This story is part of The Aftermath, a Vox series about the collateral health effects of the Covid-19 pandemic in communities around the US. This series is supported in part by the NIHCM Foundation.
Across the country, from suburban San Diego to rural Connecticut, maternity wards have been shutting down for good during the Covid-19 pandemic.
This wave of closures has been building for years, but it appears to be accelerating during the pandemic. It could make birth even more dangerous in the US, which already sees far more deaths per capita among infants and pregnant women than comparably wealthy countries. And during the first year of the pandemic, the number of maternal deaths in the United States rose sharply. Researchers from the University of Minnesota have found when a labor and delivery department closes, there tend to be more emergency deliveries and more preterm births, which are the leading cause of infant mortality.
The losses are concentrated primarily in rural areas and communities of Black and Hispanic Americans, who are already less likely to have easy access to all kinds of health care services, including obstetrics. Before the recent closures, more than half of the rural counties in the United States already didn’t have a nearby hospital where babies could be delivered.
The decision to close a maternity ward is never simple. Hospitals that have closed their obstetrics (OB) departments in the past two years cite various factors, including declining birthrates. Some say they cannot find enough physicians and nurses to deliver babies, which would make it unsafe to continue offering those services.
But the pandemic looms over each of these closures. In public hearings, hospitals have pointed to the shortage of doctors, nurses, and health care workers they experienced during Covid-19 to justify their decisions. Sometimes, they have temporarily suspended services because of pandemic-related absences, only to later make the closure permanent. Pandemic relief funding that has helped stabilize hospitals’ finances is also starting to run out.
Some hospitals argue that these closures are not financially motivated, but labor and delivery services are not a moneymaker for them. More than 40 percent of births in the United States are covered by Medicaid, and the program’s low reimbursement rates have been cited in the past to explain a hospital’s decision to close its OB department.
There has been a general trend toward consolidation and specialization in hospitals; it’s cheaper to deliver babies at high-volume maternity departments than those in communities with declining birthrates. Those units sometimes enter a downward spiral before they close: Birthrates drop, making it harder to staff the obstetrics unit and more expensive to maintain these services. The staff’s skills start to atrophy with infrequent deliveries, and hospitals cite that risk when justifying a decision to close a maternity ward.
The consequences of these closures ripple out through the community. People in labor have to travel, sometimes for half an hour or even much more, to reach another hospital where they can have their baby. Doctors and families have shared stories about women who have given birth on the side of the road when they were unable to get to a facility in time.
The counties that are most likely to have an OB department close already have a smaller number of obstetricians and family physicians, so the loss of these services at the hospital further drains health care access from the area. Mothers in these communities also report that it is harder for them to get back to work and to find support for breastfeeding and child care.
Other effects are harder to quantify but nevertheless profound. The closure of a maternity ward can fracture the relationship between a trusted community institution and the people it is supposed to serve.
“There is a fundamental shift in a rural community when a hospital closes its OB unit,” Katy Backes Kozhimannil, a University of Minnesota professor who studies maternal mortality, told me. “It’s like a place where you can’t even be born. You can only die. The sense of that is really palpable.”
In Connecticut, a community in turmoil after its maternity ward shutters
When she went into labor in November 2020, Shantel Jones lived just blocks from the Windham Community Memorial Hospital in Windham County, Connecticut. Jones called for an ambulance; according to her mother, Michelle, the ambulance driver called the Windham hospital to let them know they were coming.
But the hospital’s maternity ward had stopped giving care earlier that year. Its last delivery was in June. The hospital told the driver not to come, Michelle says. They needed to go to Norwich, a 30-minute drive.
The ambulance started down Route 32, a winding road. But they didn’t make it to Norwich in time. Shantel ended up giving birth on the side of the road. It turned out the baby boy would need intensive care that the Norwich hospital could not provide. They were rerouted again to a hospital in Hartford, 30 more minutes away.
The baby and Shantel are fine, both living now with Michelle in New Orleans. But it was a harrowing experience, one that left Michelle in disbelief about the state of the community hospital in a town she had lived in for more than 30 years. She said she was still trying to correct her grandson’s birth certificate more than a year later, because local authorities disagree on where he was actually born.
“I felt really scared for her. I didn’t know what was going to happen,” Michelle said of Shantel. “When you have a city full of women who have to have babies, how are you going to do that?”
Windham County, once a textile mill boomtown, is a relatively rural and predominantly white area. But it is also home to many Black and Hispanic families and immigrants. The county’s schools have the highest proportion of students with English as a second language in Connecticut. Willimantic, the county seat, is 44 percent Hispanic and 7 percent Black. The story of the hospital’s closed maternity ward shows how care for people giving birth can unravel and the distrust and damage it leaves in its wake.
The saga begins in 2007, when the Hartford HealthCare system acquired the financially struggling nonprofit Windham hospital. Eight years later, its ICU unit was downgraded to a critical care unit that would not be capable of handling the same level of care that it had before. Local leaders objected at the time, but Hartford HealthCare said it was necessary to keep the hospital afloat and provide adequate care.
Community leaders now say that closure led to an exodus of critical staff, such as anesthesiologists, who can be vital to labor and delivery services. The main local OB/GYN practice eventually stopped delivering at Windham and moved to another hospital in nearby Manchester — they say because of the staffing woes.
When Hartford HealthCare made the decision to close the maternity ward permanently, after it stopped childbirth services in 2020, local health providers tried to come up with alternative plans, like proposing residency programs with UConn’s medical school. They told state regulators they were rebuffed by Hartford HealthCare; the hospital has said that the plan would have been impractical.
