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My experience in maternal health, from rural South Dakota to NYC

"From SD to GA to NYC, I've seen vulnerable populations face the same barriers to healthcare." –Asiyah Franklin

by Asiyah Franklin, PhD(c), Mphil, BS

When it comes to healthcare for vulnerable populations, their circumstances may differ, but healthcare concerns mirror each other in a host of ways. As a women’s health nurse, I’ve seen the problems facing both rural and urban healthcare, especially in the context of maternal health. 

Here’s a look into some of my experiences and how we, as healthcare providers, can better serve vulnerable populations—no matter where they are. 

An introduction to rural maternal healthcare

During the 90s, I had the pleasure of serving in the US Air Force (USAF). I can’t say that I was ecstatic about my first duty station, but I was open to the experience. When my plane touched down in Rapid City, South Dakota, I was flabbergasted! I was a 19-year-old from New York City who had never been to such a rural part of the country. 

This jarring introduction to a seemingly new world quickly shifted into one of the most memorable times of my life, and a pivotal moment along my newly minted journey as a healthcare professional.

Healthcare accessibility at a rural military base

The benefits of being in South Dakota serving military members and the community that surrounded and embraced us became clear in the months immediately following my arrival. I was a healthcare coordinator/administrator in the Aeromedical Evacuation unit of my base hospital’s medical group. 

I saw our most critical and vulnerable service members and their families being whisked away in a tactical airlifter (a really big plane) that was converted into a fully equipped hospital. It could carry approximately 50 patients in need of critical or specialty care to other military bases across the United States.

The most memorable patient was a 23-year-old servicemember who had given birth to her first child and began experiencing life-threatening postpartum hemorrhage in the hours immediately following birth. Her kidneys went into rapid shutdown and failed, and she fell into a coma. She was transported to the Air Force’s largest medical center in the US, located in Fairfield, California. That day, I saw the importance of access to healthcare. Unfortunately, I never had the opportunity to coordinate her return to our base in South Dakota.

Rural healthcare accessibility outside of a military base

That experience, among others in the labor and delivery unit of our base hospital, lit a fire underneath me. I was determined to learn more about the care of birthing women during pregnancy and in the postpartum period. 

I had already attended the birth of my best friend before joining the military. However, that was mainly as a teenage voyeur and not as an informed participant in the labor and birth process. A beautiful and spirited certified nurse midwife serving as an Air Force Captain allowed me to shadow her on weekends and evenings while on-call at the base hospital. We also attended community birth events where traditional/community midwives from Indigenous communities, birthing people, and other individuals in the maternal health community came together to discuss the state of maternal healthcare and outcomes among this population. It was riveting! This was my introduction to rural maternal healthcare.

“I learned the transformative and healing power of community-based and trained midwives and how limited healthcare access in rural communities impacts maternal health outcomes. This concern persists today.”

Midwives were the most accessible form of healthcare

Over the course of my time in South Dakota, I witnessed the power of Indigenous midwives assisting birthing people in their communities as they brought forth life. There was also an abundance of support from my midwifery mentor and other non-military midwives to support the maternal health initiatives of the Indigenous populations that resided near and far throughout South Dakota and Wyoming. At this remote Air Force base in Rapid City, SD, I learned the transformative and healing power of community-based and trained midwives and how limited healthcare access in rural communities impacts maternal health outcomes. This concern persists today.

Nurse Asiyah Franklin smiling in front of a consult room in a health clinic

Maternal health in urban NYC

After separating from the Air Force many years later, I returned to NYC. I was determined to continue immersing myself in birthwork. 

I sought to find the birth community in NYC and discovered that—just like in rural South Dakota—midwives were the fabric that held communities of birthing people together. Recent research has found that midwives are staples in perinatal care delivery in both rural and urban communities, helping bridge the gap in care that has long contributed to maternal health disparities, including maternal morbidity and mortality.

Again, midwives are the first point of healthcare

Midwives serve pregnant and birthing women, but historically (and still today in some communities) they are also the caregivers for families and communities at large. Taking a look back, research shows that midwives were the community healthcare providers throughout the 19th century. Their role has inextricably linked the care of Indigenous rural communities and Black urban communities.

