Labor and delivery centers are closing in red states. What happens to pregnant women next?

The only hospital in a Northern Idaho town of 9,000 people, Bonner General Health, announced last week that it was closing its labor and delivery clinic. The hospital — situated in Sandpoint, a remote town about an hour’s drive north of Coeur d’Alene — implied in its press release that the overturning of Roe v. Wade, and the concomitant laws passed afterwards, were partially responsible. 

Indeed, in the news release, the hospital cited a variety of reasons for the closure, including the state of Idaho’s “legal and political climate.” “Highly respected, talented physicians are leaving; recruiting replacements will be extraordinarily difficult,” the hospital wrote. “In addition, the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.

The news encapsulates how the overturning of Roe v. Wade exacerbated the slow unraveling of America’s labor and delivery clinics — which have been slowly closing over the past decade, leaving millions of women in what researchers call maternity care deserts.

In 2022, March of Dimes published a report that found 6.9 million women of childbearing age lived in counties with no access or limited access to maternity care, which could negatively affect about half a million births each year. From 2020 to 2022, 1,119 counties across the country became maternity deserts — meaning there were no hospitals providing obstetric care, no birth centers, no OB/GYN and no certified nurse midwives, which affected an estimated 15,933 women. Looking at a map of areas affected, these maternity care deserts are typically in middle America and in rural counties — but the coasts and urban centers aren’t immune to closings.

Julia Interrante, a research fellow at the Rural Health Research Center, told Salon in an interview that prior to the U.S. Supreme Court overturning Roe v. Wade last year, many rural hospitals were already closing their labor and delivery clinics due to financial and staffing issues.

“There are high fixed costs for operating maternity services, [and] obviously they have to be available 24/7 because babies come when they want to come in, so having the staff on hand and the clinical training and all of the necessary staff and equipment that is required for any kind of emergency situation has a high fixed cost,” Interrante said. “When you have low birth volume, then you don’t have a good balance of payments coming in for that.”

“When we reduce the services that save people’s lives, it is very reasonable to expect that healthcare outcomes will get worse.”

Bonner General Health in North Idaho mentioned that the hospital only delivered 265 babies in 2022. Interrante said while this low birth volume is usually a reason for rural hospital closures, it’s “definitely not the whole story.”

Interrante cited issues with “recruiting and maintaining staff” as an obstacle, in particular family physicians and nursing staff. She noted that it is a misconception that obstetrician shortages are exclusively driving the maternity care crisis. Obstetricians are “not actually the most common providers of childcare services in rural communities,” she noted; rather, family physicians are.

Interrante said doctors in rural areas are under tremendous pressure to work without enough support staff. Often, she said, there are “only one or two doctors like doctors who provide the services in a rural community,” and those doctors often lack a “stable staff” in the obstetric unit. That puts a lot of pressure on doctors and “can be really hard,” Interrante noted. “Sometimes they leave because of that as well.”

These issues predated the existence of laws that criminalize physicians for providing standard care in obstetric units, and which appear to be worsening the maternity care crisis.

Dr. Melissa Simon, an obstetrician gynecologist at Northwestern Medicine, told Salon she was “not surprised” to hear that an Idaho hospital cited “political climate” as one of the reasons it is closing a labor and delivery unit. Simon emphasized that these units must make decisions to save a pregnant mother’s life if such a patient is facing a life-threatening situation.

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Simon gave an example of a patient coming in 16 to 18 weeks pregnant with a ruptured bag of water — a point in one’s pregnancy in which the baby is still far from “viability,” meaning it could not survive outside of the uterus. If state laws “mandate that a pregnancy termination cannot be offered,” that leaves doctors and hospitals in an ethical bind, Simon said. If doctors do not end the pregnancy, the mother “could become septic and die” from the lack of intervention.

When a maternity clinic closes, Dr. Simon said many pregnant women could suffer pregnancy complications in the process of being forced to travel 50 to 100 miles for maternity care — a reality for some women in this country.

“As more clinics and labor and delivery units close in hospitals because of political climate, laws, and other factors such as cost, there becomes an ensuing increase in poor maternal and fetal outcomes and ultimately a rise in poor childbirth outcomes for both the mom and baby — and a rise in maternal morbidity and mortality,” Dr. Simon said.

Interrante said when labor and delivery units close in rural areas, researchers also see higher rates of out-of-hospital births, which can come with their own complications.

“The rate at which people die because of being pregnant is dramatically higher here than in other rich countries.”

“Sometimes it’s home birth, and if it’s planned and it’s a low risk pregnancy, that can be fine, and sometimes it’s more that people end up having to go to the emergency room and they’re not prepared to handle an emergency birth situation,” Interrante said. “Even worse, that can happen, is birth on the side of the road as people are trying to get to their nearest hospital, we also see higher scheduling of cesarean sections.”

According to new data from the Centers for Disease Control and Prevention (CDC), the rate of maternal mortality — defined as deaths during pregnancy or within 42 days of giving birth — increased by 40 percent in 2021. Amanda Jean Stevenson, an assistant professor of sociology at the University of Colorado Boulder, told Salon that pregnancy is “uniquely deadly” and “uniquely disabling” in the United States.

“That means that the rate at which people die because of being pregnant is dramatically higher here than in other rich countries, and it’s also been increasing here for over a decade while it’s been decreasing in other rich countries,” Stevenson said. “So we’re not only worse than everybody else in terms of the outcomes and health outcomes associated with pregnancy, but we’ve been getting worse while everyone else is getting better; it’s almost impossible to overstate how much of a crisis this is.”

Stevenson added: “When we reduce the services that save people’s lives, it is very reasonable to expect that healthcare outcomes will get worse.”

In a 2022 study, Stevenson and her colleagues estimated that in the first year following a nationwide abortion ban, the number of maternal deaths would increase by 13 percent.

Dr. Simon said she expects more labor and delivery units to close around the country as more physicians will be forced with these impossible decisions, putting pregnant people in America in an even more precarious situation — and the problem won’t be unique to red, rural states. 

“We see this now in urban centers, there are several hospitals even in Chicago who are closing down labor and delivery units because of a variety of factors including cost,” Dr. Simon said. “The reality of closing birthing centers and L and D units across the country is going to continue until we start valuing all of our humans in this country; when there are maternity deserts, our women, our babies and our society suffers.”

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