On a frosty January evening, Nancy Kerr felt the first twinges of contractions.
Snow was piling up outside her house in the mountains of rural Spruce Pine, North Carolina, but the contractions were mild, and she was a week shy of her due date, so she assumed it was simply false labor. Kerr called her doctor, drank a glass of water and tried to relax.
At 11:30 p.m., Kerr’s water broke and she was suddenly thrust into active labor. Her husband raced around the house, throwing everything the couple needed for the hospital into his dirty work truck, and they began the six-mile descent to the hospital on winding roads covered in 5 inches of snow.
Kerr did her best to breathe through the contractions that crashed down upon her, trying not to fixate on the two occasions they’d spun off the very same roads in similar whiteout conditions.
Because of the snowstorm, Kerr’s regular physician did not arrive at the hospital in time to help her deliver. Instead, she gave birth under the guidance of the labor-and-delivery nurses who coached her through pushing — being mindful of the fact that the baby’s heart rate was dropping — while an emergency room doctor caught the newborn. Less than an hour after they arrived at the hospital, Kerr held a healthy baby girl in her arms.
If the drive had been even a few minutes longer, she is certain, she would have delivered her daughter on the side of a snowy, low-visibility road.
And if Kerr were giving birth this winter, the trip to the hospital would be significantly longer. The Spruce Pine labor-and-delivery unit will close at the end of September, the latest in a string of maternity ward closures that leave expectant mothers in the mountains of western North Carolina without access to maternal care within reasonable distances of their homes.
“It was such a reassuring experience to be able to deliver in our local hospital, and receive great care and be able to be close to home,” she said. “I don’t know what would have happened to me or our daughter had we had to drive [elsewhere].”
Mission Health, a nonprofit hospital network headquartered in Asheville, North Carolina, has operated many longstanding small hospitals throughout Asheville’s 19-county region ― most notably in rural, low-population areas like Spruce Pine and Marion, which are north of the city, and Brevard, Franklin and Highlands to the south.
Until two years ago, each of these communities had a labor-and-delivery center nearby. But in 2015, Mission began to close them. First, it was a unit at the Transylvania Regional Hospital in Brevard, servicing nearly 33,000 residents. Then in July 2017, Mission shuttered labor and delivery at Angel Medical Center in Franklin, affecting about 40,000 people in Macon County and surrounding counties. At the end of September, Blue Ridge Regional Hospital of Spruce Pine will also lose its labor-and-delivery unit, affecting the 33,000 people in Mitchell and Yancey counties who rely on that hospital.
At that point, Mission will provide birthing services only at its locations in Asheville and Marion. That means women in rural counties will have to drive at least 20 miles to give birth and — if they want to be able to see the same providers in the delivery room they saw throughout their pregnancies — to get prenatal care.
The roads through the mountains during labor pose a major concern, even without snow. The peaks in this region are the highest in the eastern United States. Except for a few major highways, such as Interstate 40, most roads weren’t built by blasting through or tunneling under these hills. They wind around them, often with precipitous drops on one side.
It is an issue facing rural communities nationwide: From 2004 to 2014, 9 percent of all rural counties lost access to hospital obstetric services, and more than half of all rural counties in this country are now without a single local hospital where women can get prenatal care and deliver babies.
It is logistically challenging and expensive to staff a unit that must be ready for women day and night, and it is difficult to make enough money when there simply aren’t enough women coming in. Nationally, more than half of births are funded by Medicaid, which pays doctors back at a much lower rate than private health insurance plans. In rural areas, that percentage tends to be even higher. Malpractice insurance also plays a role. Family physicians, who often deliver babies in rural areas, face higher malpractice premiums if they offer obstetric services, while hospitals may face low-volume penalties.
“Hospitals that have the fewest births have to pay the highest premiums, because the risk level is higher when something happens less frequently,” said Katy Kozhimannil, a professor of health policy and management at the University of Minnesota, whose research focuses on the challenges in rural obstetric health care access. “This is all from conversations with folks ... it’s not something we’ve looked at in research, but it is something that comes up in conversation with clinicians, and with hospitals.”
All of which means that delivering babies is a money loser for small hospitals already struggling to stay afloat.
Aside from the substantial inconvenience of significant travel to medical providers, these closures have rural residents concerned that they’ll be put in dangerous situations, including giving birth on the side of the road, at home or with lesser-qualified emergency providers.
