(gentle somber music) - [Jackie] The earliest years of a child's life can make a big difference in lifelong outcomes.

But really, it starts even earlier than that.

- Obstetrics has to be more than an afterthought for people.

It can't be, you know, we deliver 12,000 babies in South Dakota per year.

That's not a small number.

- It didn't take me 'til getting pregnant with her that I, like, fully processed the trauma that I experienced.

- And I know what it's like to be in pregnancy and be afraid.

- To me, it's an uncomfortable time, but it's an extremely innovative and creative time too, and what a great time to be in healthcare, to be able to help support innovation in delivery of healthcare.

- [Jackie] Maternal healthcare in South Dakota and what it means for the future.

That's tonight's "South Dakota Focus."

(bright upbeat music) - [Announcer] This is a production of South Dakota Public Broadcasting.

(bright upbeat music) (bright upbeat music continues) - We're spending this season of "South Dakota Focus" looking at how we prepare kids for the future.

But our best chances for healthy kids start with healthy moms.

We'll start our story here at a church in Sioux Falls.

So we're here tonight because this is the meeting place for the South Dakota chapter of ICAN, and ICAN stands for the International Cesarean Awareness Network.

And we're here because I want to hear more from moms who have had a birth story that maybe wasn't what they initially planned.

This support group focuses on mothers who are either recovering from or preparing for a cesarean section.

We were invited to the meeting by the group's founder, Valerie Hummel LaBounty.

- I started ICAN because I was looking for support from people who have experienced similar things that I did in birth.

My first birth was a cesarean for a breach baby.

And it was considered a planned cesarean, but it was not what I wanted.

- [Jackie] Breach babies are a really common reason for C-sections.

It means the baby is not positioned headfirst for a safe delivery.

Valerie found out her baby was breached at her 40 week appointment.

Basically the end of pregnancy.

Her doctor scheduled a C-section for the next day.

- A lot of resources.

And I know I'm fortunate in that I had time to think about it and time to process.

But you know, I didn't sleep that night.

I was mad and sad and frustrated and screaming at this baby inside of me, 'cause I was just so mad that, like, why is this happening to me?

So going into the cesarean, it was really hard to be excited about meeting my baby, because it meant a surgery I didn't want.

And I've read things or I've heard things and maybe you know a little bit, like, women who have dementia or Alzheimer's, like, they still remember their births.

So to have that experience as a birth experience, that's, you know, I love my firstborn.

I don't love my birth experience.

- [Jackie] Some of Valerie's frustration comes from the strain she sees on the medical system, even in the state's largest city.

- Seeing an OB and she was so busy.

I think that was part of why this breach was missed, because she did not spend a lot of time with me.

She didn't really feel as much as she could have to see if baby was in an optimal position.

- [Jackie] But she is grateful for other parts of her experience.

Valerie lives in Hartford, about half an hour from Sioux Falls.

She has a flexible work schedule, so making her prenatal appointments wasn't the hard part.

That's not the case in most parts of South Dakota.

On the other side of the state, in Sturgis, we meet Darbi Hunt.

She works with the Family Services Division of the Black Hills Special Services Cooperative.

Part of her job is talking with families around the state about ways to improve health outcomes.

- That really brings to light the maternal health desert that is taking place in South Dakota and has been taking place for a very long time.

If you look at South Dakota, almost all of the counties in South Dakota qualify as maternal health deserts.

And so what that means is that there really are no medical services for women who are pregnant and expecting.

There's no obstetric care and there's no hospital or birthing center where they can give birth in their counties.

- [Jackie] It's pretty common to travel for healthcare in rural states.

But as we see rural hospitals close, prenatal care options close with them, and the distance to doctors gets bigger.

The result is a state where convenient obstetric care and a healthy pregnancy can depend on your zip code.

- Obviously we know that getting good routine prenatal care is very important.

And so if you can't get that close to your home, it creates a lot of challenges for families.

And so then they're more likely to put that off or not get the care that they need.

Things that might be small things that could be easily fixed are not fixed or things are not caught.

And so then that is a big problem that starts compounding.

- So it makes sense that more specialized doctors would tend to be based in more urban parts of the state.

But when you look at it on a statewide map, it can really help put that access piece into perspective.

So this is the Health Resources and Services Administration website.

It's a federal website based on federal data.

And you can click through each county in South Dakota and see how many OBGYNs are in that particular county.

So right now we're sitting in Sioux Falls in Minnehaha County.

