Jaxon Shell minutes after his birth at Mary Breckinridge Hospital August 2010. The hospital closed its maternity ward the next month.

Rural women nationwide are facing a host of challenges as they seek proper maternity care and options for birthing and delivery.  Especially vivid proof of the problem has been the closing of the maternity ward at Mary Breckinridge Hospital in Hyden, Kentucky, last year. There’s a big dose of irony here: Mary Breckinridge Hospital, located in Appalachian Kentucky, is named for a pioneer in maternal and infant health who brought the nurse midwifery model of care to the United States.  Breckinridge along with the nurse and lay midwives she trained accomplished better birthing outcomes in the 1920s than physicians of the time were achieving in hospitals.  She did this in an area that previously had had the poorest birth outcomes in the nation.

Explaining its decision to close the maternity ward September 23, 2010, the hospital cited poor reimbursement from Medicaid, large malpractice insurance premiums for maternity care providers, and fewer births.

Midwives practicing at Mary Breckinridge Hospital continued to believe strongly in the midwifery model of care, and before its closure, the hospital’s maternity ward carried one of the lowest primary cesarean rates in the state of Kentucky. The hospital offered birthing tubs, squat bars, birthing balls, and birthing stools for women’s comfort, along with the medical amenities that giving birth in a hospital can provide. With the closing of this facility, women of the entire southeastern Kentucky region lost an important and rare option for birth, as well as the expertise of the hospital’s midwives, most of whom either moved to other parts of the state or left Kentucky altogether.

Nancy Hines, chairman of the hospital board, stated at the community forum held before the closure that the hospital averaged 12 births monthly, adding that requirements for a hospital to operate a maternity ward are 24-hour coverage for anesthesia along with an obstetrician always available for emergency needs and consultation.  In order for the hospital to keep up financially with those requirements, the facility would need to attend 25 births monthly just to break even.

Similar closures are occurring in rural areas across the nation.  In rural Virginia, Bedford Memorial Hospital closed its maternity ward for similar reasons. Bedford officials added that local women were choosing to drive elsewhere for services and physician participation had been poor.  Carilion Stonewall Jackson Hospital in Lexington, Virginia, also ceased services to birthing women in 2010.  Summa Wadsworth-Rittman Hospital in Wadsworth, Ohio closed doors in 2009, blaming fewer births and an aging population in the service area.  The state of Alabama has lost 26 options for maternity care since 1980.

While there may be fewer births in some rural areas, it must be recognized that these areas are still underserved when it comes to maternity care. According to the Center for Rural Health, a research department at the University of Kentucky, an average of seven obstetricians serve every 100,000 residents of rural Kentucky; in the state’s urban areas, there are eleven obstetricians per 100,000 residents.

At Whitesburg Appalachian Regional Hospital, also located in the Kentucky mountains, there were 453 babies born in 2008.  This is 30% of all births in Appalachian Regional Hospital’s nine facility system.  The births at Whitesburg ARH are attended primarily by a practice consisting of one obstetrician, two certified nurse midwives, and one physician assistant (who is supervised by the OB).  If the OB and PA are counted as a team, this means that each care provider personally attends around 13 births monthly along with handling regular clinic duties.

What are the consequences of taking hospital maternity services out of rural communities?  The most obvious are barriers to any prenatal care: rural women will face added problems and expense of transportation and childcare if they hope to receive prenatal care.  These costs could be high enough that some rural women, especially those who either are uninsured or who rely on government assistance for proper maternity care, would not be able to obtain it.

Studies also show that the rates of medical intervention in birth are higher at rural hospitals where care providers are feeling the pressure of a high patient load.  A correlation can be seen between shortages of medical staffing and interventions like labor induction or cesarean surgery, whether or not there was an actual medical need for such procedures. 