“We cannot ignore the fact that when a health care system or a hospital decides that it’s no longer worth the risk to keep the obstetric unit open, that risk does not go away,” said Kozhimannil. “It migrates from the hospital to the homes of the people living in that community.”
The stakes for expectant mothers are high. The United States has the worst rate of maternal deaths in the developed world, and that rate is rising. Women living in rural areas tend to fare worse for reasons that aren’t yet entirely understood, though underlying health problems and limited access to high-quality prenatal care are thought to play a crucial role.
The battle to keep maternity wards open
For its part, Mission blames the cuts on low demand and financial losses at these locations. Deciding to close these labor-and-delivery services was “incredibly difficult,” Mission Health spokeswoman Rowena Buffett Timms told Carolina Public Press. But she said it stemmed from the company’s “responsibility to ensure that we have the region’s best interests in mind.”
For Mission, the decision came down to financial sustainability and the ability to continue providing other forms of care amid what Timms described as “the abject chaos in health care policy in our nation.”
Nationally, it’s not just labor and delivery that is being slashed; entire hospitals are disappearing. States in the South and those that did not choose to expand Medicaid under the Affordable Care Act have been particularly hard hit. In addition to the challenges that have long plagued rural hospitals — difficulty recruiting and retaining staff, deteriorating facilities — they have been hit by Obamacare-era cuts to a program that reimbursed hospitals for bad debt without any of the financial boost the health care overhaul offered states that expanded Medicaid.
At Angel Medical Center in Franklin, Timms said the company was unable to continue sustaining losses of up to $2 million annually on the labor-and-delivery program as it prepared to invest in a badly needed $43 million new hospital. The company estimates that not including a labor-and-delivery center in the new facility will cut $7 million in cost.
“We have shared previously that there has been no growth in newborn deliveries in the region and there is no growth forecast,” Timms said of Angel.
Timms described Spruce Pine as having the third-lowest volume of births of any facility in the state, so low that she claims it was difficult for the staff to “maintain proficiency.”
Not only were these counties more sparsely populated, but mothers “voted with their feet,” according to Timms, by traveling to Asheville to give birth. About 60 percent of Yancey County women and 40 percent in Mitchell County went to Mission’s facilities in the larger city despite drive times of close to an hour. Dr. Dorothy DeGuzman, a family physician with a specialty in high-risk obstetrics who has admitting privileges at Blue Ridge Regional Hospital in Spruce Pine says she sees that in her own patients. Some simply feel more comfortable delivering at a larger hospital with a neonatal intensive-care unit.
“There are women who drive to Asheville when they don’t have to necessarily, and there also are women who are too high-risk for us,” she said. “For example, someone who had complicated twins should go to Asheville. Someone who comes in in pre-term labor, they go to Asheville. We deliver babies at 35 weeks and up. We do transfer when it’s clinically appropriate.”
This has also factored into a decision to include a maternity unit in the plans for an upgraded Mission facility in Marion, slated to open in 2018. Timms described this consolidation as “the only responsible decision.”
And the activity of other hospitals in the region contradicts this rationale ― while national trends reflect Mission’s reasoning, other local companies are increasing their investment in maternity care. Eight small community hospitals ― in Murphy, Hendersonville, Sylva, Clyde, Morganton, Rutherfordton, Columbus and Boone ― operate labor-and-delivery services, and none has cut back on birthing services during the time Mission Health has been making cutbacks. In fact, several describe increasing demand for their maternity units and a philosophy in which labor-and-delivery services are integral to their work.
“The care we provide at The Baby Place at Park Ridge Health is completely in line with our mission,” according to Beth Cassidy, director of the birthing facility in Hendersonville, about 25 miles south of Asheville.
“For the community to know that they have an option to receive high-quality, compassionate care for mother and baby provides a peace of mind and confidence for each family member.”
Steve Heatherly, CEO at Harris Regional Hospital, in Sylva between Asheville and Franklin, expressed a similar sentiment, describing birthing services as “a vital need.”
DeGuzman questioned whether the company leadership comprehends Mission’s mission.
“No one makes money delivering babies,” DeGuzman said. “I, as a physician, lose money when I am delivering a baby versus me seeing patients in the office. So no one makes money off it. You do it for the community. You do it because it’s your passion.”