Equitable maternal healthcare in these settings is grounded in five pillars that examine and acknowledge the whole person, not just their reproductive health needs. Read on to learn more about each pillar.

“...midwives were the community healthcare providers throughout the 19th century. Their role has inextricably linked the care of Indigenous rural communities and Black urban communities.”

Acknowledging challenges in health equity

To provide adequate care for disadvantaged communities, it’s important to realize that they have unique health concerns and barriers that keep them from getting quality care. These include: 

Chronic conditions: Diseases like diabetes, heart disease, and mental health disorders are prevalent in both urban and rural settings. The approach to managing these conditions needs to be adaptable to the resources and needs of each community.

Socio-economic factors: Poverty, education level, and job opportunities significantly influence health outcomes in both rural and urban areas, albeit in different ways. 

Learn how a collective approach can better address these challenges.

Community-centric approaches

Involving the community, whether urban or rural, will improve outcomes. These community approaches can include:

Collaboration: Partnerships between urban and rural healthcare providers and organizations can lead to shared learning and better health outcomes. 

Empowerment: Engaging local communities in health initiatives ensures that solutions are culturally appropriate and more likely to be successful.

Learn more about the success of community-centric approaches in hospitals.

Cultural competence

Even with the best intentions, quality healthcare cannot be provided if there is a cultural disconnect. Keep these in mind when providing care to a culture that’s not your own: 

Cultural nuances: Both urban and rural settings have unique cultural characteristics that impact healthcare delivery. A culturally competent approach is necessary to build trust and provide effective care.

Patient-centered care: Acknowledging and respecting cultural differences leads to better patient engagement and health outcomes.

Learn more about the importance of cultural competence in healthcare.

Access to care

The challenges of getting healthcare may be different in urban and rural settings, but the result is the same: a lack of care. Here’s a look at some of the specific obstacles each face: 

Urban centers: The challenges here often include overcrowded facilities, long wait times, and sometimes a lack of personalized care due to the high patient volume.

Rural areas: These regions face unique challenges, such as limited healthcare infrastructure, fewer healthcare providers, and greater distances to travel for care. 

Learn more about the impact of health equity in rural and urban settings.

Social determinants of health

Preventative measures can help address negative health outcomes, but first, those common threads, or social determinants of health (SDOH), must be identified. Here are some common SDOH:

Environment: Urban areas might struggle with issues like pollution and noise, while rural areas may deal with limited access to clean water and fresh food.

Education and economic factors: In both settings, the level of education and economic stability play a significant role in health outcomes. Efforts to improve education and economic opportunities can lead to better health.

Learn more about SDOH.

“These observations have helped me remain constant in my commitment to understanding the needs of and serving historically marginalized populations, no matter their geographic location.”

My goal to bridge the gap in health equity

Over the past 28 years, I’ve learned that there isn’t a great divide between rural and urban health issues and outcomes. Since my time in South Dakota, I’ve also had the pleasure of serving the birthing community in rural and urban Georgia. 

Again, I saw the similarities between patients in rural Georgia and those in the booming metropolis of Atlanta. From SD to GA to NYC, I’ve seen vulnerable populations face the same barriers to healthcare. These observations have helped me remain constant in my commitment to understanding the needs of and serving historically marginalized populations, no matter their geographic location.

As healthcare professionals, it's our responsibility to understand the complexities of health equity in both urban and rural settings. By acknowledging the common threads and unique challenges, we can develop more effective, community-centric, and culturally-competent approaches to healthcare. By bridging the gap in health equity we ensure that every individual, regardless of where they live, has access to the care and resources they need to lead healthy lives.

Carrying the torch

I’m writing this today in memory of the 23-year-old Airman First Class and new mother who never had the opportunity to see her child grow up. I’m carrying the torch, working to reduce the number of women who succumb to the same fate. That’s because women in marginalized communities, whether rural or urban, deserve access to quality healthcare. Learn more about ways you can join me in improving health equity.