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Announcer: This is The Takeaway with Melissa Harris-Perry from WNYC and PRX in collaboration with WGBH Radio in Boston.

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Melissa Harris-Perry: In Windham County, Connecticut, some members of the community are distraught about the closure of the maternity ward at their local hospital, Windham Community Memorial.

Lynn Eye: Windham County is a medically underserved county of Connecticut.

Melissa Harris-Perry: Lynn Eye is one of those residents.

Lynn Eye: Our small community hospital was acquired by Hartford Healthcare, which is one of the two biggest healthcare systems in the state.

Melissa Harris-Perry: After the acquisition, Windham County ICU was downgraded to a critical care unit in 2015. Then in 2020, the hospital ceased childbirth services and then closed the maternity ward altogether. Now pregnant people in the community have to travel 30 minutes away down winding two-lane rural roads to Norwich.

Lynn Eye: I would just like to say as a mother who delivered all three of my children at Windham hospital, and a new grandmother whose daughter was unable to deliver my first grandchild at Windham Hospital, it's a loss for the community. We're taking away that fundamental, essential, vital service in a community that has lots of young families that would love to be able to deliver there.

Melissa Harris-Perry: Losing maternity ward is increasingly common. According to recent reporting by Vox, many of these closures are happening primarily in rural air areas or in predominantly Black and Latino neighborhoods. For more on this, we spoke with Alecia McGregor, assistant professor of health policy and politics at Harvard Chan School of Public Health, and Katy Backes Kozhimannil, professor at the University of Minnesota and director of the university’s Rural Health Program.

Alecia McGregor: There are a number of reasons why this is happening. First, there are financial reasons. Obstetric units face very high costs relative to other service lines in the hospital. This is in part because they have very high fixed costs, high personnel costs, high equipment costs yet when it comes to reimbursements, OB units often face a larger share of care that's reimbursed at a lower rate. Because more than 40% of all childbirths in the country are paid for by Medicaid, OB units are taking that financial hit. That's often one of the reasons that this is occurring.

When it comes to the justifications that hospitals make, we can hear anything ranging from declining demand in the area or declining birth volumes. Often we also hear narratives around declining quality of care at some OB units or in some areas. For instance, take a recent example in Washington, DC. In 2017, the only remaining OB Unit in Washington, DC closed its doors in the wake of a few widely publicized medical errors that took place there. We often hear stories around declining quality as some of the precipitating factors for obstetric unit closures.

Melissa Harris-Perry: On the one hand, Alecia, I hear you talking about what feel like long-term issues of the cost to carry malpractice insurance for OBs who are in practice of actually attending birth is higher. I hear you saying that there are these differential rates of reimbursement depending on particularly Medicaid versus private insurance. In communities maybe with higher Medicaid use, potentially rural communities, maternity wards that are serving women who are living in poverty, that that means for them they're actually potentially not even earning enough to stay open.

Katy, I guess I'm wondering in part if these are longer-term baked-in realities to our system, why the acceleration and closures? Is this related to the pandemic? Has something changed that is causing this now?

Katy Backes Kozhimannil: Alecia really very clearly described some of the long-term financial challenges that obstetric units face. They have to be ready to take care of a person giving birth 24 hours a day, 7 days a week, and that costs money. It also requires personnel. You need to make sure you have the clinicians there to take care of people during pregnancy and labor and delivery and to take care of babies once they're born. In addition to that, you need to make sure that there's sufficient birth volume for clinicians to feel like they have their skills in taking care of people.

The constraints around safety tend to come from the comfort that clinicians have in terms of their training, but also in terms of the volume of births that they see of different types. I think the last factor that I see and hear that comes together and that speaks to your question of in this moment now is the issue of local community needs. People need childbirth care. People give birth in communities all across the country and folks don't always understand hospital financing. [laughs] Those of us with PhDs sometimes struggle to understand these things.

What is interesting, we just completed a survey of rural hospital administrators, rural hospitals that provide obstetric services, and clearly rural obstetric unit closures are not just in rural communities, but we see a steady decline over time. In the time that I've been studying it, we have not seen a specific acceleration of obstetric unit closures in rural communities, but we have not yet had a chance to really study what's been happening during the pandemic. What has been changing is that local needs are shifting pretty dramatically.

When we asked rural hospital administrators how many births do you need financially to make this viable, and from a safety perspective, to make sure you're providing high-quality services? Hospital administrators, it varied very widely across different settings and different communities, but on average, they said about 200 births a year for both financial viability and safety.

I think very importantly that is not a magic number because more than a third of all rural hospitals that do provide obstetrics are providing it at a volume lower than that. When we ask them why they said because local people need it. What one administrator told me is the people here are poor, they don't always have cars. They are going to give birth and we need to be here for them. There is a commitment on the part of some hospitals and communities to make sure that there are birthing services available for folks locally.

Melissa Harris-Perry: Alecia, where does someone give birth if they're in a community-- This point about once you're at a certain stage of labor you're going to give birth. If you are in a community that is not served by a maternity ward, you go into labor and there is no turning back, where does that birthing person give birth?

