In early December, Vice President Harris marked the first ever Maternal Health Day of Action, emphasizing the work still left to do to keep both mothers and babies healthy in this country. The United States has long struggled with abysmal maternal morbidity and mortality and the all too frequent closure of hospital maternity wards isn’t helping.
Babies will always be born. So, timely access to high quality obstetric care is a must. How do we make that a reality for all?
Access to obstetric care
A 2020 report by March of Dimes shows that ten percent of births occur in counties with inadequate maternity care. Over two million women of childbearing age live in counties with no obstetric care — maternity care deserts — and another 4.8 million live in counties with minimal care available.
And access keeps dwindling. For example, the Windham Hospital in Connecticut is in the process of closing its maternity ward. A 2016 study surveyed over 260 rural hospitals and found that about seven percent closed their wards between 2010 and 2014. Another study found that, from 2014 to 2018, there was a net loss in obstetric services in rural counties nationwide (though a net gain in urban counties).
Hospitals often argue they are forced to close their maternity wards because of low birth volumes and financial challenges. This is what Windham Hospital has said as well as the hospitals interviewed in the 2016 study. They noted physicians retiring and an unavailability of anesthesia services, low birth volumes leading to undertrained staff, and budget cuts and hospital system consolidations.
Mothers and advocates maintain that ward closures lead to increased health risks. For one, travel times during labor automatically increase. One woman impacted by the Windham Hospital closure delivered on the side of the road on the way to a different hospital. Additionally, a recent study found that living in a maternity care desert is linked to higher risk of death during pregnancy and up to one year postpartum.
Both sides have fair points. Maintaining “under-performing” maternity wards may not be possible — or, more importantly, safe — but closing them does reduce access for expectant mothers. So, how do hospitals stay in the black while still providing critical obstetric care?
Keep the wards open
Some argue that hospitals should just keep their maternity wards open. Policymakers should financially safeguard maternity care through increased reimbursement rates — especially for Medicaid, the number one payer — or value-based payment models, such as bundled payments.
While understandable, this likely isn’t a long-term solution. (Childbirth is already extremely expensive in the United States.) Being open is one factor, but maternity wards must also be safe. They must be adequately staffed, and the staff must be adequately trained. Anything less is dangerous and retaining high quality staff in low volume wards will remain challenging, even if reimbursements go up.
Precarious wards could also increase staffing of non-physician providers. The National Advisory Committee on Rural Health and Human Services contends that certified nurse midwives can provide a critical access boost in rural areas if allowed to practice at the top of their licenses. March of Dimes agrees in their 2020 report, including access to doulas in their list of recommendations.
Close the wards
Closing a maternity ward may end up being the only option because of financial and/or staffing concerns. Hospitals can prepare for the inevitable by training other staff in obstetrics and maintaining emergency supplies, such as blood for transfusions. John Cullen, a family physician in Valdez, Alaska, said in an interview that “even if a community is not planning on providing maternity care, they still are going to be providing maternity care.” Cullen’s hospital trains its nurses in labor and delivery and regularly conducts simulations to keep skills sharp. They have to; the next maternity ward is six to seven hours away.
Another approach when closure is unavoidable is to partner with neighboring hospitals, as the American College of Obstetricians and Gynecologists encourages. This leads to important care continuity. For example, in New Mexico, five sparsely populated, poor, rural counties formed a maternity care consortium, with telehealth as the cornerstone. Non-physician staff run satellite obstetric clinics at community health centers and physicians from the nearest hospital videoconference in. Mothers also receive “telehealth kits” so they can check their blood pressure and glucose levels at home and report back to their care team in real time.
The bottom line is that, while closing maternity wards may be inevitable, it will not stop babies from being born. Somehow, hospitals must utilize limited resources effectively and efficiently to continue to care for women in labor. The lives of mothers and babies cannot wait.