With fewer delivery options, pregnant women scramble
Margie Mason gave birth to her first child in Asheville, an hour from her home in Spruce Pine, and described the experience as impersonal. For example, when it was time to go home, the doctor on call forgot about her, she said, forcing her to wait 10 hours while the hospital tried to contact him.
“I was so frustrated because I felt like no one knew me personally,” Mason said. “It felt like the nurses would just forget about me during the day.”
When she was expecting her second child, friends recommended Blue Ridge, five minutes from her home on good roads.
“It was an amazing, absolutely amazing experience,” she said. “I love how small it is. The nurses were so attuned ― ‘Oh, your baby’s sleeping? We’ll come back in an hour to see if he’s awake and get all the readings we need to.’ It was incredible.”
Now 28 weeks into her third pregnancy, Mason is once again facing a delivery at a distant facility with a doctor who will be new to her.
Her doctor, DeGuzman, is moving away before she will deliver because the facility where she has admitting privileges is closing. DeGuzman moved to the area six years ago with the specific aim of delivering babies and providing high-quality prenatal care in a rural setting. Mason says her doctor is so devastated by the closure of labor and delivery at Blue Ridge Hospital that she is moving to California at the end of October.
“Dorothy is the most amazing doctor that I’ve ever seen,” Mason said. “She literally just cried on me when she told me that she’s leaving, because of how passionate she is about labor and delivery.”
Mason is now working with DeGuzman to determine her best option. She will either travel to a freestanding birth center in Asheville, which is more than an hour’s drive, or to the next-closest Mission-owned hospital in Marion, 30 minutes away, to put herself in the care of whatever doctor is on call. Though both options accept her Medicaid, both have drawbacks, and Mason is stumped about what she should do.
“I think about it all the time,” she said. “All the time.”
“I’ve been sarcastically saying that I’m going to camp out in a gift shop in a hospital for a while now,” she added. “I’ve even looked at home births just because logistically I could be delivering in the car. So do I just commit to having a home birth? [Blue Ridge Hospital] is still so close, but they’ve been very clear on, ‘If you do deliver here, we’re bringing your baby to Asheville after in an ambulance.’ So that’s why I’ve leaned away from a home birth, because I don’t want to be in that situation if there’s an emergency.”
Sarah Ruth Owens is a doula, trained to assist women during labor and delivery, who lives in northern Georgia, across the state line from Angel Hospital. She has heard from two clients who decided to have home births after the facility stopped offering maternity services last summer.
One is a woman Owens had talked out of a home birth in the first place, pointing to the midwifery model in place at Angel that would allow her to try for the “natural” birth she desired.
The other woman asked Owens if she would help oversee a risky “unassisted” (meaning unsupervised) delivery at home. Owens declined, explaining it was unsafe, and was able to find a midwife 2½ hours away who would attend the birth. It’s still risky, though perhaps not as bad as going it alone.
Owens said Mission’s decision to cut its facility at Angel has “put women like me in a really tough spot.”
“That’s two women in a very small community,” she said. “You’re not talking about thousands of women who deliver here; you’re talking about hundreds.”
There is not much solid national data looking at what happens to women in rural settings when local obstetric services disappear, though one study in France found it led to an increase in home birth, which is already more common in rural areas. Kozhimannil, the Minnesota professor, is at work on a study looking at the risk for women who don’t get adequate prenatal care.
“The further people have to travel, the fewer visits they tend to come to,” she said. Up to 70 percent of rural hospitals that cut labor and delivery continue to offer some form of prenatal and general gynecologic care — as Mission has in its facilities — but that does not necessarily offer much comfort to expectant mothers who do not want to see one provider for nine months only to be met by a stranger during one of the biggest moments of their lives.
“A lot of people in the community want to access prenatal services where they are going to deliver their baby.”
Women’s health experts are worried
Staff at the closed facilities have plenty to say about the mixed messages they received from Mission and their frustrations on behalf of their patients.
DeGuzman has been working in the Spruce Pine area for six years. She worries about what women will do without the local hospital as a delivery option. She also bristles at Mission’s suggestion that staff proficiency was a problem, saying the hospital was unable to provide her and her fellow providers with any evidence that their patient outcomes were in any way diminished.
