Obstetrical Risk

Obstetrical Risk / en Sat, 26 Apr 2025 13:39:59 -0500 Fri, 10 Jan 25 15:25:20 -0600 ‘Best of’ AHA's Advancing Health podcast highlights workforce wellness, rural obstetric services /news/headline/2025-01-10-best-ahas-advancing-health-podcast-highlights-workforce-wellness-rural-obstetric-services The AHA's Advancing Health podcast recently celebrated the end of 2024 by releasing highlights from some of its most popular episodes of the year. The roundup includes a selection from "The Growing Role of Chief Wellness Officers in Health Care" with Jonathan Ripp, M.D., senior associate dean for well-being and resilience and chief wellness officer of the Icahn School of Medicine at Mount Sinai. Following that is a selection from "How a Rural Health System Continues to Provide Essential Obstetric Services" with Julie Petersen, CEO of Kittitas Valley Healthcare. <a href="/advancing-health-podcast/2024-12-23-best-advancing-health-wellness-workforce-and-obstetric-services-rural-america" target="_blank">LISTEN NOW</a><div></div> Fri, 10 Jan 2025 15:25:20 -0600 Obstetrical Risk AHA podcast: How a Rural Health System Continues to Provide Essential Obstetric Services /news/headline/2024-07-15-aha-podcast-how-rural-health-system-continues-provide-essential-obstetric-services Kittitas Valley Healthcare, based in Ellensburg, Wash., was delivering 300-350 babies each year in the region prior to 2022, offering the area’s only comprehensive obstetric services. But when its three full-time OB/GYNs left, KVH was suddenly faced with a huge problem. Julie Petersen, KVH CEO, discusses how the organization kept its promise to preserve essential obstetric services for women of all ages. <a href="/advancing-health-podcast/2024-07-15-how-rural-health-system-continues-provide-essential-obstetric-services">LISTEN NOW&nbsp;</a> Mon, 15 Jul 2024 16:03:48 -0500 Obstetrical Risk How a Rural Health System Continues to Provide Essential Obstetric Services /advancing-health-podcast/2024-07-15-how-rural-health-system-continues-provide-essential-obstetric-services Prior to 2022, Kittitas Valley Healthcare (KVH) was delivering 300 – 350 babies each year, offering the region's only comprehensive OB/GYN&nbsp;services. But when its three full-time OB/GYNs left, KVH was suddenly faced with a huge problem. In this conversation, Julie Petersen, CEO of Kittitas Valley Healthcare, discusses how her organization kept its promise to preserve essential obstetric services for women of all ages.<hr><div> &nbsp;</div><div class="raw-html-embed"><details class="transcript"><summary> <h2 title="Click here to open/close the transcript.">View Transcript &nbsp;</h2> </summary> 00;00;00;18 - 00;00;23;07 Tom Haederle Every rural care provider in the United States can attest that finding, hiring and retaining clinicians across just about any specialty is getting harder and harder. In south central Washington state. Kittitas Valley Health Care, KVH, the only provider offering comprehensive OB-GYN services for many miles around, was suddenly faced with a huge problem. Within the space of about a year 00;00;23;08 - 00;00;37;27 Tom Haederle its three full time OB-GYN specialists all decided to leave. 00;00;38;00 - 00;01;05;12 Tom Haederle Welcome to Advancing Health, a podcast from the �� Association. I'm Tom Haederle with AHA communications. Prior to 2022, KVH was delivering between 300 and 350 babies each year. Its six bed labor and delivery unit was the most in-demand service the hospital offered. In this podcast, we learn from the hospital's CEO how KVH kept its balance and its promise to area residents to preserve critical obstetric services 00;01;05;19 - 00;01;09;27 Tom Haederle in the wake of the departure of several highly experienced clinicians. 00;01;09;29 - 00;01;22;18 John Supplitt Good day. I'm John Supplitt, senior director of AHA Rural Health Services. And joining me is Julie Petersen, CEO, Kittitas Valley Health Care and Public Hospital District. Good afternoon. Julie. 00;01;22;20 - 00;01;23;20 Julie Petersen Hello. 00;01;23;23 - 00;01;56;18 John Supplitt For our listeners, Kittitas County Public Hospital District number one, also known as Kittitas Valley Health Care, provides care to Kittitas County and surrounding areas in central Washington state. KVH includes a 25-bed critical access hospital and provides care through clinics and specialty services in upper and lower Kittitas County. Julie, we're here to discuss how KVH has responded to a crisis to ensure continued access to obstetrical care in Kittitas County, Washington. 00;01;56;20 - 00;02;00;10 John Supplitt How essential is obstetrics to your community? 00;02;00;12 - 00;02;22;10 Julie Petersen We know from our latest Community Health Needs Assessment that admissions for women of childbearing age is our number one admission to our hospital. So this will include delivery as well as complications from deliveries and prepartum and postpartum issues. So it's not just an essential, it's a core service for our community. 