Hospitals with high concentrations of Medicaid recipients are particularly vulnerable, due in part to low reimbursement from the safety-net program, which pays for nearly 40% of the nation's childbirths. These hospitals often serve populations with higher rates of chronic disease, which increases the risk of potentially dangerous pregnancy complications.
Without a labor and delivery ward, many high-risk patients no longer have access to high-quality childbirth services, prenatal and postpartum care, support groups and education courses.
“These communities are losing all of those services as well,” Interrante said.
Emergency departments in such areas are likely to face an increased number of births, according to Interrante’s research. Many patients may have gone without routine care, further increasing the risk of complications while forcing first responders and emergency room doctors to provide services outside their expertise.
Mitigating risk
In Connecticut, officials have used the certificate-of-need process—in which hospitals have to obtain approval to decrease the number of available hospital beds—to bargain with facilities seeking to shut down their labor and delivery wards.
Recently, the Connecticut Department of Health Strategy, which oversees the certificate-of-need process, reached a settlement regarding the future of maternal health services at Hartford HealthCare-owned Windham Hospital. The hospital originally shut down its labor and delivery ward in 2020 and has since sought the state’s approval to eliminate it entirely.
Hartford HealthCare cited declining birth rates—fewer than 100 per year—and staffing shortages as reasons it could no longer maintain safe operating conditions for pregnant patients in the community in response to requests for comment about the closure.
In November, the hospital and state came to an agreement in which Windham could close its labor and delivery ward but must retain pre- and perinatal services. The settlement also requires the hospital to explore the feasibility of opening a freestanding birthing center, where lower-acuity births could take place.
Connecticut created the licensure classification for freestanding birthing centers in 2022. The facilities are located outside of hospitals, do not have anesthesia services and cannot conduct cesarean sections.
The feasibility report required from Windham as part of the settlement will serve as a guide for hospitals and states about alternative care sites that could be used to maintain access to regional services for low-risk pregnancies, said Dr. Deidre Gifford, executive director of the Connecticut Department of Health Strategy.
“It's not going to work in every single case, but it might help address the crisis, particularly if it also includes the prenatal and postpartum care,” Gifford said.
The future of maternal healthcare
As birthing infrastructure shrinks, providers and officials are rethinking maternal healthcare delivery strategies to sustainably address access and social determinants of health.
“It’s not just the labor and delivery closures that are going to impact women’s health and obstetrical outcomes. We’ve got to look at [the problem] as a whole,” Gifford said.
Maternal mortality rates for the U.S. are among the highest in the developed world. And black women are two to three times more likely to die from pregnancy-related complications in the nation than non-Hispanic white women, according to the Centers for Disease Control and Prevention. More than 80% of all maternal deaths are preventable, according to the CDC.
“Women are dying at a much higher rate than they should be. African-American women are dying at a much higher rate than in the poorest nations on this planet," said Wendelyn Inman, associate professor of public health at Tennessee State University. "It shouldn’t be.”
Addressing poor maternal health outcomes requires a comprehensive approach, considering factors such as chronic disease, behavioral health, substance use disorders and overall access to healthcare services, Inman said. In addition, payment strategies and staffing solutions are needed in order to make childbirth services sustainable, she said.
The U.S. Health Resources and Services Administration has distributed grant funding to establish research centers to explore maternal health inequities and implement solutions, with a focus on maternity care deserts and Black mothers. Health systems and medical schools are also piloting the use of artificial intelligence, virtual medicine and mobile maternity health units to close workforce gaps and improve access to care.
States are increasingly certifying the use of doulas and midwives to provide services to pregnant patients, helping to alleviate the burden on doctors and nurses and ensure individuals receive wraparound services throughout the term of their pregnancy and into postpartum. At least 11 states fund doulas through their Medicaid programs, and eight more are implementing the benefit next year, according to the Medicaid and CHIP Payment and Access Commission. Meanwhile, at least 19 states have licensing designations for midwives, according to the National Academy for State Health Policy.
“Frankly, [disparity in maternal health outcomes] is a symptom of the country’s overall decline in health status and deteriorating access to basic preventative services that are contributing to this challenge," Gifford said.
