When Plumas District Hospital closed its maternity ward in 2022, Plumas County joined a list of 12 California counties with no healthcare facility that delivers babies. The Seneca and Eastern Plumas healthcare districts had discontinued labor and delivery services years before.
The closure of labor and delivery centers throughout Plumas County is part of a national trend in “maternity care deserts.” Five hundred hospitals have closed their labor and delivery departments since 2010, leaving rural hospitals and more than a third of urban hospitals without obstetric care, according to the New York Times. Studies have shown that closures of rural maternity wards can lead to an increase in births in emergency rooms or outside of hospitals, according to Katy Kozhimannil, professor of health policy at the University of Minnesota.
The challenge of maintaining labor and delivery services for rural providers
Several factors are driving the wave of maternity ward closures. One major component is cost. Medicaid, the public insurance program for low income families, covers more than 40% percent of all births in the United States. But the program typically reimburses hospitals for only about half of the actual cost of birth.
Another is staffing. According to Lori Link, director of midwifery services at PDH, nursing schools began teaching a new model of care that demanded specialization rather than the cross-training model, which had been in place at PDH and elsewhere for decades. Having a second obstetrics nurse became standard, along with an anesthesiologist and neonatal specialist. The transition from cross-disciplinary to specialized nursing was accelerated by the COVID pandemic. Nurses left the profession in droves, including veteran nurses who were accustomed to a work environment where they served all areas of the hospital.
Then the waiver that had allowed PDH the flexibility to use on-call staff to support delivery was eliminated, said Lisette Brown, chief clinical officer at PDH. That forced PDH to provide a full delivery staff at all times, similar to an emergency room crew. This led to a reliance on more expensive traveling nurses.
Seneca Health Care District in Chester closed its maternity ward 20 years ago for many of the same reasons. Chief Executive Officer Shawn McKenzie attributes the closure to a litigious environment, a need for capital outlay, an inability to recruit qualified professionals, and a low return on investment to the community due to low birthrates.
“Everyone wants to deliver locally,” said McKenzie. That has to be weighed against the safety of the delivery. Most people — even those in the medical community — do not fully understand what it takes to run an obstetrics program in compliance with the standards set by the American College of Obstetrics and Gynecology, he said. Meeting these standards in “rural/frontier environments” is nearly impossible with today’s provider and qualified nursing shortages, McKenzie added.
Changing patient needs
PDH has a long history of delivering babies. According to Tiffany Leonhardt, director of business development, the hospital had delivered around 100 babies a year since 1959. In the early 2000s, the numbers began to decline. By 2015, the number of babies delivered at PDH had dropped to 60. With fewer births taking place in the hospital, staff had fewer chances to gain experience, and felt less competent to deliver babies, said JoDee Read, PDH chief executive officer.
The shift reflects a mix of factors. Mothers have increasingly chosen to have their babies at home or at a birth center, assisted by a midwife. Between 2017 and 2021, Plumas County women chose home births about as often as they chose PDH (the only remaining local facility) or out-of-county hospitals, according to the California Department of Public Health. That’s part of a national trend: Research shows that from 2019 to 2020, community births increased by 20%, and births in freestanding birth centers by 13.2%.
Both the fear of hospitals after COVID and increased awareness of maternal morbidity contributed to the change, according to hospital administrators. The focus on staying well and not treating pregnancy like a disease appeals to many mothers, added Link. Midwives’ emphasis on healthy habits and diet produces positive outcomes for mothers and babies. And women have a greater sense of control and personalization in their care.
The last obstetrics program standing
Following the pandemic, it was clear to PDH officials that changes would be required to make maternity services sustainable. In 2021, PDH held several public forums inviting the community to share their concerns and wishes. A majority of women expressed a preference for labor and delivery at PDH; just 35% expressed a preference for home birth, said Leonhardt. Some women wrote letters appealing to the hospital. They worried about the future of their community if women were forced to drive several hours to a hospital on roads that are not always reliable due to weather.
There are many drawbacks to a lengthy drive on mountain roads, especially in winter, said Dr. Mark Satterfield, Plumas County public health officer. Some women have babies quickly. A mother could choose to stay closer to the hospital where she’ll give birth — but that can be financially and logistically difficult, particularly for parents with other children at home. Induced labor can allow for a scheduled birth, but that carries risks too, including increased likelihood of cesarean section.
Although PDH clients expressed a demand for obstetrics, the financials proved unfeasible. In June 2022, the hospital announced the cessation of labor and delivery services. Private midwives could still attend home births in the county, but no institutionally-backed services would be available. Expectant parents who wanted the support of doctors and nurses at delivery would need to travel, often 90 minutes or more, in order to receive care.
During PDH’s public forums, financial sustainability proved elusive. As a result, in June 2022, the hospital ceased its labor and delivery services. Expectant parents seeking institutional support now face long travel times to access care, creating significant logistical and financial challenges, especially in a region with unreliable roads and harsh weather conditions.
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