00;02;22;12 - 00;02;39;03 John Supplitt And I think I want to pull a thread on that because it's remarkable when I looked at your community health assessment and improvement plan, to see these conditions as being the highest source of admissions to the hospital for women of all childbearing ages, including teenagers. 00;02;39;03 - 00;03;03;04 Julie Petersen Correct. And we staff a dedicated labor and delivery unit, a six-bed labor and delivery unit. We are a 25-bed critical access hospital. So our general medicine CCU population includes a number of different DRGs and conditions. But again, the number one major diagnostic classification that we have is those moms prepartum postpartum and the deliveries themselves. 00;03;03;04 - 00;03;25;28 Julie Petersen And we deliver about 300 to 350 babies a year in Kittitas County. We have about 80% of the of the market of deliveries. And we're very, very careful in how we screen our moms. We know our limitations with our labor and delivery program. But again, that's 300 to 350 babies a year that rely on us to deliver them in Kittitas County. 00;03;25;29 - 00;03;27;24 Julie Petersen We are the only hospital in the county. 00;03;28;00 - 00;03;44;15 John Supplitt And that's a remarkable number. And I think we need to really get a sense of where you are relative to the other providers in your area with respect to location. You're in south central Washington to the south of you. The nearest city is Yakima. 00;03;44;17 - 00;04;05;00 Julie Petersen That's correct. So any direction you want to go to deliver outside of Kittitas County, you're going to have to travel over a mountain range. You travel to Wenatchee, which is a mountain pass. That's about 40 miles. You can travel to Yakima, 35-40 miles over a mountain range or into the Seattle metropolitan area of the Cascades. 00;04;05;02 - 00;04;12;17 John Supplitt And so recently, you've experienced significant disruption, disruption in your OB-GYN services. Tell us what happened. 00;04;12;20 - 00;04;43;23 Julie Petersen Prior to 2022, we have worked with a pool of community providers, including those sole practitioners who retired in 2022. We also had an FQHC in our community that participated in our call and delivery program. And due to changes in the residency program and then just a tight OB market, that program has slimmed down in our community. But we have employed three OB-GYNs, and our community has been kind of the core of our model. 00;04;43;26 - 00;04;59;00 Julie Petersen But in 2022, all three of those providers gave us notice that they would be leaving. Two of them continue to live in our community, but they travel to metropolitan areas to participate in labor programs in the large hospitals. 00;04;59;02 - 00;05;13;20 John Supplitt Well, and again, I have to pull a thread on this because your model through 2022 was an employed service through your own OB-GYNs, which is remarkable to think that you were able to recruit them into the first place and that they were committed to the community for so long a period of time. 00;05;13;28 - 00;05;40;10 Julie Petersen Right. And that that level of commitment, that market of being able to employ an OB-GYN who is responsible for their patients, 24/7 who disrupts their clinic life to go to the hospital to deliver a baby on the middle of a Wednesday afternoon. That market is harder and harder to draw to, and that is absolutely what we were trying to maintain in KVH, again with the participation of some great partners 00;05;40;10 - 00;05;47;29 Julie Petersen in the FQHC and some private practitioners. But within the span of about 14 months, that entire model just came up hard on us. 00;05;48;03 - 00;05;55;19 John Supplitt So you get punched in the gut as you see this attrition in your employed model of care. How did you respond to this crisis? 00;05;55;21 - 00;06;22;12 Julie Petersen Well, the governing board, we are an elected board of five commissioners in Kittitas Valley. And they came out of the gate assuring the community and assuring our staff that we were going to remain in the OB business. So my charge was to make it happen. We'd already been recruiting to replace the traditional OB-GYN providers that we'd had in the past and we were not having very much success. 00;06;22;14 - 00;06;45;14 Julie Petersen We did come across a family practice OB who has surgically trained, who's a key component of our program going forward. But after about 12 to 14 months of looking to backfill our OB-GYNs, we had no choice but to look outside for an outsource service, and we found a partner in OB hospitalist group or OBHG. 00;06;45;16 - 00;07;11;29 Julie Petersen So again, I think the first thing we did was make the commitment from the governing board on down that we were going to continue to deliver babies in Kittitas County, and that's key, because one place where we're particularly strong is in our nursing program. We have an amazing group of labor and delivery, specialty trained nurses who have stuck through us, with us through this entire sort of meltdown in OB. 00;07;11;29 - 00;07;17;11 Julie Petersen And the last thing we wanted to do was make ourselves vulnerable to losing those nurses. 