Topnish, Wash. — Three days before Christmas, the only hospital in this remote town 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 the Astrea Topenish hospital in January alone, and the sudden closure – which violated the hospital’s commitment to the state to maintain vital services in this rural area – left them vulnerable. Plans foiled.
Victoria Barajas, 34, expecting her first child, was scrambling to find a new doctor before her due date, Jan. 7. Jazmin Maldonado, a 29-year-old schoolteacher who was soon to give birth, wondered how she could make it to the hospital in time.
After the first miscarriage, doctors had placed a stitch in her cervix to prevent a second one, and the stitches would have to be rapidly removed once labor started.
Astria Toppenish Hospital is one of a string of providers across the country that have stopped providing labor and delivery care in an effort to control costs — even as maternal deaths in the United States are rising at an alarming rate, and more women are suffering from complications. is developing which can be fatal.
The closure in Toppenish bucks national trends as financially-strapped hospitals reach a harsh conclusion: childbirth in low-income communities doesn’t pay.
From 2015 to 2019, at least 89 maternity units in rural hospitals across the country were closed. According to the American Hospital Association, as of 2020, nearly half of rural community hospitals did not provide obstetric care.
Over the past year, the pace of closures has accelerated, as hospitals from Maine to California have closed maternity units, mostly in rural areas where populations have shrunk and the number of births has declined.
A study of hospital administrators conducted before the pandemic found that 20 percent of them said they did not expect to provide labor and delivery services in five years’ time.
According to a study by the Commonwealth Fund, women in rural areas are at a higher risk of pregnancy complications. Those living in so-called maternal care deserts are three times as likely to die during pregnancy and closer to care critical years later, according to a study of mothers in Louisiana.
Ambulances are not reliable in many rural areas like the Yakama Reservation, which covers over a million acres. There aren’t too many emergency vehicles, and long wait times due to long distances. In fall and winter, thick fog often envelops the roads, making driving treacherous.
In Toppenish, desperation and fear erupted at a recent city council meeting, which attracted a crowd so large it spilled out of chambers into the hallway. Astrea, a health care system based in Washington state, had committed to providing some services, including labor and delivery, for at least a decade after acquiring the hospital, residents noted.
Now the hospital said it cannot do this and the state has not taken any action. Leslie Swan, a Native American doula, said, “Lives will be lost—people need to know that.”
At the meeting and in interviews, several women said that the doctors and labor and delivery nurses at the Astrea Topenish hospital had saved their lives. Adriana Gail, a 35-year-old mother of three, survived a rare life-threatening complication called amniotic embolism during one of her deliveries and credited the hospital with saving her life.
The mayor, Elpidia Saavedra, 47, had an obstetric emergency 10 years ago when an ectopic pregnancy ruptured. Simone Dietentholer, 39, said she almost died as a teenager when she had a miscarriage and lost a huge amount of blood.
“It’s a lifeline that we had, and now that part of that lifeline is being cut off,” said Ms. Dietentoller, who works on the reservation at the Titavax Birth Justice Center, which provides support to pregnant women and new mothers. Does and providing space for a local obstetrician to see women once a week to provide easier access to care.
“It’s just another reminder of how scary it can get out here.”
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 births.
Recent data suggest that the problems are particularly acute among minority communities and especially Native American women, whose risk of dying from pregnancy complications is three times higher than that of white women. Their children are almost twice as likely to die during their first year of life as white children.
Women of color are more likely to live in maternity care deserts or in communities with limited access to care. According to the March of Dimes, a maternal health nonprofit, seven million women of childbearing age live in counties with no hospital-based obstetric care, no birthing centers, no obstetrician-gynecologists and no certified Not a nurse midwife, or at least a 30-minute drive away from where those services are.
The closure of a maternity unit often triggers a decline in health in remote communities. Without ready access to obstetricians, antenatal care and critical postnatal tests, the potential for risky complications increases.
But running a labor and delivery unit is expensive, said Katie Kozhimanil, 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 specialized nurses and backup services, including pediatrics and anesthesia.
“You have to be ready to have a baby at any time,” said Dr. Kozhimannil.