You click on the map, you can see the 24.

But let's see, we're in Brown County, Aberdeen area.

We're down to seven.

Maybe we're in Pierre or Hughes County.

That's two OBGYNs for that county.

Or say Oglala Lakota County or Pine Ridge area, one OBGYN for that whole county.

Now, especially in more rural areas, it's not uncommon for OBGYNs to split their time across different clinical sites in different counties maybe.

But even with that in mind, that is still a whole lot of empty counties.

More than 2/3 of the state with no OBGYNs.

The distance to a prenatal appointment is just one piece of the puzzle for a pregnant person in the state.

Dr. Kimberlee McKay is an OBGYN and Clinical Vice President with Avera Health in Sioux Falls.

- If you are now a poor pregnant patient who has trouble with transportation where your car might not be reliable or gas is more expensive, you have to drive an hour each way for your prenatal appointment.

And then you're out of work for pretty much that entire day just to go to your appointment.

And you're working at a place that perhaps has less than 50 employees that doesn't have really a great medical leave or any kind of policy around going to doctor's appointments.

These patients are forced to make really hard choices.

You know, do I go to work and earn my minimum wage and feed my family, or do I go to my prenatal appointment?

- [Jackie] Assuming no complications in a pregnancy, what's the recommended number of those prenatal appointments to kind of paint a picture for folks of what that time commitment looks like?

- About seven to 10 would be kind of for a low risk.

(laughs) We don't see very many low risk patients here.

We just don't.

But yeah, seven to 10.

- [Jackie] Well, that's interesting that you say that.

So then talk to me about how some of the more common complications and then what that adds to it.

- Well, yeah, so I think we all know that the population is more unhealthy.

So you know, there's higher obesity rates just in general in the United States.

And so when your baseline health starts out as obese and sort of the things that go along with that, which is diabetes and hypertension, those are not good partners for pregnancy, diabetes, and hypertension.

Like, these are risk factors that can both impact the fetal health and neonatal health and overall the lifetime of that child.

But certainly that makes it so mom's more at risk for C-section, more at risk for early delivery, more at risk for developing a severe kind of high blood pressure.

- [Jackie] Dr. McKay says high blood pressure is a complication that needs consistent monitoring throughout a pregnancy, but it doesn't have to mean that patients go it alone between appointments.

- You can buy a blood pressure cuff, you can take your blood pressures, you can write 'em down twice a day, and you can email 'em to your doctor.

But there's always gonna be kind of this lag between, you know, I see the blood pressures, and then I immediately kind of reflex and adjust your blood pressure medications.

So when we're innovating around how do you take care of moms where they are, where my brain goes is, we need to give them a Bluetooth monitor that just automatically sends me the values and have a software that monitors and tells my team when the blood pressure needs to be adjusted so that I have something that's always surveilling the patient.

And so when we talk about trying to change outcomes, that's really what we're trying to innovate in, is what's the intervention on the medical side that's going to allow for us to really manage that disease state in a way that allows us to get ahead of it versus just react to it.

- [Jackie] A few years ago, Dr. McKay had a similar idea for another increasingly common complication, gestational diabetes.

The CDC says that condition has increased from 6% in 2016, to more than 8% of all pregnancies nationwide by 2021.

And that rate goes up with a mother's age.

Dr. McKay says in 2016, even before COVID, her team was monitoring patients remotely after receiving a federal grant.

- And let me tell you how many people thought we were crazy.

They said, "You can't teach insulin on a cell phone.

You can't do education.

This is not standard of care."

To which I said, "Well, it's not tertiary care standard of care, but this is rural.

We have to work with patients."

And so, you know, we sent patients a Bluetooth monitor.

It had a software that surveilled the glucoses.

It would alert the team for when they needed an adjustment.

We adjusted insulin doses for patients sitting in cars (laughs) or at the grocery store or in a bathroom.

What we took from that program is that Wi-Fi access is a social determinant of health.

Like, connectivity is really, really important.

Being able to pay for that connectivity is important.

- [Jackie] That first grant was a launching point for maternal telehealth care in the state.

Since then, Avera's gestational diabetes patients who are monitored virtually, have seen a 27% decrease in vaginal delivery complications and an 18% decrease in cesarean complications.

And it turns out the patients aren't the only ones who can benefit from those virtual connections.

We are on our way to Parkston today.

That's about an hour and a half west of Sioux Falls, like, half an hour south of Mitchell, just to orient you to where we are.