00;07;17;13 - 00;07;26;23 John Supplitt Well, and I'm going to share a couple of observations. First and foremost, this is a public district hospital and that the board is committed to delivering babies to this community. 00;07;26;27 - 00;07;28;09 Julie Petersen That's absolutely correct. 00;07;28;09 - 00;07;31;11 John Supplitt And that's at the core of your mission. 00;07;31;11 - 00;08;01;28 Julie Petersen Right. That was never a question. And I think the way we see this is, again, our folks have been rigorous and determining who should deliver at KVH. We don't do high risk deliveries. And when you take 300 to 350 moms who can deliver in a safe hospital environment and put them on the road over mountain passes or 35-40 miles stretches, you take low risk, comfortable births, and you turn them into high risk births. That was not acceptable at my board. 00;08;02;00 - 00;08;25;25 John Supplitt And then the other observation is, as we see hospitals drop obstetric services from their service components, I again reflect on the fact that as a public district hospital, your commitment to the community is at the core of what it is that you do. And in this particular, you're willing to take on this loss- leader in order to make sure that there's access to safe care to the women that live there. 00;08;25;27 - 00;08;49;29 Julie Petersen And we see this service line also. At the core of this service line is labor and delivery and obstetrics. And that certainly is the biggest challenge in terms of continuing the service line. But it is bigger than that. We are a county of about 45,000 people, and we're a little bit unique in that we are growing as a sort of a long distance neighbor to the Seattle metropolitan area. 00;08;49;29 - 00;09;12;05 Julie Petersen We are growing and we're holding our own in terms of age. So we're not aging the way some rural communities are. So long term, we need not only to be able to deliver our own babies, but we need to be able to take care of women generally in our community, the reproductive health needs of women, gynecological needs of women in our community are core to this as well. 00;09;12;07 - 00;09;25;28 Julie Petersen And if you can't attract OB-GYNs, if you can't attract the nurses who care for women in the clinics in the hospital, you're going to lose your ability to take care of women generally, and reproductive health specifically. 00;09;26;01 - 00;09;43;00 John Supplitt Julie, let's talk about the selection of OB hospital group as your agency to service this labor model. There had to be some research that went into that. There had to be some board buy-in and acceptance of this. Tell us a little bit about that process and how it went. 00;09;43;02 - 00;10;08;02 Julie Petersen During the pandemic and initiating our research, one of the things that we learned is in a very short period of time, many, many hospitals had transitioned to a labor site model. And while it's largely an urban/suburban phenomenon, we saw some of it moving into the rural communities as well. So we looked for somebody who had experience in rural communities. And rural is different than urban, 00;10;08;02 - 00;10;33;24 Julie Petersen they needed to be able to or willing. They needed to attract candidates who would work in a clinic setting, who would do general GYN surgery, and to that time as a laborist as well. So we needed to partner with someone who would be flexible, who would include our own dedicated staff, our family practice OB that I mentioned, our certified nurse midwife. 00;10;33;26 - 00;10;58;09 Julie Petersen We had folks who we knew were really dedicated to our community, and we needed a partner who would build around them. So we worked with GBHG. They basically said, sat down with us and said, let's build some schedules. Let's see how we can make this work. And we settled on a three week a month rotation. When you were on call to deliver babies, that's all you do. 00;10;58;11 - 00;11;21;23 Julie Petersen So again, delivering maybe a baby a day, that's not overly burdensome. It is a 24 hour commitment. But for seven days that's what you do. The next week you get off, you return to clinic work and just clinic work for the following two weeks. And that seems to have been an attractive model, not just for our own delivering physicians, but for OBGH as well 00;11;21;23 - 00;11;25;00 Julie Petersen and they're having some success in recruiting to that position. 