Now the patients’ risk will only be greater.
“Women will be delivering in cars or at home,” she said. “Some will get hardly any prenatal care.”
DeGuzman said medical staff is working out plans with patients they already have. “We’re basing it on where they live,” she said. Some patients at Spruce Pine lived farther away, including near Burnsville in Yancey County, which has no hospital. “If they’re in Burnsville, we tell them to go to Asheville; if they’re in Spruce Pine, we tell them to go to Marion. Some are going [farther north] to Boone. We’re taking it on a case-by-case basis.”
The planning has not reassured everyone. “They’re so worried,” DeGuzman said. “They’re so stressed, and you know especially the ones due ― and I have several ― that are due, like, the month after it closes.”
She is also concerned that some patients are planning home births, which she sees as very risky when they are more than an hour from a hospital that could do an emergency cesarean section.
For DeGuzman, however, this change signals an end to her work here.
“I’m leaving Oct. 27, because I didn’t want to stop delivering babies,” she said. “That’s my passion. … About three or four months into it, when it became pretty clear [Mission CEO] Ron Paulus was going to do this, I applied for a job in California.”
Roberta Bowles was the nurse manager at Angel labor-and-delivery before it closed in July. The decision took her by surprise. She has worked for the hospital off and on since 1994 and said she has no sympathy for Mission.
“It was the best-kept secret in the whole world,” Bowles said. “When they were making that decision, they did not pull in the obstetric providers. They just really snuck up on everybody.”
She was ordered to call a meeting of staff but not told why. When she persisted and finally learned the bad news, she was devastated. “I had to keep a straight face and not cry for my staff. I was totally blindsided. Totally.”
The meeting was worse. “People were stunned,” Bowles said. “People were crying, because you knew by July 14 you didn’t have a job anymore. I had hired a girl from Virginia who had been here just a year. Another nurse moved from Sylva over here; they had just bought a new house and moved in the week before, and now there’s no job for her. She’s still not employed. It was life-changing for many, if not all of us.”
Though Mission reassured her staff they could apply for jobs internally, Bowles said that it is her understanding that only one of her nurses has a job with the company, while 14 of the 26 women on her staff are still unemployed. Many are young mothers themselves and are simply unable to juggle childcare, long shifts and several-hour drives to a new job.
Bowles’ concerns aren’t just for her staff, however. They are for the mothers she runs into at Walmart or at the grocery store who ask her what they should do. Some, she fears, will have home births far away from any hospital with lay midwives. It’s a situation she saw much more of when she first moved to the area in the mid 1990s and saw many “compromised moms and babies” come to the hospital after home deliveries gone wrong.
“That scares us as providers,” she said. “It’s like, “Oh, no, here we go again.”
Other expectant mothers have told her they don’t have much of a plan beyond going to Angel’s emergency room when they go into labor, a prospect that makes Bowles uneasy. Before her last day, she led a two-hour class for the emergency room nurses and EMS staff on the basics of precipitous delivery, high-risk conditions and the signs that a birth is taking a turn for the worse. It did not make her feel any more confident about what will happen to women who show up at the emergency room in labor.
“A two-hour class does not make you an OB nurse,” she said. “I’m just scared for patients. They’re scared, too, when I talk to them.”
On Sept. 20, with the Blue Ridge labor-and-delivery unit set to close in 10 days, Dr. Brie Folkner was present when a patient arrived in severe distress. Folkner sent an email to Paulus the next day:
I just witnessed Dr. Murphy perform an emergency c-section on a (patient) who came in ruptured with meconium and didn’t know she was pregnant. No prenatal care, no idea of gestational age and she had had four previous c-sections. I was called to attend the newborn as the physician on newborn call.
She called Mission’s neonatal intensive care team just before the delivery to alert them of the situation, but they did not arrive until 30 minutes after the baby was born. Then it was another hour’s wait for an ambulance to come and drive the pair to Asheville. The mother and baby survived, but Folkner is horrified about what may happen if a similar situation arises after Blue Ridge closes its doors to expectant mothers.
“What’s the plan?” she asked. “I refuse to watch people die.”
CORRECTION: An earlier version of this article indicated Cannon Memorial Hospital never had a maternity ward. Cannon Memorial’s maternity ward ceased operation in 2015, and the graphic has been corrected.