And we're going there to talk to a doctor who's involved with the RMOMs grant.

Avera was awarded this federal grant about a year ago.

It's another grant related to access to obstetric care in rural areas.

But in addition to kind of connecting patients with those resources, it's also about connecting providers with a network of resources in that respect.

So Avera is targeting a handful of East River counties for this grant, and Parkston falls in one of those areas.

Parkston is home to this clinic, Avera St. Benedict.

It's where Dr. Paul Berndt practices family medicine.

- I'm a Minnesota transplant, grew up in Southern Minnesota, but my wife is from about 15, 20 minutes from here.

And that was kind of what brought us to the area and the rural community, was being close to the family farm and close to them.

I really wanted to find a practice that was comprehensive, that you could take care of people throughout their whole life and do everything.

And that's getting to be rarer and rarer.

Very few communities are offering the full spectrum family medicine.

I had a faculty in residency that always called it cowboy medicine, but that's kind of what I wanted.

I wanted something where you could do everything.

You could care through people throughout their whole life.

- Dr. Berndt says Parkston's Clinic sees a few dozen births a year, not enough to justify a full-time OBGYN, but definitely enough to warrant some extra training and support.

- So we're really lucky through Avera.

It's easy to get in touch with our OB and MFM specialists.

We have resources such as the Gestational Diabetes Telemedicine Clinic where we can get somebody three hours away logging their blood sugars with a nurse and a dietician in Sioux Falls.

And so trying to bring in those resources so that even if someone geographically lives a long ways from a big city, we can still get them that specialty care.

- [Jackie] That connection to colleagues can make a big difference, especially when a doctor doesn't do a procedure very often.

- Well, and then, Dr. Berndt, here's a good story.

(Jackie chuckling) - [Jackie] I'm gonna hate that I didn't have this yesterday to ask him about it.

- He called me, this was probably a year ago, and he, you know, his site does 50, 60 deliveries a year, but they're a very important access point for a specific population.

And he had a patient show up who was in labor, you know, seven, eight centimeters dilated.

The baby wasn't in the right position, and he had to do a classical C-section.

And he called me and he said, "How do I do this?"

(laughs) And we talked through it.

I said, "Call me back when you're done."

And he did it and got the baby outta there.

And yeah, he did good.

I mean, there's not... Like, he does C-sections.

There's not a huge difference.

But just to have that resource was good.

- You know, I think one of the biggest honors as a provider is when someone trusts not only the mother of the family, but also their unborn child to you.

And so that's not something that we take lightly when we do obstetrics.

It's a huge part of the practice.

And the most gratifying part is after the fact, you know, you have a wonderful delivery.

But then also sharing in those first cries with mom and dad and baby, seeing that baby and the child growing up.

Next thing you know, you're at the grocery store and you watch 'em running around.

And just the sense of community that that creates, the relationships that that makes with your patients is really unmatched.

And I think that is what draws me, and I think a lot of providers, to obstetrical practice.

I think a big part of our small communities and our rural communities is our young families.

And so I think by looking at how we keep our communities strong, and how we keep them prospering and growing, it's being able to provide care for those families close to home.

- [Jackie] Which brings us to another partial solution to the maternal healthcare puzzle.

Pregnancy checks right at home.

- Now, we can't have a strong workforce if we don't have strong and healthy families.

And so today I'm announcing that I want to expand our Bright Start Program statewide.

It's been an overwhelming success for eligible mothers.

That's why I would like you to endorse the program and continue to support it.

- [Jackie] Lawmakers agreed, and last year, South Dakota's Bright Start Home Visit Program expanded from 19 counties to all 66.

It connects low-income, first-time pregnant people with a nurse.

That nurse is available for home visits throughout the pregnancy until the child's second birthday.

The program was already popular in certain areas.

Here's Secretary of Health Melissa Magstadt during a meeting with lawmakers earlier this summer.

- [Melissa] I'll give you a little early peek that we're seeing a huge uptick in the use of our Bright Start, especially in Pennington County and in Huron.

And there's actually, I think, a waiting list in Huron of 61 people.

- [Jackie] In that same meeting, Secretary Magstadt showed that South Dakota has more infant and maternal deaths than other states in the region.

I asked her how a program like Bright Start can address those rates.

- You would have seen in that presentation that in our infant, the less than one year infant mortality, very much connected to preterm birth, very much connected to low birth weight.

So small, born maybe full-term, but small for gestational weight.

Things that pregnancies didn't go well and could have been intervened earlier.