00;11;25;05 - 00;11;39;07 John Supplitt Which is excellent news and I'm sure a relief to you. So this is how you're going to put this model into practice. How has the community received the message, or do they even understand the message that you're changing the model? Is it relevant to them? 00;11;39;09 - 00;12;03;08 Julie Petersen You know, you lead with the fact that except in a rural community, people don't expect the OB they see in their clinic to deliver their baby in very many facilities anymore. So this is not new to people. It's new to Kittitas and to our population, but they were very much aware of it. And if they delivered somewhere else, that's probably the model that they had seen. 00;12;03;11 - 00;12;20;07 Julie Petersen The thing we had to say over and over again is that we are committed to this. It's not going to be easy. We're not going to be able to do it overnight. But we have never been on divert for deliveries. So whatever it took to pull that together and keep that service intact, our board has been willing to make that commitment and do that. 00;12;20;07 - 00;12;26;03 Julie Petersen And frankly, I think the community has come to believe us. They've seen how we've struggled, but they know we're in it. 00;12;26;06 - 00;12;38;17 John Supplitt Nevertheless, Julie, it's a radical change in the way in which you've delivered OB in the past. I'm curious to know, given the importance of the nursing component, how has your nursing service responded to the change? 00;12;38;20 - 00;13;02;27 Julie Petersen Labor and delivery nurses are the number one reason that we're seeing rural communities go out of the OB business. So while we have struggled with an OB-GYN component with first assist, of course have to have anesthesia available. You have to have someone there to take care of the baby as well. You have to have pediatricians or acute newborn providers and a cesarean section to take care of the babies. 00;13;02;27 - 00;13;27;02 Julie Petersen So it takes a team. But our nurses are the bedrock of that. And we talk about labor and delivery. Eleven hours of labor and delivery is all about the nurse. The doc walks in and is there for a short period of time. Our nurses are dedicated. They have a lot of longevity, and they are just used to doing whatever it takes to get the job done, and that's what they've done for the last 15 months. 00;13;27;05 - 00;13;51;26 John Supplitt So all these things considered, given the changes that you're planning - two questions. The first is what's the timeline for implementation? You really started this process back in 2022-2023. You've moved forward for the research. You made the decision to go to be with OB hospitalist Group in October of 2023. What's the timeline now for looking forward in terms of making this permanent? 00;13;51;28 - 00;14;23;06 Julie Petersen We believe we will be fully staffed between our own providers and OBGH in July of this year. So it has been a long haul. We've been on the pediatric side of it. We've been building our acute newborn so that that's a very reliable group now. And anesthesia as well. So we feel like once we have weathered the storm of a lot of locums and short term locums, and we get our OBHG hospitalist on board, our own folks on board, we're going to be ready to go. 00;14;23;06 - 00;14;53;12 Julie Petersen So July, August of this year. And again, a component of this and one of the ways that we make this affordable - and labor and delivery has always been a loss leader - but one of the ways we make this affordable is through this OB-GYN model is we do have built in GYN surgical time. So we're able now or we will be able to take care of more of the general gynecological needs of the women in our community than we've ever been able to take care of before. 00;14;53;15 - 00;15;05;17 John Supplitt Well, and I think that that's the question, and that'll be the last question I ask. And that's the one that everybody wants to hear, is, how are you going to pay for this? How are you going to meet the expenses to make sure that this service remains viable moving forward? 00;15;05;20 - 00;15;34;24 Julie Petersen So every schedule we've put together also includes that GYN surgery day. So our OB-GYN will be doing more surgery than are the ones that have been working 24 hours a day to deliver babies were willing to do. So GYN services will continue to increase. This, frankly, is a service that we have always look to our 340B savings to help support and like everyone else who delivers babies, we lose money on it 00;15;34;24 - 00;15;46;20 Julie Petersen so we made a direct connection to those 340 B savings. So we keep a close eye on that as well. It is not going to be easy financially. We will struggle because of this. But again, we're committed. 00;15;46;22 - 00;16;05;27 John Supplitt Well. And you raised some very important points is that none of these programs exist without the other. And 340B is essential to rural community hospitals across the country. It is the margin for many critical access hospitals and what you're suggesting, it's going to be pretty much the margin for you to be able to continue this OB service. 