Alisha Alderson placed her folded clothes and every little thing she needed for the last month of her pregnancy in various suitcases.
She never imagined she would have to depart the comfort of her home in rural eastern Oregon just weeks before her due date.
But following the abrupt closure in August of the one maternity ward inside 40 miles, she decided to remain at her brother’s house near Boise, Idaho — a two-hour drive through a mountain pass — to be closer to a hospital.
“We don’t feel protected being thus far away from a birthing center,” said Alderson, noting her advanced maternal age of 45. “I used to be sitting in a hair salon a couple of days ago and a few people began joking about me giving birth on the side of the road. And in that moment, I just pictured all of the things that might go improper with my baby and broke down in tears in front of strangers.”
A growing variety of rural hospitals have been shuttering their labor and delivery units, forcing pregnant women to travel longer distances for care or face giving birth in an emergency room.
Fewer than half of rural hospitals now have maternity units, prompting government officials and families to scramble for answers.
One solution gaining ground across the US is freestanding midwife-led birth centers, but those also often depend on nearby hospitals when serious complications arise.
The closures have worsened so-called “maternity care deserts” — counties with no hospitals or birth centers that supply obstetric care and no OB providers. Greater than two million women of childbearing age live in such areas, nearly all of that are rural.
Ultimately, doctors and researchers say, having fewer hospital maternity units makes having babies less protected. One study showed rural residents have a 9% greater probability of facing life-threatening complications and even death from pregnancy and birth in comparison with those in urban areas — and having less access to care plays an element.
“Mothers have complications all over the place. Babies have complications all over the place,” said Dr. Eric Scott Palmer, a neonatologist who practiced at Henry County Medical Center in rural Tennessee before it ended obstetric services this month. “There shall be people hurt. It’s not an issue of if — simply when.”Reasons behind the closures
The problem has been constructing for years: The American Hospital Association says at the least 89 obstetric units closed in rural hospitals between 2015 and 2019. More have shuttered since.
The predominant reasons for closures are decreasing numbers of births; staffing issues; low reimbursement from Medicaid, the federal-state medical health insurance program for low-income people; and financial distress, said Peiyin Hung, deputy director of the University of South Carolina’s Rural and Minority Health Research Center and co-author of research based on a survey of hospitals.
Officials at Saint Alphonsus, the hospital in Baker City where Alderson wanted to offer birth, cited a shortage of OB nurses and declining deliveries.
“The outcomes are devastating when protected staffing will not be provided. And we is not going to sacrifice patient safety,” based on an emailed statement from Odette Bolano and Dina Ellwanger, two leaders from the hospital and the health system that owns it.
While they said financial concerns didn’t factor into the choice, they underlined that the unit had operated within the red during the last 10 years.
An absence of cash was the foremost reason why Henry County Medical Center in Paris, Tennessee, closed its OB unit. CEO John Tucker told The Associated Press that it was a essential financial step to avoid wasting the hospital, which has been struggling for a decade.
The proportion of births there covered by Medicaid — 70% — far exceeded the national average of 42%. Tennessee’s Medicaid program paid the hospital about $1,700 per delivery for every mom, a fraction of what the hospital needed, Tucker said.
Private insurance pays hospitals more — the median topped $16,000 for cesarean sections in Oregon in 2021. State data shows that’s greater than five times what Medicaid doles out.
Tucker also said the variety of deliveries had dropped lately.
“When volumes go down, losses actually get larger because a lot of that cost is absolutely fixed,” he said. “Whether we’ve got one baby on the ground or three, we still staff at the identical level since you sort of should be prepared for whatever is available in.”
The last week in a delivery ward
Six days before the Tennessee unit closed, only one woman was there to deliver. All the other rooms contained empty beds and bassinets. The special care nursery was silent — no beeping machines or infants’ cries. Art had been faraway from the partitions.
Lacy Kee, who was visiting the ward, said she’ll should drive 45 minutes and cross the state line into Kentucky to offer birth to her third child in early October. She’s especially concerned because she has gestational diabetes and recently had a scare along with her fetus’ heart rate.