All of those are very evident in that maternal or that infant mortality rate increase.

And so one of the key strategies for all of those things that we can put our finger on and start moving that lever is prenatal care.

And the maternal mortality rate.

You've seen in that presentation that some of our maternal mortality rates is that that death that occurs within a year of a mom having a baby is motor vehicle accidents, substance use and suicide.

So anything that finds that postpartum depression early, anything that helps support moms maintaining healthy behaviors like substance use disorder and making sure that there's a continued healthy behaviors in that postpartum period is gonna help reduce those numbers as well.

And it's one of those levers that we can sort of lean in and help support that pregnancy.

And that's how those pieces are connected.

So Bright Start is one of our key strategies for impacting both of those.

- [Jackie] Magstadt says Bright Start has served about 3,000 families in 23 years, and those nurses have helped moms identify early labor, work through breastfeeding and answer questions about caring for a new baby.

- We have places that have known about Bright Start for a lot of years and very connected, used a lot.

We have places that are so used that we're having to beef up more resources in those areas, which I love that.

I want every woman to have access to this that is wanting to and is eligible and would like to take a part of this.

I want it available.

- To be eligible for Bright Start, the mother must be in her first pregnancy and her income must qualify her for federal assistance programs like Medicaid or the Children's Health Insurance program.

And even with those requirements, the number of potential Bright Start patients has drastically increased by expanding the program statewide.

What do you and the Department of Health need so that every woman could have access to this?

- I think that this piece, we've got the legislature and the governor supporting the resources of it.

We've got the nurses trained now.

We need to get the word out.

We need to get the word out.

We've got 23 years of success right underneath our belt.

We're ready.

- [Jackie] I asked if that applied to areas with a wait list like Huron.

- You know, we are very fluid with our resources.

When a community needs more of us, we're gonna shore that up.

When communities need to learn about us, we're also gonna make ourselves known as well.

- Great, so not at capacity by any means.

Not in a low workforce.

You are ready for families.

- We're gonna take, yep, absolutely every one of 'em.

If that means that we got, you know, a few days to get you in where we need to go and we need to shore up those resources there, we're gonna move them there.

Absolutely, 'cause we're not gonna miss a mama who wants to have our help.

We're gonna be right there for them.

- When Governor Kristi Noem proposed the Bright Start expansion in her 2021 budget address, she made a pointed connection to the anticipated Supreme Court ruling on Roe v. Wade.

- You all know that I'm pro-life, but too often pro-lifers get falsely criticized for not caring about mothers and about their children after their child is born.

As we get closer and closer to our goal of protecting every single unborn child, our pro-life focus should include programs like Bright Start that helps set up families and mothers for success.

- [Jackie] The US Supreme Court struck down constitutional protections for abortion access in the summer of 2022, about a week before the statewide Bright Start expansion started.

- [News Anchor] Today, abortion is illegal in eight states.

- [Jackie] Another South Dakota law took effect along side that Supreme Court decision, a so-called trigger law now bans nearly all abortions in the state.

The lone exception is an abortion to save the life of the mother.

That seems straightforward, but it's not.

The lawmakers could change that.

- You know, I didn't actually grow up in a political home.

I don't know if I'd shared that with you, but I grew up in a home where we were very apolitical.

We really didn't talk about politics at all.

And so my journey into nursing was how I actually got interested in politics.

- Representative Taylor Rehfeldt is a high ranking Republican in the State House.

She's also a mom of three, including baby Tallie, who's just a few weeks old when we visit her.

Rehfeldt felt ran for office after an experience with policy that shapes her career.

- I started working on a policy issue for Nurse Anesthetists and I was president of our association.

And what we were working on is making sure that our scope of practice was updated so that I could, and we could, practice the full scope of our license.

And so through that process, I was exposed to the legislature and saw that really, there wasn't a lot of people that looked like me or had a family and experience like me.

And so I thought it was important from that perspective to make sure that people and voices like mine were represented, and what I mean by that is women, people with families, people with children, people where both parents are working.

And so I've been proud to really offer that experience in the legislature.

- [Jackie] Rehfeldt was pregnant with Tallie when she introduced a bill earlier this year to clarify the state's abortion ban exception.

- I think what we need to remember in the process of pregnancy and birth is that there are two patients and not just one.

So our conversations are often driven just about the baby, which I love babies.

I have three children.

I think that they're wonderful, and I don't like abortion, and I love mothers, and I think that we need to take care of mothers as equal as we take care of babies.

