Rural hospitals close maternity units

Three days before Christmas, the only hospital in this remote city on the Yakama Indian Reservation abruptly closed its maternity unit without consulting the community, the doctors who delivered babies there or even its own board.

At least 35 women were planning to give birth at Astria Toppenish Hospital in January alone, and the sudden closure -- which violated the hospital's commitment to the state to maintain critical services in this rural area -- threw their plans into disarray.

Victoria Barajas, 34, expecting her first child, scrambled to find a new doctor before her due date, Jan 7. Jazzmin Maldonado, a 29-year-old schoolteacher due to give birth soon, wondered how she could make it to a distant hospital in time.

Adriana Guel holds her one-month-old son, Arturo, at her home. RUTH FREMSON/The New York Times

After an earlier miscarriage, doctors had placed a stitch in her cervix to prevent a second one, and the stitch would have to come out fast once labour began.

Astria Toppenish Hospital is one of a string of providers across the nation that have stopped providing labour and delivery care in an effort to control costs -- even as maternal deaths increase at alarming rates in the United States, and as more women develop complications that can be life-threatening.

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.

From 2015-19, 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.

The Yakima Valley Farm Workers Clinic. RUTH FREMSON/The New York Times

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.

A study of hospital administrators carried out before the pandemic found that 20% of them said they did not expect to be providing labour and delivery services in five years' time.

Women in rural areas face a higher risk of pregnancy-related complications, according to a study by the Commonwealth Fund. Those living in so-called maternity care deserts are three times as likely to die during pregnancy and the critical year afterward as those who are closer to care, according to a study of mothers in Louisiana.

Ambulances aren't reliable in many rural areas like the Yakama reservation, which spreads over 404,700 hectares. There aren't many emergency vehicles, and the vast distances make for long waits. In the fall and winter, dense fog often blankets the roads, making driving treacherous.

In Toppenish, the 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.

The Astria Toppenish Hospital in Toppenish. RUTH FREMSON/The New York Times

Astria, a health care system based in Washington state, had committed to keeping certain services, including labour and delivery, available for at least a decade after acquiring the hospital, residents noted.

Now, the hospital said it could not afford to do so, and the state has taken no action. "There will be lives lost -- people need to know that," said Leslie Swan, a Native American doula.

A Downward Spiral

The United States is already the most dangerous developed country in the world for women to give birth, with a maternal mortality rate of 23.8 per 100,000 live births -- or more than one death for every 5,000 live deliveries.

Dr Jordann Loehr, an obstetrician who works at the Yakima Valley Farm Workers Clinic. RUTH FREMSON/The New York Times

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. Their babies are almost twice as likely to die during the first year of life as white babies.

The closure of an obstetrics unit often begins a downward health spiral in remote communities. Without ready access to obstetricians, prenatal care and critical postpartum checkups, risky complications become more likely.

But running a labour and delivery unit is expensive, said Katy Kozhimannil, director of the University of Minnesota Rural Health Research Center. The facility must be staffed 24 hours a day, seven days a week, with a team of specialised nurses and backup services, including paediatrics and anaesthesia.

"You have to be ready to have a baby anytime," Prof Kozhimannil said.

Cultural Awareness

Astria Toppenish's patients are a particularly vulnerable population that includes a large community of farmworkers who toil in the Yakima Valley vineyards, orchards and hops fields.

Toppenish Mayor Elpidia Saavedra at the city council. RUTH FREMSON/The New York Times

So many children come from low-income homes that local schools provide free lunch. Patients often struggle to come up with gas money to go to doctor's appointments. Chronic diseases that complicate pregnancy -- such as diabetes, heart disease and substance abuse -- are common.

"They are poor in spite of working hard," said Dr Jordann Loehr, an obstetrician who works at the Yakima Valley Farm Workers Clinic.

Snow-covered hills outside Toppenish. RUTH FREMSON/The New York Times

Many women opted to give birth at Astria Toppenish because of its reputation for respecting patients' wishes and for cultural sensitivity -- including a labour room for Native American women that faces east, an ancestral practice, and permission for as many family friends and "aunties" in the delivery room as the mother wanted.

The nurses did not rush women in labour, and the unit had a cesarean section rate of 17%, way below the national average of 32%. They taught first-time mothers about infant care and breastfeeding -- but also about how to use a papoose board safely, and why mothers shouldn't overbundle a newborn, a common practice.

Many residents fear the obstetrics closure is a prelude to the hospital closing its doors altogether in a repeat of what happened in 2019, when the Astria Health system declared bankruptcy and later closed the largest of its three hospitals, a 150-bed facility in Yakima. Astria had purchased the hospital just two years earlier.

Schoolteacher Jazzmin Maldonado, left, with her wife, Sofia. photos:  RUTH FREMSON/nyt

For now, the four obstetricians in town -- all women -- are digging in. Loehr has led a community drive to reestablish a maternity unit by creating a public hospital district, a special entity that would be governed and funded locally with taxes or levies.

Dr Anita Showalter, another obstetrician, recently delivered Ms Barajas' baby, but at an Astria hospital farther away. She already had suffered one miscarriage, and Dr Showalter stayed with her through 37 hours of labour. Baby Dylan was born Jan 15 at 1.52 am. "My heart is full," Dr Barajas said in a text.