Rural hospitals keep closing their maternity units, leaving many women far from care and their babies at more risk

Hills outside of Toppenish, Washington. Ambulances are often slow to arrive on the Yakama Indian Reservation, which spreads over a million acres. (Photo by Ruth Fremson, The New York Times)

Suspensions of obstetric services in rural hospitals "appear to have accelerated" in the last year, "as hospitals from Maine to California have jettisoned maternity units, mostly in rural areas where the population has dwindled and the number of births has declined," reports Roni Caryn Rabin of The New York Times. "A study of hospital administrators carried out before the pandemic found that 20 percent of them said they did not expect to be providing labor and delivery services in five years’ time."

The closings are predicted to continue. "From 2015 to 2019, there were at least 89 obstetric-unit closures in rural hospitals across the country. By 2020, about half of rural community hospitals did not provide obstetrics care, according to the American Hospital Association," Rabin writes. "In the past year, the closures appear to have accelerated, as hospitals from Maine to California have jettisoned maternity units, mostly in rural areas where the population has dwindled and the number of births has declined."

Hospital closures leave pregnant women feeling vulnerable and betrayed. Rabin reports from Toppenish, Washington, where "frustration and fear erupted at a recent City Council meeting, which drew such a large crowd that it spilled into the hallway outside the chambers." Astria Toppenish Hospital "had committed to keeping certain services, including labor and delivery, available for at least a decade after acquiring the hospital," Rabin writes. "Now the hospital said it could not afford to do so, and the state has taken no action." Leslie Swan, a Native American doula, told Rabin, “There will be lives lost — people need to know that."

Toppenish is on the Yakama Indian Reservation, but is "the canary in the coal mine" for other rural hospitals' obsttric units, Cassie Sauer, president and chief executive of the Washington State Hospital Association, told Rabin, who writes, "The closure in Toppenish mirrors national trends as financially strained hospitals come to a harsh conclusion: Childbirth doesn’t pay, at least not in low-income communities."

Obstetric units are expensive. They "must be staffed 24 hours a day, seven days a week, with a team of specialized nurses and backup services, including pediatrics and anesthesia," Rabin reports. "In Washington State, Medicaid would pay $6,344 for a childbirth, about one-third of the $18,193 paid by private plans, according to an analysis by the Health Care Cost Institute. . . In wealthier communities, private insurance helps offset low Medicaid payments to hospitals. But in rural areas where poverty is more entrenched, there are too few privately insured patients."

Rabin recounts the downward spiral of U.S. maternal care: "The United States is already the most dangerous developed country in the world for women to give birth, with more than one death for every 5,000 live deliveries. . . . Recent figures show that the problems are particularly acute in minority communities and especially among Native American women, whose risk of dying of pregnancy-related complications is three times as high as that of white women. . . . According to the March of Dimes, the maternal health nonprofit, seven million women of childbearing age reside in counties where there is no hospital-based obstetric care, no birthing center, no obstetrician-gynecologist and no certified nurse midwife, or where those services are at least a 30-minute drive away."

That has effects on mothers and babies, the Centers for Disease Control says: "Severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health. Using the most recent list of indicators, SMM has been steadily increasing in recent years and affected more than 50,000 women in the United States in 2014."