias, like lack of access, poor policy, and the threat of reduced funding for programs aimed at certain demographics.

Other issues that can contribute to maternal mortality are connected to housing insecurity and intimate partner violence. Clarke explained Novant's three-tiered strategy geared toward increasing ease of access for expecting mothers.

The strategy focuses on social determinants of health, personable care and early prenatal care.

"The reality is we don't live in a vacuum," she said. "As patients and as human beings, we each interact with the world, and each patient's world looks different."

Social determinants of health include access to transportation, nutritious food, safe housing, education and community support.

In 2023, Novant reported that each month, an average of 3,000 patients screen positive for food insecurity at Novant Health medical group clinics, with 400 to 600 patients not having food on a given day.

Novant has set up partnerships to address inequities, like referring patients to the nonprofit food bank Nourish Up and providing free transportation with a community health worker to and from the food bank. It includes new and expecting mothers.

Clarke compares trying to change social determinants of health to boiling the ocean.

"It's on us as healthcare workers to help make these outcomes better for our patients," she said. "We have the ability to have influence and we can directly make a difference for our patients."

Earlier access to care is crucial, especially in a country where access to family planning care is becoming increasingly hard to find. Clarke says that's why it's important to get care as early as possible.

"We need to be more aware of our pregnant population," she said.

McCree's experience at Novant Health Ballantyne Medical Center is the opposite of Pineville.

McCree's mother and grandmother faced life-threatening complications with their third birth. Their experiences were on her mind since her son, Noah, would be her third.

"It's really scary as a mother of color to go into institutions where you know there is a prior history of being discriminated against," she said.


"It was like everyone was passing the baton. There was never a lapse," McCree said.

Nurses tried a bulb induction, where a balloon is filled with fluid to stretch the cervix to a safe diameter before the mother can push. However, the baby still wasn't coming. Having been traumatized from her previous experience, McCree refused to let Swiyyah perform an amniotomy.

While the nurses and McCree were weighing a switch to Pitocin, a pain medication that causes faster and harder contractions, Noah was born.

McCree is part of a Facebook group for Black mothers in Charlotte, where people frequently ask for recommendations on Black doctors.

"That comes from a sense of fear that if you don't have someone who looks like you, the likelihood of you being treated normal - not special, just normal - might not be given," she said.

While there are public-private partnerships meant to address historic harms to Black moms, it is still significant. As long as it exists, it will continue to sow distrust.

"I think it's hard to ask how do you remove fear from places that have created the fear," McCree said. "I think that'd be a better question for the people that created the fear in the first place."


Kylie Marsh wrote this article for the Charlotte Post.


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