Into Worry Born: for low-income women in the rural heartland, stress is pregnancy's constant companion. By Rita Florez, Photos by Nicholas Benner. Woman bottle-feeding an infant

Nineteen-year-old Lila Jones is never sure about how she’ll make the hour-long journey from her home in Shelbyville, Mo., population 550, to her prenatal doctor appointments in Moberly. “My mom takes me sometimes,” says Jones, who is expecting her first child in about 10 weeks. “I don’t have my own vehicle, and if my mom can’t get off work, I have to find other ways to get to the doctor.”

not having a car is a major source of stress for Jones. Being unemployed doesn’t help either. “It would be really different if I had a job,” Jones says. “I would have money to pay for a ride. I wouldn’t have to worry about how to get the gas money.”

Jones’ mother, Darlene Jones, says each round-trip drive to Moberly costs between $25 and $30. That’s no small sum for Darlene, a manager at a Subway restaurant in nearby Shelbina. Finding the time can also be a problem. Lila’s mom works most Saturdays. Coordinating the transportation can be “a bit of a challenge,” she admits.

It’s a challenge faced by hundreds of low-income rural women and their families, both in Missouri and beyond, says MU’s Tina Bloom, an assistant professor in the Sinclair School of Nursing. Bloom’s work aims to determine how transportation problems, unemployment, social isolation, domestic abuse and other worrying realities affect the health of both mother and child.

In short, she says, pregnant rural woman deal with far more anxiety than health-care providers had previously supposed. “There’s a myth about an idyllic, rural life. When we think of difficulty, stress and strife, we think of the inner city. But when you dig into the few studies about rural people, you see they have a lot of stress and health disparities.”

Bloom counts herself as one of the experts who once tended to discount challenges faced by cash-strapped rural women. While earning her doctoral degree, Bloom studied the struggles urban women faced during their pregnancies at the Oregon Health and Science University in Portland. From her point of view, it seemed only natural to focus on the challenges faced by low-income inner-city women. Real poverty, she thought, existed only in urban areas. Once she joined the faculty at MU, however, Bloom soon came to realize that many rural communities were struggling too, and that pregnancy-related challenges and outcomes among low-income women living there frequently went unexamined.

Blonde woman sitting on couch reaching for toddler nearby.(red stripe graphic)

HOPING FOR MORE

Crystal Riley, 17, reaches for her 2-year-old son Kayden. Riley, who is currently pregnant with her second child, struggles to make ends meet while working for minimum wage at the Little Dixie Regional Libraries. Her goal, she says, is to finish high school this summer so she can enroll in a cosmetology program. “I plan on getting a better paying job,” she says.

Bloom is determined to do her part to address the information void. Her most recent study, published in the journal Issues in Mental Health Nursing, sought to determine, through face-to-face interviews with a sample of pregnant women in situations similar to those of Lila Jones, how life in the hinterlands affected womens’ health and well being.

Her findings were far from reassuring. Pregnant rural women, she discovered, were often isolated from the community, family and friends. Many reported feeling lonely and out of touch. Some had been victims of abuse. Even if the opportunity to vent about their problems arose, Bloom’s subjects said they would hesitate to “talk out” their issues with friends or family.

“They said it was really helpful to them to talk, but it was so risky, because in a small town, ‘Everybody knows everybody, and everybody knows everybody’s business,’” Bloom says. “Every single woman says that to me: talking about your problems means opening yourself up for the potential for gossip.”

Diana Taylor, Randolph County, Mo.’s, WIC coordinator, says her office comes into contact with mostly unmarried women. “The traditional security of marriage is not common,” she says.

Taylor and her staff spend a lot of time talking to women about how personal choices will affect the health of both mother and child. But stress-related behaviors often get in the way of a sensible prenatal regimen. One of the most serious lapses, Taylor says, is smoking. Many of her frazzled patients continue to use tobacco even though they understand it could lead to low-birth weights and babies with chronic health problems.

“Even though they tell us they’ve quit or cut back, stress leads them to make less healthy choices in eating and smoking,” Taylor explains. “The most common thread in the lives of the women we come into contact with is a lack of support. When there’s a strong support network, they tend to make better choices.”

Taylor lives in Moberly, a town of about 13,000 people. As she sees it, the most serious problems involve the want of basic needs. “Moberly has very good public housing, but there’s usually a long waiting list,” Taylor says. “There are also less job opportunities in the more rural areas. Having lived in Moberly, I will say there are fewer opportunities and outlets. There’s also not a lot to do.”

