Barriers to providing obstetric services
Thirty-six percent of counties in the U.S. do not have obstetric providers or a hospital or birth center offering obstetric care, according to a report released in 2023 from nonprofit organization March of Dimes. About 300 birthing units have closed in the last five years, according to the organization.
Rural areas and critical access hospitals are typically the hardest hit by maternity care cuts. The American Hospital Association estimates at least 89 obstetric units closed in rural hospitals between 2015 and 2019—before the COVID-19 pandemic brought its own challenges. The problem also extends to urban areas, however. Two hundred urban counties lost at least one obstetric unit between 2019 and 2020, according to the American Hospital Association.
Inpatient maternity units are costly to maintain and often unprofitable. Healthcare providers, especially in rural areas, often cite the lack of patient volume as a reason for closures.
A spokesperson for Sandpoint, Idaho-based Bonner General Hospital, a critical access hospital that closed its labor and delivery unit in May, said the unit lost $2 million last year due to high staffing costs and low birth numbers. To financially sustain the services, Bonner General needed to deliver 500 babies annually—roughly double the number it delivered last year, the spokesperson said.
At OhioHealth Van Wert Hospital in Van Wert, Ohio, staff delivered one baby every two to three days on average, a spokesperson said. Van Wert ended inpatient maternity services at the end of September, but it still performs gynecologic procedures such as hysterectomies or endometrial ablation.
Rising patient acuity due to pre-existing conditions such as diabetes, obesity and hypertension also required a higher level of care than Van Wert could provide, the spokesperson said.
“Changes such as this are never an easy decision to make. As we look at the continued trends in labor and delivery, we want to make sure the highest-quality resources and support are available for our obstetric and newborn patients,” Joy Bischoff, president of Van Wert Hospital, said in a statement.
Insurance coverage creates an added challenge. Many births are paid for by Medicaid, which tends to reimburse providers at a lower rate than other payers. As of 2020, 42% of mothers were covered by Medicaid at the time of birth. Coverage varies across states, from 22.6% in Utah to 61.4% in Louisiana, according to the National Center for Health Statistics.
Western Wisconsin’s Pederson estimated reimbursements from commercial and government payers cover half the cost of providing labor and delivery services at her system.
Employee shortages present yet another hurdle, especially for critical access or community hospitals in rural areas. Staffing a maternity unit requires a range of specialized talent, including obstetricians, obstetric nurses, anesthesiologists, pediatricians and respiratory therapists.
“As we moved into COVID and staffing [shortages], it just continued to become more and more challenging,” said Ada Bair, CEO at Memorial Hospital in Carthage, Illinois, which closed its labor and delivery unit in December. “We were at the point where we literally didn’t have any applications for open positions in [obstetric care].”
Many obstetric nurses at rural facilities float to different departments because of low delivery numbers, and that type of fluid schedule is not always desirable, Bair said. She added that shortages forced Memorial Hospital to rely on expensive contract labor before the closure.
Prior to closing, the unit at Memorial Hospital was delivering about 120 to 125 babies per year, Bair said. Patients seeking labor and delivery services must travel roughly 45 miles to Blessing Hospital in Quincy, Illinois.
Responding to maternity care challenges
Despite the challenges of maintaining maternity care, some providers are working to expand access or developing improved ways to connect patients with services.
Western Wisconsin has committed to investing in obstetric services, especially as multiple closures at other facilities in the region have brought more patients to the organization's door, Pederson said. Community donations help close the gap as well.
Pederson said the health system has committed to add three rooms at its birthing center, bringing the total to five. She said birth volume has increased about 20% in the last year. The additional birthing rooms are part of a nearly $7 million hospital expansion, which includes new medical-surgical rooms.
Western Wisconsin’s birthing center also plans to add another OB-GYN physician and certified nurse midwife as part of its five-year plan, Pederson said.
"We really see obstetrical care as the heart of our hospital, and we believe that you can't be a community hospital without delivering babies, so our whole team is swimming in the direction of, 'Let's find a way to sustain obstetrical care,'" she said.
Sanford Bemidji Medical Center in Bemidji, Minnesota, is using a $3.67 million federal grant it received in 2021 as part of the Rural Maternity and Obstetric Management Strategies program to provide maternity care access to patients in poor and geographically isolated areas. Sanford provides care to multiple tribal communities in northern Minnesota. Many of those patients are living in poverty, do not have access to transportation and have pre-existing health conditions.
With the grant money, the health system plans to establish two satellite locations at Indian Health Service clinics for patients to access Wi-Fi and connect via telehealth with an obstetrician or other clinicians, who could advise them on whether to seek in-person care.
Sanford is also setting up a virtual hospitalist program in northern Minnesota to connect local emergency departments with obstetric specialists in real time to provide higher-level care for conditions such as preeclampsia or pre-term labor.
Van transportation for patients is also in the works.
Dr. Johnna Nynas, an OB-GYN leading Sanford’s efforts, said the goal is to build a sustainable network that supports patients in the long term—which may take a couple of years to gain traction.
“We know the people on the ground who know their services in their community best, and we’re creating a formal relationship to work together and create seamless care for women,” Nynas said. “It should be easy. It shouldn’t take someone like me who has a doctorate degree to know how to work the system within healthcare and understand what I need to do.”