Kee also had to change from the Henry County obstetrician she trusted for her other pregnancies, Dr. Pamela Evans, who will stay on the hospital as a gynecologist.
Evans fears that things like preterm deliveries, infant mortality and low-birthweight babies — a measure by which the county already ranks poorly — are sure to worsen.
Prenatal care suffers when people must travel long distances or take numerous time without work work for appointments, she said.
Not all insurance covers deliveries out of state, and a few alternative in-state hospitals families are are an hour or more away.
Evans’ office and exam rooms contain bulletin boards covered with photos of infants she’s brought into the world.
During a recent visit, Katie O’Brien of Paris handed her a recent photo of her son Bennett — the third of her children Evans delivered. The 2 women cradled the infant and hugged.
The closure “makes me absolutely wish to cry,” said O’Brien, 31. “It’s a horrible thing for our community. Any young person seeking to move here won’t want to come back. Why would you would like to come somewhere where you may’t have a baby safely?”
A spot to show
About two hours away, inside a house within the woods, a handful of girls sat in a circle on pillows for a prenatal group meeting at The Farm Midwifery Center, a storied place in Summertown, Tennessee, that’s greater than a half-century old.
Led by midwife Corina Fitch, the ladies shared thoughts and concerns, and at one point tied on scarves and danced together.
One after the other, Fitch pulled them right into a bedroom to measure bellies, take blood, hearken to fetal heartbeats and ask about things like nutrition.
Betsy Baarspul of Nashville said she had an emergency C-section in a hospital for her first child. She’s now pregnant along with her third, and described the difference between hospital care and birth center care as “night and day.”
“That is the right place for me,” she said. “It seems like you’re held in a way.”
Some states and communities are taking steps to create more freestanding birth centers.
Connecticut Gov. Ned Lamont recently signed laws that may license such centers and permit them to operate in its place for low-risk pregnancies.
Alecia McGregor, who studies health policy and politics on the Harvard T.H. Chan School of Public Health, called midwife-led birth centers “a serious type of contender among the many possible solutions” to the maternity care crisis.
“The sorts of lifesaving procedures that may only be conducted in a hospital are vital for those very high-risk cases,” McGregor said. “But for nearly all of pregnancies, that are low-risk, birth centers is usually a very vital solution to lowering costs throughout the U.S. health care system and improving outcomes.”
An absence of information and the small variety of births in freestanding centers or homes prevents researchers from fully understanding the connection between birth settings and maternal deaths or severe injuries and complications, based on a 2020 report from the National Academies of Sciences, Engineering, and Medicine.
The Farm said fewer than 2% of clients find yourself having C-sections, and a report on deliveries in its first 40 years showed 5% of clients were transported to the hospital — which Fitch said can occur due to things like water breaking early or exhaustion during labor. Clients often give birth at The Farm or in their very own homes.
“We all the time have a backup plan,” she said, “because we all know birth is unpredictable and things can come up.”
Rural hospitals will must be a part of the equation, doctors told the AP, they usually consider governments must do more to unravel the maternal care crisis.
Oregon politicians mobilized when the Baker City hospital announced in June that it was shutting down its birth center — including Oregon Gov. Tina Kotek, US Sen. Ron Wyden and Baker County Commissioner Shane Alderson, Alisha’s husband.
As a brief fix, they suggested using OB nurses from the US Public Health Service Commissioned Corps, a branch of the country’s uniformed services that largely responds to natural disasters and disease outbreaks.
It was a novel and “modern” idea to request federal nurses to spice up staffing at a rural maternity unit, Wyden’s office said.
While it didn’t find yourself panning out, the general public health service sent experts to Baker City to evaluate the situation and recommend solutions — including looking into establishing a freestanding birth center.
Shane Alderson desires to help people who find themselves facing the identical tough decisions his family needed to make.
He said rural communities shouldn’t be stripped of health care options due to their smaller size or due to the variety of low-income individuals with public insurance.
“That’s not equitable,” he said. “People can’t survive like that.”