Alecia McGregor: Just from looking at our numbers, the majority of OB units that closed in a 15-year period that we've studied have been Black and Latinx OB units. Even though the share of deliveries taking place about half of them were deliveries among white women, the OB Units that are more likely to close are those serving communities of color and low-income communities. Given that, we're starting to see an increasing number of urban so-called maternity care deserts emerge in these very communities that are serving the populations that are at greatest risk.

When it comes to where a birthing person will go or will be able to go in the wake of these closures, we've done some qualitative research in a major city in New Jersey that lost all of its maternity wards over the last few decades. We found that women and birthing people there have an overwhelming lack of choice. They have no choice, but to go to a nearby suburb for that care, and granted, the environments between where the former hospital was and the new hospital is, these environments are very different so people definitely have to move to a place that's far outside of one's, I guess I should say comfort zone in order to get care.

The types of barriers that are associated with this change include not only are there clearly delays in arriving at the site of delivery and barriers to receiving adequate prenatal care and adequate postpartum care, but even family members and members of a woman's support network, they face barriers in attending the delivery. Women were less likely to have the normal members of their support group, say their mothers or their partners or others, be able to attend their births. This is critical, especially for people who have birth complications or traumatic births, which were relatively common in the population that we interviewed.

One interviewee, for example, her mother had developed MS in recent years and she can't drive well so of course, she wasn't able to get to that hospital. The OB unit is no longer in walking distance as it once was for that community. For those people who didn't have access to a reliable means of transportation, access was severely, severely constrained for these folks and there was no bus line running in between these areas. Constraints such as these really turned out to disrupt continuity of care and to disrupt access at the time of delivery for sure.

Melissa Harris-Perry: Quick time out. Back with more on The Takeaway in just a moment.

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Melissa harris-perry: Thanks for sticking with us on The Takeaway. I'm Melissa Harris-Perry. We've been looking at the shuttering of maternity wards across the US with Alecia McGregor, assistant professor of health policy and politics at Harvard Chan School of Public Health, and Katy Backes Kozhimannil, who is professor at the University of Minnesota.

Katy Backes Kozhimannil: What happens to people when a maternity unit closes, rural obstetric unit closures were more likely in rural counties that had a higher proportion of Black reproductive age residents compared with white folks. We also found that these closures were more frequent in states that had less generous Medicaid programs, and that speaks to the financial piece around closures. That was the first question. The second is the question you asked about what happens. What we found was that there were differences based on how far away the rural community was from an urban center.

The most remote rural communities, we saw an increase in out-of-hospital births and that could be either planned home births, which can be a very safe and good option for folks, or it can be births that are happening, precipitous births that happen very quickly, that happen by the side of the road that are not planned so it's hard to say for that particular outcome. We saw a massive increase in emergency room births. By massive increase I mean tripling of where it was before. You didn't see emergency room births in communities that had obstetric units.

Then once that goes away, if there's still a hospital and it has an emergency room, that's where births are happening. The other thing that we saw in the more remote rural communities was an increase in preterm birth rates. That is especially concerning because preterm birth is the leading cause of infant mortality, which is higher among Black and Indigenous infants, and is higher among rural residents compared with urban residents.

We saw slightly different outcomes for rural communities that were located adjacent to next to urban areas. In those cases, we still saw an increase in out-of-hospital births. We also saw an increase in emergency room births. That increase declined over time suggesting that there was some adjustment that happened, and then people figured out where they needed to go, systems were in place so you didn't see the emergency room births happening as frequently.

Melissa Harris-Perry: When you focus us in there on preterm births, that's exactly where I want to go. That is this issue of the consequences of this, right? This is not exclusively a matter of inconvenience. It's not exclusively a matter of discomfort although those things certainly matter. We're talking about mortality, morbidity, life and death for both birthing persons and for babies, right?

Katy Backes Kozhimannil: Exactly. It is not just a matter of convenience. It is a matter of health and life and death. It is a matter of family. It is a matter of whether or not you celebrate your baby's first birthday, or it is a matter of how your baby develops cognitively, emotionally, physically over time. These are really important issues. It is not without consequence when we talk about obstetric unit closures in both rural and urban areas.

Alecia McGregor: I just want to chime in because in our research in New Jersey, we found evidence that suggests something similar as well. We analyzed the effects of obstetric unit closures on severe maternal morbidity. What we found in those zip codes where obstetric units closed over a 10-year period was that for those women who delivered in the years before that obstetric unit closed, their risk of severe complications at the time of delivery were lower than for those women who delivered after their obstetric unit had already closed.

Melissa Harris-Perry: Alecia McGregor is assistant professor of health policy and politics at Harvard Chan School of Public Health. Katy Backes Kozhimannil is professor at the University of Minnesota. Thank you both for joining us.

Katy Backes Kozhimannil: Thank you.

Alecia McGregor: Thank you.

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