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Commentary: Reckoning With the Loss of Rural Labor and Delivery Departments

I came into the world amid generational change, a blurry line somewhere between Gen X and the Millennials. Given the abundance of pop culture markers that tell you how you should classify yourself, I always felt like I was a bit of an outlier when it came to my generational identity. But there’s another element to my childhood that sets me apart from those “kids today” that is rapidly disappearing. I was born in a rural hospital – the Clearwater County Memorial Hospital in the town of Bagley, Minnesota. At the time of my birth, the population was just over 1,300 residents. In my hometown though, I was no outlier. Roughly 2/3 of my graduating class was also born at that same hospital and many of us had siblings that were born there too. Beyond the fact of my birth in Bagley, my mother was also employed as a nurse at that same hospital and has shared numerous stories over the years of just how crucial the hospital was to the community. The routine life cycle played out there, as at any hospital, but it was also an institution that operated as a fulcrum of the region. Along with the school, it was a top employer. And a generation ago, serving the needs of mothers and their new babies was one of the hospital’s core functions. Not anymore. 

Today, the County Hospital in Bagley remains open as a 25-bed critical access institution, a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services known as CMS. Congress created the Critical Access Hospital (CAH) designation through the Balanced Budget Act of 1997 in response to over 400 rural hospital closures during the 1980s and early 1990s. But the hospital ceased delivering babies over a decade ago and is now owned by Sioux Falls based Sanford Health, a behemoth in the space of health care in the upper Midwest. Sanford’s acquisition in 2012 was born out of necessity – Clearwater County Memorial Hospital was built in 1949 and one of the last county-owned institutions in the state. It had also been operating in the red for several years prior to its acquisition. Sanford’s resources have ultimately been a good thing for the Bagley hospital. While the company’s initial commitment was only for three years, employees and community members celebrated the 10-year anniversary of Sanford’s acquisition in 2022 with an open house and festival. Given the myriad challenges so many rural hospitals face around the country, the stable financial footing Sanford Health offers an economically marginalized rural region is worthy of celebration. But Sanford’s acquisition also meant the streamlining of services to make the hospital more profitable and that in turn led to the total elimination of obstetric care. 

Today, medical services in Bagley County come under the banner of Sioux Falls-based Sanford Health. (Photo: Sanford Bagley Medical Center’s facebook page.)

Increasingly Harrowing Stories

The accelerated closure of rural hospitals has touched every part of the country and even if the hospitals themselves stay open because of a Critical Access designation, their labor and delivery units are disappearing. Multiple media outlets have reported on the dire situation. Families driving over four hours in blizzard conditions in the middle of night because their local hospital ceased delivering babies 18 months earlier. A mom in rural Illinois forced to deliver a baby on an Interstate 55 off-ramp a month after the labor and delivery unit in the small town of Lincoln, Illinois, closed. A soon-to-be mom in labor who navigated an isolated mountain pass in rural Washington on her way to the hospital with barely enough gas to get there.  

Stories like these have become much more common in the past few years. At the same time, maternal mortality rates across the United States have increased significantly. In 2021, the rate of maternal deaths that occurred while pregnant or within 42 days of being pregnant was 32.9 per 100 000 live births, 10 times the rate for countries of comparable high income. The proliferation of maternity care deserts in rural America is an adjacent issue to overall maternal mortality, and policymakers across the United States need to do more. According to the March of Dimes, maternity deserts are defined as counties where there are no hospitals providing obstetric care, no birth centers, no OB/GYN and no certified nurse midwives. Today Clearwater County, where I was born, is a maternity care desert.

How We Got Here

The reasons so many hospitals in rural America are shuttering their labor and delivery units are complicated, but common threads emerge in why these decisions are justified by an increasing number of hospital administrators. Three major strands seem to guide health care administrator thinking on this issue: 1) Labor and delivery departments are expensive to operate and the number of births in rural communities don’t justify the cost to operate labor and delivery departments; 2) Risk and liability to doctors and medical staff have become untenable in a much more litigious environment if a delivery goes badly; 3) It is challenging to recruit new OBGYN doctors and other reproductive professionals like Certified Nurse Midwives to rural areas. 

If policymakers care about fostering a vibrant and resilient future for rural America, they would safeguard rural hospitals by creatively and sustainably funding labor and delivery departments in rural places. And while many rural healthcare stakeholders advocate for increased reliance on technology like telehealth and mobile health clinics, expectant mothers shouldn’t have to deliver their babies over Zoom, or drive 2+ hours to receive care. Furthermore, one recent study demonstrates that the closure of labor and delivery units in rural areas is linked to the reduced quality of prenatal care, even if healthcare institutions are providing it.

What Policymakers Can Do

States like Texas (where rural hospitals more broadly are in especially dire circumstances) that have opted not to expand Medicaid, should reconsider that decision as the rate of rural hospitals  at risk of closure steadily increases each year. But a simple federal solution exists as well – significantly increasing Medicare and Medicaid reimbursement rates that actually reflect the skyrocketing costs of healthcare and maternity care in particular in a post pandemic America. In fact, the American Hospital Association supports this action, among many other initiatives in their call for Congress to pass the Rural Hospital Support Act which is a piece of legislation that has broad bipartisan backing. 

The circumstances of my own birth 40+ years ago were complicated. My mother was required to be on bedrest for several weeks prior to my birth, and when I was born on a brutally cold February day, I made my entrance prematurely. Because my parents also farmed and did not have extended family to rely on in my hometown, I know that it would have been a tremendous financial and emotional burden if my mother had been hospitalized hours away from my father in the weeks leading up to my birth. Yet, this is now the reality so many rural people and couples face as they navigate their pregnancies with reduced, minimal, or zero access to maternity care. 

Ultimately, a national reckoning is playing out across the country when it comes to rural healthcare, exposing so much that is broken, whether it’s healthcare costs, maternal mortality rates, or increased health disparities between rural and urban populations. Unless policymakers (regardless of their political affiliations) and civic leaders take action to solve this crisis, rural people are left with limited options, while the future of the nation’s rural communities more broadly is one of precarity and accelerated population loss.

Anna Thompson Hajdik is a senior lecturer at the University of Wisconsin – Whitewater in the Languages and Literatures department. Her rural background and continued interest in agriculture informs her research and writing, as well as her “extracurriculars,” including serving as vice president of the Wisconsin Dairy Goat Association.

The post Commentary: Reckoning With the Loss of Rural Labor and Delivery Departments appeared first on The Daily Yonder.

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