Aside from the ordinary rigors of life, women's health includes reproductive health and birth control, domestic violence/sexual assault support, and childbirth support. Maintaining reproductive health is more treacherous for rural women because of four important obstacles: access to information, transportation, financial burden and difficulty in locating a provider.
Unlike most health care, reproductive health is a politically charged issue, especially in more conservative rural communities. There is almost a universal absence of abortion services in rural Oregon. Information about condoms, RU-486 and other birth control options can be hard to come by, especially if a person is young, embarrassed or doesn't know where to look. Urban adolescents can find anonymity fairly easily; rural teens, unless they travel to a larger town, cannot.
Privacy is also at a premium in rural communities, and choices are of doctors are few. Urban women have the option of selecting a provider based on that person's gender, background, "bedside manner" and a variety of other personal preferences. They also don't risk running into their doctor in the supermarket. Most rural communities have no more than a handful of doctors and relatively few female doctors giving women relatively few options from which to choose. They must often choose between seeing a doctor they are not comfortable with, traveling long distances to other towns or forgoing regular care altogether.
Domestic Abuse/Sexual Assault
Oregon's Office for Services to Children and Families notes that large, rural counties in the eastern half of the state have unique "service delivery challenges" for both domestic violence and other basic service providers. Some of these challenges are the same as for other privacy-sensitive issues. Abused women may not have the education or money to leave a relationship, nor the emotional tools to realize that they do not deserve what is happening to them.
A study completed by the University of South Dakota School of Medicine determined that rural women were far less likely to report domestic violence. In the state's larger towns, sixteen percent of women said they experience physical assault, while only three percent did in the rural areas. "It is unlikely [that] domestic violence is less prevalent in rural areas," says Dr. Elizabeth Dimitrievich, who supervised the study. Rather, she interprets these numbers to reflect fear of repercussion and/or the lack of privacy one can have in a small town. "If somebody reports it, it affects not only them but their families, and gossip spreads. Everybody knows."
Ditto sexual assault and rape. Though statistically, fewer incidents occur in rural areas than in suburban or urban areas, rape and sexual assault are crimes most often committed by someone known to the victim. Rape continues to be the least reported crime.
Obstetrics is currently undergoing a major crisis-as malpractice insurance rates double or even quadruple in one year's time, more and more rural providers are electing to drop their obstetrics support. A recent Oregon Health & Science University study found that 22 percent of obstetrics doctors have left the practice since 1999; of them, 74 percent were outside of Portland. This leaves women driving further, in all kinds of weather, to the nearest delivering hospital.
What may help to close the gap is resurgence in midwifery. Insurers welcome claims from many midwives, especially because their costs can be one-third that of a traditional hospital birth, and fewer of their clients tend to pursue malpractice claims. Most hospitals have at least one midwife on-staff. In 1994, 4,772 of Oregon's hospital deliveries had a certified nurse midwife in attendance (10 percent). In 2001, almost 15 percent of new Oregonians were delivered by a midwife in a hospital. Non-hospital deliveries constitute another 2 percent of all births.
"I know several midwives who have gone to rural areas," says Sue Fahey, a certified nurse midwife in Grants Pass. "They're more busy than they thought they would be." She feels that they have met with success in part because of the overall health care shortage and in part to take up where obstetrics doctors are leaving off, both in hospital settings and in private practice.
"Last year, [an obstetrics] doctor in Roseburg had two huge malpractice awards against him," she says. His insurance provider dropped him, and subsequently two other doctors stopped taking obstetrics patients, leaving one physician and one midwife in the hospital. "It's incredibly busy."
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