Jasmine Gutschow felt nauseous when she woke up a few days before Thanksgiving last year. She brushed it off as typical pregnancy symptoms. She told her fiance he should head into work – the baby, not due for six more weeks, wouldn’t be coming anytime soon.
Three hours later, after her contractions started, after they sped for the hospital after their 2003 Tahoe broke down after her contractions quickened to every two minutes and Gutschow’s fiance frantically dialed 911, it had become crystal clear that this baby had other ideas.
Gutschow sat curled in the passenger seat on the shoulder of Highway 10 near Upland, trying not to scream in pain and scare the two other children in the car – there had been no time to find a babysitter.
“I really don’t want to have this baby on the side of the road,” Gutschow said as she told Gregory – call the ambulance.
The car problem: A faulty fuel pump.
The bigger problem: The couple lives 50 miles, and an hour’s drive, from the hospital where Gutschow receives maternity care.
The couple lives in Franklin, inside a county of 2,889 residents in south-central Nebraska. Like 55 other counties in the state, Franklin County has no hospital offering birthing services.
The long drive can lead to far worse outcomes than mere added mileage. Rural regions of the state accounted for roughly 40% of births from 2016 to 2018. During that time, rural Nebraska had a rate of roughly 52 severe maternal mortality cases per 10,000 deliveries, notably higher than the urban rate of 45, according to the Nebraska Department of Health and Human Services.
And access to pregnancy care is getting worse.
Since 2017, Nebraska has lost six birthing units in rural hospitals already 35 miles away from the nearest hospital, said Sydnie Carraher, program coordinator for the Nebraska Perinatal Quality Improvement Collaborative.
As delivery rooms dwindle, emergency calls from expectant parents have become more frequent, said Elizabeth Burki, an EMT and one of the Hildreth first responders who answered Gutschow’s call.
“The help is not there,” Burki said.
When the ambulance arrived, Gutschow struggled to uncurl her body from the only position where the pain wasn’t unbearable and lay flat on the stretcher. Her fiance and the kids had to stay on the side of the highway as the ambulance pulled away.
Gutschow was alone with no pain medication.
One EMT called Gutschow’s obstetrician. Another reassured her they had trained for this exact scenario. In fact, the Hildreth first responders had done a Simulation in Motion Nebraska training – a simulated emergency delivery – less than 48 hours before Gutschow’s call.
They sped toward Kearney. But a contraction came, Gutschow’s water broke and it became obvious they wouldn’t make it to a hospital. Hildreth EMTs hadn’t delivered a baby in 70 years, Burki said.
In small-town Nebraska, a lack of both babies and funding have made deliveries more difficult.
Sixteen counties in Nebraska average fewer than 50 births a year, according to the U.S. government.
If a hospital only sees a handful of births a year, it’s tough for staff to confidently offer obstetric care, said Mariana Tuttle, research fellow at the University of Minnesota’s Rural Health Research Center.
Low birth rates also make funding labor and delivery services difficult, especially in rural regions where half the births are funded by Medicaid – which reimburses at half the rate of private insurers, Tuttle said.
She said it’s a compelling reason to expand Medicaid in states like Nebraska.
In the 2022 Legislature, Sen. Anna Wishart introduced a bill that would extend Medicaid coverage for new parents. That bill died in committee, said Sara Howard, a former state senator who’s now a policy advisor for First Five Nebraska.
“I think there was a reluctance to invest additional dollars beyond what's already being invested,” Howard said.
Small-town moms have a substantially greater risk of severe maternal morbidity than big-city moms, Tuttle said.
“People deserve to be able to live in these beautiful rural spaces and still have safe and healthy outcomes and labor and birth,” Tuttle said.
The dangers of giving birth in a rural area increase for parents of color, said Christian Minter, the Maternal and Infant Health Manager in Nebraska for March of Dimes.
The average infant mortality rates for Black and American Indian/Alaska Native infants in Nebraska were more than double the mortality rate for white infants from 2017 to 2019, According to March of Dimes.
“Many Native American moms do live in some of these rural counties and so looking at their access to health care is important as well,” Minter said.
Maintaining a birthing unit might simply not be possible in some of Nebraska’s smallest counties. Arthur County, for example, averaged only 11 births a year from 2017 to 2019.
Where it might not be feasible to keep a delivery unit open, family medicine physicians can increase prenatal care access at clinics and help transfer their patients to larger hospital systems when the time comes, Tuttle said.
But it’s not just delivery hospitals disappearing in rural Nebraska.
From 2017 to 2021 the state lost 56 family medicine physicians. Ninety-one of the state’s counties – every county except Douglas and Lancaster – are now designated as a “shortage area” for at least one type of primary care doctor. By 2021, 14 rural Nebraska counties lacked both a family medicine physician and obstetrician, according to a 2022 report by the University of Nebraska Medical Center’s Rural Health Initiatives.
Without intervention, it will get worse. In the coming decade, a large portion of Nebraska’s doctors are expected to retire across all specialties in rural parts of the state, said Nicole Carritt Director of Rural Health Initiatives at UNMC.
Recruiting certified nurse midwives is one cost-effective way of increasing care for non-high risk pregnancies in rural parts of the state where recruiting physicians may prove impossible, Minter said. And the number of those midwives is growing slightly in Nebraska even as the number of small-town physicians declines.
But Nebraska is one of only three states where certified nurse midwives have to practice under the supervision of a licensed physician, according to the American College of Nurse Midwives.
That regulation presents a challenge for certified nurse midwives trying to practice in small Nebraska towns that don’t have a doctor, Minter said.
For now, hour-long drives, like the one from Franklin to Kearney, remain the norm in small-town Nebraska. The long trips make even unlikely stories like Gutschow’s wild ambulance ride more likely.
On that morning a few days before Thanksgiving, the ambulance made it only 10 miles away from Gutschow’s car and family before she gave birth to her son, Raiden.
The ambulance now carrying mother, newborn and relieved Hildreth EMTs stopped at the nearest hospital in Minden. But that hospital didn’t have the necessary equipment to care for Gutschow’s brand-new son.
Hours into his life, Raiden was put on another ambulance so he could finally arrive in Kearney.
“Normally right after you have birth at the hospital, the baby's right there with you in the room and you start that bonding time,” Gutschow said. “We didn't get that until at least four hours afterwards, and I barely got to see him since he was so premature.”
Gutschow missed bonding time with her son. His father missed the entirety of Raiden’s birth. Instead of her fiancee holding her hand, an EMT – a complete stranger – squeezed Gutschow’s hand through delivery.
“[Gutschow] was just so incredibly brave,” Burki said. “It was amazing to be a spectator in what she was capable of doing.”
Today, Burki regularly receives photo updates of Raiden, who is mastering his crawl alongside his brother. He has already made multiple visits to the EMTs who delivered him.
“We all became aunts and uncles,” Burki said.
The now 9-month-old Raiden owns a one-of-a-kind birth certificate, which lists his place of birth as “Mile Marker 32.”
Delivering Raiden is one of Burki’s best memories as an EMT.
She also never wants her ambulance to become a delivery room again.
“Not every outcome is gonna be smooth as that one was,” Burki said. “What happened that day is probably more likely to happen again with how things in rural America, not just in Nebraska, are going.”
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