These procedures carry great risks to both mother and baby, and when used without medical necessity can cause unnecessary harm.  According to the Mayo Clinic, the risk of death for a mother increases four times when a mother gives birth via cesarean as opposed to delivering vaginally.  With induction of labor come increased chances of needing emergency c-section, having a pre-term birth, and requiring pain medication.

All of these procedures also come at a higher cost.  Depending upon location, care provider, and the length of the hospital stay, the cost of giving birth in the hospital can range from $3,000 to $6,000 for an uncomplicated vaginal birth, and $10,000 to $40,000 for c-section.  Those uninsured mothers who receive cesarean surgery will acquire a large financial burden on top of the costs of caring for a newborn.  States with high cesarean rates along with large numbers of pregnant women on Medicaid bring the cost of this issue into the state budget.  

A 2005 study published by North Carolina Rural Health Research and Policy Analysis
(Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill) noted, “There are reasons to suggest that c-section rates at rural hospitals might be different than c-section rates at urban hospitals. The diffusion of best practices, such as the safe delivery of infants by vaginal births to women with previous deliveries by c-section (VBAC), may be slower in rural communities, resulting in higher c-section rates at rural hospitals. There may also be non-medical reasons for an increased rate in rural facilities, particularly small hospitals. For example, lack of surgical coverage on weekends could lead to scheduled c-sections in anticipation of problems necessitating surgical intervention.”

Another study published in the Online Journal of Rural Nursing and Health Care (2006) researched the induction rates in a rural midwestern hospital experiencing a nursing shortage: “Findings showed an induction rate of 37.8%. Inductions resulted in 58% of the hospital’s unplanned cesarean sections. Several physicians said that they scheduled inductions to guarantee the availability of a qualified labor and delivery nurse. However, none of the physicians were aware of the high rate of inductions at this rural hospital.”
It is apparent that rural women face a higher risk for complications during childbirth and poorer outcomes for their babies as access to quality maternity care becomes harder to obtain.  Of the four states mentioned previously in this article as having closed hospital maternity services, three fall in the top 15 states for the highest cesarean rates as of 2007, according to the National Vital Statistics Reports.
When looking at a lack of birthing options, how does a rural woman protect herself and her right to receive healthcare that is consistent with current scientific evidence about risks and benefits (see http://www.childbirthconnection.com and The Rights of Childbearing Women)?

Traditionally rural women (as well as women in urban areas prior to 1900) were primarily served by midwives and gave birth in the home.  In most states in the US it is now hard to choose homebirth and find a midwife or obstetrician to attend the birth if you are in a rural community, as those attending births in homes seem to be focused in more urban areas.  In some states, Kentucky and Alabama included, either laws or non-licensure make it illegal to practice midwifery in homes.  Of the ten states that provide Medicaid reimbursement for in-home midwifery care, seven fall in the bottom half of states’ cesarean rates, demonstrating a possible solution to the rural woman’s dilemma.

The option of opening free-standing birth centers in rural areas is something to consider as well, where midwifery and/or physician care can be received independent of a hospital setting, but in a facility that combines a homelike atmosphere with available technology and resources for childbirth.  Placing a birth center in locations within reasonable transport distance to the nearest hospital providing maternity care in case of emergency would bring access to the prenatal care women need closer to home.

While there is no simple solution to the issue of decreased maternity care for rural families, the need for that solution is immediate.  In a healthcare system where maternity care providers are facing the highest malpractice insurance premiums of any physicians, and as obstetricians  become fewer in number, it is not surprising that we are seeing closures of maternity services in rural hospitals and increases in the rates of medical interventions.  Rather than fighting to keep a system that is not benefitting rural women, healthcare providers, or state governments, we need  new models of care and ways in which that care can be obtained safely, close to home.

Kelli B. Haywood is a Lamaze certified childbirth educator, birth doula, and certified prenatal yoga instructor.  She lives in southeastern Kentucky with her husband and two daughters.  See her weblog about childbirth and prenatal care: Birthtrue.

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