And so I brought the bill forward, because when you had the trigger law take place in the previous statute, there was a definition of what it meant to preserve the life of the mother.

And it was defined in the medical emergency definition, which basically what it says is that if there's a chance of irreversible injury to a major bodily function, then that would apply, and the physician would be able to intervene for the life of the mother.

Well, that definition's no longer in place.

So now it just says life of the mother and doesn't really have any explanation of what that means.

And so providers are looking for clarification.

- [Jackie] The American College of Obstetricians and Gynecologists, or ACOG, is a nationwide professional association.

Dr. Amy Kelley is the legislative chair of the South Dakota chapter of ACOG.

When it comes to the state's exception to the abortion ban to save the life of the mother, Dr. Kelley says it's more complicated than it seems.

- [Amy] Do I get to decide when it's life-threatening?

Does the patient get to decide when it's threatening enough?

Does the government get to decide?

And at 2:00 in the morning, that's an issue.

(laughs) You can bleed to death from a previa in 15 minutes.

- [Jackie] A placenta previa happens when the placenta blocks the cervix and causes heavy bleeding during labor.

But this law presents another challenge.

South Dakota doesn't have a residency program for OBGYNs.

Dr. Kelley knows several medical students who've had to leave the state to finish their training, who are no longer planning to come back because of this legal ambiguity.

Add to that the nationwide shortage of OBGYNs, and South Dakota is at a serious disadvantage recruiting maternal health specialists to the state.

In a story for "South Dakota Searchlight" earlier this year, state Attorney General Marty Jackley would not offer an interpretation of the trigger laws exception.

Jackley said it's, "Not appropriate for the Attorney General's office to address hypotheticals."

That means it'll take a court case to set precedent unless the legislature adjusts the legal definition.

As for Representative Rehfeld's bill, she tabled it when some key stakeholders pulled their support.

- I think any mention of changing the trigger law or addressing some of the issues makes people fearful.

And so I also think that education is a piece of it, that some people thought, "Well, do we really need to at this point?

Should we just see how it goes?"

But what people fail to realize is that it's not about just seeing how it goes, because we're talking about people's lives.

And I'm one of those moms that's had high-risk pregnancies.

In 2014, I had a stroke, and what that means is a clot went into my brain and I was unable to speak.

And that's a life-threatening condition.

And so as a result, when I'm pregnant, I have a high risk of clotting again.

And so I could have another stroke very easily.

I've also had heart issues when I'm pregnant, and I know what it's like to be in pregnancy and be afraid.

Not that I would ever wanna have an abortion, but I wanna make sure that I can have the healthcare that's available to me to save my life or to make sure that I don't have a permanent disability that impacts my ability to be a mom or care for my children for the next 30, 40 years.

- [Jackie] Is this something you expect to bring again in the next session?

- I do.

It's been hard to try to find consensus again, but I do believe that it's vitally important to have the conversation again.

And if the only thing that I accomplish is providing education to the legislature and to the public about why this is important, I still plan to bring it forward, because I think that accomplishes some.

And it's not just about getting a bill passed, it's about having conversations and facilitating those conversations.

- [Jackie] South Dakota's Secretary of Health, Melissa Magstadt, is optimistic about the challenges the state is facing in healthcare.

- There's this interesting time right now that we have this workforce challenge, we have healthcare desert challenge, but in those periods of time, that is when the most creative things come forward.

To me, this is an uncomfortable time, but it's an extremely innovative and creative time too.

And what a great time to be in healthcare, to be able to help support innovation in delivery of healthcare.

- [Jackie] Being a mom in South Dakota is complicated.

It can mean the choice between a day's wage and a prenatal care appointment.

Bringing healthcare closer, either virtually or through in-home visits, can make a big difference.

But that's just the first piece of the puzzle.

- At the end of the day, telehealth is not gonna solve every single problem.

It's going to solve...

It's going to be a bridge to particular interventions.

And so we can't think of telehealth as the end all be all.

We have to use it in a way that's meaningful.

- The span of healthcare is literally in every policy decision.

And I'm not talking about pharmaceuticals or insurance or scope of practice bills or, you know, access to healthcare in rural communities.

I'm talking about housing, food, childcare.

Everything impacts health.

- [Jackie] The future of South Dakota relies on new families and they rely on moms having access to healthcare and continued investments in their communities, because bringing a new child into the world, however they arrive, is only the beginning.

(bright uplifting music)