(square graphic)kay-lea epperson, 19, and her husband Nathan, struggle with the isolation and lack of social activities. “There’s not a lot to do [in Moberly],” said Epperson, who gave birth to her daughter, Gracie, on October 30, 2012. “Not having transportation makes it even harder,” she says.

The family take regular walks to get out of the house, she says, but doctor visits are a challenge. Because Epperson doesn’t have a car, she relies on LogistiCare, a company that provides “non-emergency medical transportation,” according to its website. Epperson explains that the service is a benefit stemming from her Medicaid insurance. To secure a ride to the doctor, Epperson must make an appointment with LogistiCare five days before it’s time to meet with her doctor. Forgetting poses further challenges. “I usually have to find a ride quick,” Epperson said. “Or I have to call and reschedule for five days ahead. Basically I just have to reschedule.”

Being unemployed hurts the young family as well. “We get Social Security,” Epperson said. “But finding work is hard.”

For other teenagers, like Crystal Riley, 17, not having a stable job isn’t the problem. It’s finding work that pays enough for her to support herself, her 2-year-old son Kayden and her little girl due July 31, 2013. Riley lives in Moberly and works in the town’s branch of the Little Dixie Regional Libraries, where she earns $7.35 per hour for 20 hours of work per week, “If I’m lucky,” she says.

Stretching the money can be hard, so Riley relies on WIC vouchers to help her feed her family. “You take the vouchers to the store, and you get stuff like eggs and cheese,” Riley explained. Without the vouchers, Riley says, she and her son probably wouldn’t eat as many healthy foods as they do.

Being in high school limits Riley’s opportunities, as well. Her goal is to finish school this summer so she can go to cosmetology school. “I plan on getting a better paying job,” she says.

When professional and social activities are in short supply, alcohol and drug use can become temptations for women like Riley, researchers say. Bloom has noted many of her research subjects report that addiction and alcoholism are common in the community.

“I would ask them, ‘Why do you think this is?’” Bloom says. “The most common answer was that women say there was nothing to do. People were bored. But a couple of women went beyond that and said they thought people were also depressed and treating themselves.”

Blonde woman sitting on couch reaching for toddler nearby.(red stripe graphic)

LIFE WITH LIMITS

Kay-lea holds Gracie while a technician at the Moberly Rural Medical Center monitors Kay-lea’s blood pressure.

The specter of domestic violence also looms large over the lives of low-income rural women, says Bloom. If a woman is living with domestic abuse, and her partner discovers she’s talking about their relationship to others, she could be in danger.

Mary Beck, the managing attorney who runs the family violence clinic at the University of Missouri School of Law, says rural, pregnant women are particularly vulnerable because of their physical isolation.

“Abused women may not have a car or the money to get to healthcare,” Beck says. “And their abusers may not want them to get to healthcare for fear of exposure of the abuse.”

According to Bloom, research suggests women living in rural communities are more likely to suffer domestic violence. Physical and emotional isolation is often a tool used by abusers against their pregnant victims, studies show. And the geographic isolation of rural living may further increase risk.

“We tend to also see an equal or higher occurrence of domestic violence in rural populations and — especially for those isolated or remote residents — a greater risk for severe intimate partner violence or homicide,” Bloom says. “When you don’t have as many resources to get help, that’s going to increase risk. And when you live farther out, when it takes a lot longer for law enforcement to get to you, that also increases risk and the likelihood that you may die in a violent incident.”

Bloom also found that a large proportion of the rural women she interviewed suffered from post-traumatic stress disorder, or PTSD, symptoms.

PTSD is a result of traumatic exposure, Bloom explains. Generally, people think of post-traumatic stress disorder as being a side-effect of combat, Bloom says. “But for women in particular, PTSD tends to be from complex trauma exposure. It’s hard to say that one thing caused it, because women are more likely to be exposed to violence across their life spans. They’re more likely to be victims of child sexual abuse; they’re more likely to be victims of dating violence, intimate partner violence and random sexual assault.”

Better family violence training could go a long way in alleviating some of the problems faced by rural pregnant women, both Bloom and Beck say.

The American Medical Association’s Council on Ethical and Judicial Affairs, as well as the American College of Emergency Physicians and the National Institutes of Health, have pinpointed domestic violence, family violence and intimate partner violence as issues of critical importance that should be addressed in medical school and healthcare provider training programs.

(square graphic)achieving this goal in rural areas won’t be easy. It’s no secret that the most advanced prenatal care programs and facilities are centered in cities. “Many providers of prenatal care in rural areas don’t have more sophisticated abilities to provide care for complicated cases,” Beck says. “Often, prenatal care in very rural areas is offered by primary care physicians rather than specialists in women’s care. That diminishes their ability to respond to problems that are unique to pregnant women.”