Staff shortages have driven up costs, and hospitals have been forced to bring in contract nurses, who can cost up to three times as much as a staff nurse. Labor and delivery nurses are in high demand, and pay for them can be even higher.
Most pregnant patients at Astria Toppenish had insurance coverage, but mostly Medicaid, which pays hospitals much less than private insurance plans. Half of pregnant women in the United States are on Medicaid, and it pays poorly in all states.
In Washington state, Medicaid will pay $6,344 for the birth of a child, about a third of the $18,193 paid by private plans, according to an analysis by the Health Care Cost Institute. Private plans.
In wealthier communities, private insurance helps hospitals offset lower Medicaid payments. But in rural areas where poverty is high, privately insured patients are few.
“Toppenish is the canary in the coal mine,” said Cassie Sawyer, president and chief executive of the Washington State Hospital Association, noting that many hospitals serving low-income communities in the state are in similar financial trouble.
Astria Toppenish’s administrator, Cathy Bambrick, said the hospital had no cash reserves and the labor and delivery unit lost $3.2 million last year after a temporary Washington state initiative ended paying increased Medicaid rates. happened.
She said that the cost of nursing increased because the hospital contracted nurses.
He said there was no money in the budget to replace a child safety system last year when it failed. Recently, the ultrasound machine had stopped working, and since the hospital could not afford a new machine, Ms. Bambrick paid $50,000 for a refurbished machine.
Ms. Bumbrick said although Astraea Toppenish serves low-income populations, it does not qualify for any of the myriad government programs that help fund rural health services and hospitals in the state.
“We fall through the cracks,” Ms. Bambrick said.
Patients with Astrea toppenisch are particularly vulnerable populations, including a large community of agricultural workers who toil in the vineyards, orchards and hops fields of the Yakima Valley.
So many children come from low-income homes that local schools offer free lunches. Patients often struggle for gas money to get to doctor’s appointments. Chronic diseases that complicate pregnancy – such as diabetes, heart disease and substance abuse – are common.
“They work hard but are poor,” said Dr. Jordan Lohr, an obstetrician who works at the Yakima Valley Farm Workers Clinic.
Many women choose to give birth at Astrea Toppenisch because of its reputation for respecting patients’ wishes and for cultural sensitivity—which includes a labor room for Native American women to the east, an ancestral practice, and many family facilities. Friends and “aunties” are allowed. As the mother wanted in the delivery room.
Nurses did not tend to women in labor, and the cesarean section rate in the unit was 17 percent (below the national average of 32 percent). He taught first-time mothers about infant care and breastfeeding – but also how to safely board a papoose, and why mothers should not tie up a newborn, a common practice.
Nurses in the hospital introduced new mothers to ideas that ran counter to long-held beliefs.
“There is a cultural understanding in general in our population that you don’t hold newborns – it makes them needy,” said Angie Scott, a labor and delivery nurse. “We tell them, ‘No, you can’t spoil a newborn. Babies who are held more in the first year of life tend to be more confident. It’s important to hold your baby.'”
Many residents fear that maternity closures lead to hospital doors closing entirely, which is what happened in 2019, when Astrea Health System declared bankruptcy and subsequently closed the largest of its three hospitals, the 150- in Yakima. Bed facility closed. Astrea had bought the hospital just two years ago.
For now, four obstetricians in town — all women — are doing the digging. Doctor. Loehr has led a community campaign to re-establish a maternity unit by creating a public hospital district, a specialized unit that would be governed and funded locally with taxes or levies. ,
Another obstetrician, Dr. Anita Showalter, recently delivered Ms. Barajas’ baby, but far away, at an Astria hospital. She had already suffered a miscarriage, and Dr. Showalter stayed with her through 37 hours of labor. Baby Dylan was born on January 15 at 1:52 p.m. “My heart is filled,” Ms. Barajas said in a message.
Shayla Owen, 35, of Goldendale, went into labor the day before Valentine’s Day, and her husband drove her 70 miles over a desolate mountain pass to a hospital in Yakima. By the time he reached there, he had almost run out of gas.
Isaiah’s baby weighed 8 pounds 3 ounces after 10 hours of labor. Ms Owen said she made the right decision when she chose not to give birth at home.
He said, ‘I had bleeding after delivery. “So I was glad I was in the hospital.”