00;16;06;00 - 00;16;33;26 John Supplitt I think I really, on behalf of all of our listeners, want to thank you and your board for the commitment to making sure that OB is available to the residents of your community. That they're not put at risk for unsafe deliveries, unhealthy situations, becoming unsafe because they have to cross a mountain pass. I think it's a huge commitment on behalf of your community and your leadership in making this happen to really implementing this practice and making it come so quickly 00;16;34;00 - 00;16;37;01 John Supplitt given the crisis that you were confronted with just a few months ago. 00;16;37;07 - 00;16;38;25 Julie Petersen Well, thank you. It's a privilege. 00;16;38;28 - 00;17;09;02 John Supplitt I want to thank my guests. Julie Peterson, CEO of Kittitas Valley Health in Ellensburg, Washington, for sharing her important story and providing essential health services and reimagining OB to ensure continued care for the residents of Kittitas County. Your commitment is inspiring, and we'll be watching closely as you grow and evolve under this new model of care. I wish you every success in your effort and hope to learn more about how we can learn from your experience. 00;17;09;04 - 00;17;19;01 John Supplitt I'm John Supplitt, senior director of Rural Health Services. Thank you for listening. This has been an Advancing Health podcast from the �� Association. 00;17;19;04 - 00;17;27;15 Tom Haederle Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts. </details></div>&nbsp; Sun, 14 Jul 2024 23:18:39 -0500 Obstetrical Risk Kittitas Valley Healthcare /case-studies/2024-04-22-kittitas-valley-healthcare <div class="container"><div class="row"><div class="col-md-8"><img src="/sites/default/files/inline-images/kittitas-health-meeting-essential-health-services-and-reimagining-obstetrics-in-a-rural-community-rural-case-study-april-2024.jpg" data-entity-uuid="28a48008-613f-4c4e-b19e-3e9d5513fca3" data-entity-type="file" alt="Kittitas Valley Healthcare Logo" width="268" height="112" vspace="15px" hspace="15px" class="align-left"><h2>Meeting Essential Health Services and Reimagining Obstetrics in a Rural Community&nbsp;</h2>Situated in Ellensburg in the heart of central Washington, Kittitas County Public Hospital District No. 1, also known as Kittitas Valley Healthcare (KVH), provides care to Kittitas County and surrounding areas. Kittitas County is 2,297 square miles and home to about 48,000 residents, growing fast at an average rate of 2.13% annually. Ellensburg is at the intersection of Interstate 90, which runs midway through the entire county connecting the major cities of Seattle, 110 miles west, and Spokane, 175 miles east, with I-82 connecting Yakima 36 miles south.<img src="/sites/default/files/inline-images/map-image-meeting-essential-health-services-and-reimagining-obstetrics-in-a-rural-community-rural-case-study-april-2024.jpg" data-entity-uuid="6aaf9b16-b9fe-444e-83bb-614e44360adb" data-entity-type="file" width="NaN" height="NaN"><h3>Defining Essential Services&nbsp;</h3>KVH includes a 25-bed critical access hospital and provides care through clinics and specialty services in Upper and Lower Kittitas County. According to the 2021 Kittitas Community Health Assessment &amp; Improvement Plan, the leading causes of hospitalization in the county are: 1) complications of pregnancy, childbirth and puerperium, and 2) certain conditions originating in the perinatal period. For young adults ages 18-24, the leading cause of hospitalization is complications of pregnancy, childbirth and puerperium, and for children 17 years of age or younger, it is certain conditions originating in the perinatal period.Given the demand, it is clear that the core of essential services provided by KVH is women’s health services, including obstetrics and gynecology (OBGYN). However, in 2023, all three full-time (FT) OB/ GYNs gave notice of intent to leave the organization. KVH was in crisis. While OB services never paid for themselves, the board was committed to delivering babies for the community. With the loss of its FT OB/GYNs and the demand for a breadth of women’s health services, KVH needed a fix.<h3>The Market Drives the Need to Change&nbsp;</h3>KVH delivers around 300 babies per year. Prior to 2022 and COVID-19, KVH provided maternity and gynecological care to the community through OB/GYNs. The original practice model involved employing three OB/GYNs and one certified nurse midwife (CNM).&nbsp;But after providers left the practice, this traditional model was no longer viable. In addition to losing 24/7 OB call capacity, other types of services linked to OB/GYN care were compromised, such as GYN surgery and the capacity to perform routine, office-based gynecological procedures.