These general liabilities become particularly acute when domestic violence is involved. “Abused women are more unlikely to affirmatively volunteer that they’re being abused,” Beck says. “Rural practitioners don’t have the sophistication to ask the question of every woman they see, ‘Is anybody hurting you?’ Or separating the pregnant woman from the abuser who comes with her and insists on being in the examination room.”

Another problem is how society thinks of abuse, Beck says. “A lot of people think abuse is limited to bruising blows,” she explains. “It is just as manipulative and abusive to threaten to shoot a woman by holding a gun to her head, which leaves no marks, or by refusing to provide her with transportation to the doctor. Those things are very hard for people to identify.”

Bloom believes that many of the difficulties nurses and doctors face with pregnant women they believe are being abused could be solved by better training. “Our education for nurses and physicians could often be better in terms of domestic violence education,” Bloom says.

Part of the issue lies in a perceived awkwardness in asking about such personal issues. Sometimes, Bloom says, healthcare practitioners either just don’t know how to ask the questions or believe the woman is more likely to go back to her abuser. But the federal government, she says, has taken action in this area.

“The Affordable Care Act addresses domestic violence,” she says. “There is a screening for it as a preventive care measure that insurance companies have to cover now, so that’s a policy piece that helps move healthcare providers in the right direction.”

But any significant strides in alleviating stress related to violence against these pregnant women will likely happen when medical care providers get more training.

“It needs to become part of the curriculum,” Bloom says. “It’s important that healthcare providers learn how to ask the questions, to respond effectively, to help rural women find resources they need, and to be supportive. Rural women need support and extra assurances of privacy so that they feel comfortable opening up about violence and other stressors in their lives. The women I met were often amazingly strong and resilient, even in the face of all their difficulties, and they cared deeply about their children. Making sure that rural pregnant women have the resources they need to manage stress is good for their health and their kids’ health, and therefore it’s good for all of us.”

Reader Comments

Edward Steps wrote on July 4, 2013

Great article! I is time to start raising awareness about these important issues we take for granted and are affecting most rural communities in the U.S. Although most of us have an idea of the challenges young single pregnant mothers face, we as a community, must be more proactive in supporting efforts and initiatives which promote more education for our children and better access to resources to medical and social services in rural communities. Great job!

Faith Phillips wrote on July 9, 2013

While this is a difficult topic to address and often makes educators uncomfortable, I agree that weaving this into the curriculum is increasingly important. We do simulations where medical students are faced with a woman hiding bruising around her eye and they must get that woman to talk to them, hopefully developing a plan or at least scheduling a follow up with the provider. The students are always amazed at how difficult that encounter is when actually faced with that patient dilemma. Is it possible to get the professional associations to require training in this area as maintenance of certification? Keep up the great work, Tina!

Albert A. Reine, Jr. RN wrote on August 6, 2013

Logisticare is guilty of abuse. As you have finally pointed out that it is manipulative and abusive to refuse transportation to medical appointments. Logisticare gets wealthy by denial of transportation and are expert in manipulation of the coordination of trips to diminish the quality of service. The diminished quality of Mo HealthNet NEMT program is so bad it is a public safety issue. And for the frailest and weakest it is dangerous. Mo HealthNet has been aware of these problems for years and has plenty of complaints to take action, but fails to do so. TV news has covered the safety problems of Mo HealthNet Non-emergency Medical transport, and wealth of information can be found on the internet. It is time for Healthcare providers to speak out for those with-out a voice and contact Mo HealthNet and Mo HealthNet oversight committee to report the NEMT abuse. This NEMT Program is full of 1099 fraud that's also been reported to the Department of Labor. As a Nurse the state board requires that we report abuse, not just study it. So I strongly encourage you to do so.

Anne Carman wrote on August 9, 2013

I grew up in this area, the oldest of nine who have all been able to escape poverty. What is different today is dropping out of school, having children without being married and having them before the age of 22. The Pew Charitable Trust says that this combination almost guarantees a life of poverty anywhere in our country. Yet today's youngsters would seem to be exposed to options for a better life through the schools and media. I am confused and dismayed by their inability to see what their choices will bring them.

Ruth Mack, RN wrote on August 31, 2013

It seems to me that that many of the needs addressed in this article could be met by nurse midwives or womens health/maternal health advanced nurse practioners using mobile clinics to serve the women in their own town, or much closer than an hour away. I don't know if this is anything the Sinclair School of Nursing has looked into, but it would be a way to increase access to care for these high risk women.

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