&nbsp;Nursing is a key component of the model. Nurses drive the service and are omnipresent. There are a minimum of two labor and delivery nurses 24/7 to staff a dedicated labor and delivery unit. To be effective, KVH must sustain an OB RN pool, CRNA capacity, cesarean section first assist capacity and acute newborn providers 24/7/365.&nbsp;<h3>Innovative Model for Delivering Best Care in Rural OB&nbsp;</h3><img src="/sites/default/files/inline-images/facility-image-essential-health-services-and-reimagining-obstetrics-in-a-rural-community-rural-case-study-april-2024.jpg" data-entity-uuid="8f2d4c08-7d37-4f06-90d9-d7ca03725416" data-entity-type="file" alt="facility images" width="381" height="214" class="align-right">KVH had to think creatively about how to address this staffing concern. They had successfully worked with hospitalists and outsourced anesthesiology in the past. So, in 2023, leaders began to consider outsourcing obstetrics as an option. After considerable research and discussions with their clinical team, KVH engaged OB Hospitalist Group (OBHG), signaling a transition away from the OB/GYN employment model.<img src="/sites/default/files/inline-images/mother-child-imeeting-essential-health-services-and-reimagining-obstetrics-in-a-rural-community-rural-case-study-april-2024_0.jpg" data-entity-uuid="2fc5190d-6da3-4688-9d25-8b05b1d27084" data-entity-type="file" width="224" height="371" vspace="15px" hspace="15px" class="align-left">The new plan, launched in October 2023, includes securing three FT OB/GYNs who each work a five-day stretch of both clinic and OB call and then have 10 days off, returning after this 10-day break in service between rotations. The focus during clinic work is to restore capacity for all pregnant patients and routine gynecological care with procedures and surgeries.Routine OB care is provided by an employed KVH family practice OB, a CNM and an advanced registered nurse practitioner. With the five-day rotations for OBHG OB/GYNs, many shifts cross over between weekends and the work week, providing some respite from 24/7 demands on weekends and holidays. Dedicated time for both clinic and OB call functions is scheduled whenever possible.For KVH to break even on OB/GYN care, several strategies need to be implemented as they continually onboard OBHG. Based upon estimates, KVH needs to increase gynecological surgical volumes by 9.5 to a total of 10 cases per month, with an average reimbursement of $7,000 per case to break even and cover the cost of OB/GYN care in this community. This is only possible by using the OBHG model.&nbsp;Now more than six months into the transition, it may take up to nine months for the new model to become fully staffed by OBHG providers. In the interim, KVH is building resources and increasing the frequency of teaching drills and simulation training with their teams (anesthesia, acute newborn and surgical assist) and solidifying referral networks and relationships between providers for both maternal fetal medicine and gynecological oncology.<h2>Conclusion</h2>KVH is optimistic that its new model will be fully staffed with OBHG providers on time, as planned. Presently, KVH employs a surgically trained family practice OB, but retains support from recently retired obstetricians. KVH partners with a teaching community health center and has sent FPs there to be surgically trained in performing c-sections, which helps to advance skills and supports overall recruitment.KVH must maximize scheduling of gynecological clinic visits, surgeries and procedures by focusing OB/GYN expertise on GYN care in the clinic setting. They seek to restore GYN care for menopausal symptoms and concerns. KVH must continue work to secure maternal fetal medicine providers, so patients aren’t forced to travel to either Seattle or the Tri-Cities for care, their current options.Finally, KVH board and leadership will work with legislators and payers to secure and retain adequate reimbursement or funding to sustain comprehensive women’s health care, including obstetrical and gynecologic care in the local community. Funding and reimbursement must keep pace with these local and national challenges.For additional information contact:Tricia Sinek Strategic Projects Coordinator Kittitas Valley Hospital (509) 962-7301 603 South Chestnut Street Ellensburg, WA 98926</div><div class="col-md-4"><a class="btn btn-primary btn-wide" href="/system/files/media/file/2024/04/rural-case-study-meeting-essential-health-services-and-reimagining-obstetrics-in-a-rural-community-rural-case-study-april-2024.pdf">Download the PDF</a><a href="/system/files/media/file/2024/04/rural-case-study-meeting-essential-health-services-and-reimagining-obstetrics-in-a-rural-community-rural-case-study-april-2024.pdf" target="_blank"><img src="/sites/default/files/2024-04/cover-meeting-essential-health-services-and-reimagining-obstetrics-in-a-rural-community-rural-case-study-april-2024-2.png" width="512" height="662"></a><div class="external-link spacer">&nbsp;</div></div></div></div> Mon, 22 Apr 2024 13:54:14 -0500 Obstetrical Risk