In Windham, a community coalition has formed to try to block the closure, arguing before a state board recently that the hospital failed to properly consult with its constituents before closing the ward and warning that the health care consequences could be dire. They see the closure as a premeditated, inevitable move meant to largely consolidate Hartford’s labor and delivery services at the William W. Backus Hospital in Norwich, a 30-minute drive from Windham.
Hospital executives, in those public hearings held over the department’s fate, tell it differently. They say they have tried to keep the ward open, but doing so was no longer tenable. The decision was not primarily a financial one, they say, although deliveries in Norwich cost about one-fourth what they do in Windham because a greater volume of patients creates cost efficiencies. Instead, they cite causes that are driving closed maternity wards across the country, starting with a low birthrate.
The number of births at Windham dropped from 374 in 2014 to fewer than 60 by halfway through 2020. When the main OB/GYN practice in the area decided it would deliver babies exclusively in Manchester, hospital leaders say it became difficult to properly staff the unit. The risk grew that with so few births, doctors’ and nurses’ skills would stagnate, which could lead to errors and worst outcomes. Experts say this risk is one common reason that OB departments close.
By November 2019, the Hartford HealthCare board was already talking about closing the ward permanently. Then came Covid-19, which its executives said in public hearings had made it more challenging to properly staff their facilities.
State regulators are still considering whether to permit the maternity ward’s closure; however, Hartford HealthCare has already been fined for closing the unit without state approval. The hospital system told me it could not comment on the record because of the pending state ruling.
In general, experts say the reasons given by Hartford HealthCare can be legitimate: Skills can deteriorate if hospital staff don’t get enough practice delivering babies. But they also warned of the risks of closing an obstetrics ward, both in the decreased access to care and in the fraying of the connection between the hospital and its patients.
“That risk doesn’t go away, but the risk is abandoned by the hospital,” Kozhimannil said. “If the hospital doesn’t grapple with that, I think there is real damage to the relationship.”
Those bonds are breaking in Windham, compounded by a feeling that the town has lost control of its own community hospital, a common theme in these closures.
In 2000, there were around 30 independent nonprofit hospitals in the state, including Windham, says Lynne Ide, who studies policy at the Universal Health Care Foundation in Connecticut and opposes the closure in Windham. Now there are four, the rest subsumed into larger hospital systems. Hartford HealthCare was recently sued by a group of citizens and another hospital, who alleged its consolidations have led to anti-competitive practices.
The hospital system is pledging to continue providing prenatal and postnatal services to Windham’s mothers and to provide transportation for mothers who need to travel to Norwich or Manchester (also about a 30-minute drive away) or another hospital in order to deliver.
But advocates argue that one of the routes from Windham goes along Route 6, which has become known locally as “Suicide 6” because of the high number of fatal accidents. Town council members have called Hartford HealthCare “vulture capitalists.” The hospital has in turn said there has been widespread misinformation about the closure.
“These institutions are making these siloed decisions without collaborating,” said Rose Reyes, a Willimantic town council member who is part of the coalition trying to stop the closure. “Without input, without respecting and deferring to the community.”
Maternity ward closures nationwide are putting patients at risk
Windham is just one example of a widespread trend.
In Texas, at least six rural hospitals have limited or suspended their obstetrics services in the past few years. According to the Texas Tribune, only 40 percent of rural hospitals in the state have a labor and delivery unit. Some patients must drive hundreds of miles to give birth. One woman gave birth in the parking lot of a hospital, after driving an hour to reach it, according to a hospital executive in the Texas Panhandle.
North Carolina lost at least nine maternity wards since 2013, before the pandemic; another closed in mid-2020. A hospital in Lowville, New York, was forced to suspend its labor and delivery services in September 2021 after an exodus of nurses who refused to receive the Covid-19 vaccine. Several OB departments have closed in Florida hospitals during the pandemic, including one that suspended the services because of a Covid-related staffing shortage, then later closed permanently. In those cases, as in Windham, hospitals insist they were making the best decision for patients, even as some of their own doctors protested the closure.
The same story has played out in rural Ohio, in suburban San Diego and in southeastern Pennsylvania, where a closure will mean the number of hospitals with birthing units has been cut in half in the past 20 years.
More closures could be coming. Leslie Marsh, CEO of a rural hospital in Lexington, Nebraska, told me that facilities in her area have either already shut down their labor and delivery services or began discussing whether they would. She says she wants to keep providing it because she believes it is important for the community, especially after another hospital about 45 minutes away closed its maternity ward.
But 80 percent of new mothers who deliver at her hospital are on Medicaid, which has the lowest reimbursement rates of any insurer in the US. And Covid-19 has strained their ability to staff the department.
“You begin to ask the question: Can we offer OB services anymore?” she said. “That will likely be the reason we would stop doing OB services, if staffing shortages were such that we could no longer manage.”
Nobody is tallying in real time the number of obstetrics departments that shutter during the pandemic. But experts believe the downward trend seen before the pandemic may be getting worse.
The research conducted by Kozhimannil’s team on the effect of pre-pandemic closures would suggest that these closures are going to lead to worse outcomes for mothers and their babies and worsen access in the areas already struggling. The closures hit the least populated counties with the fewest doctors. They also tended to have a higher proportion of Black women who were of a reproductive age.
The researchers found that even when there was another nearby hospital for deliveries, there was still an initial spike in people delivering in the emergency room. Although the rate declined over time, it remained meaningfully higher than before the obstetrics closure.
In hospitals that did not have a nearby facility, there was an increase in the number of out-of-hospital births — maybe planned but maybe not. It is a worrisome trend, since rural communities already have higher infant and maternal mortality rates. After an OB ward closed, preterm births also increased, Kozhimannil’s team’s research found, a metric linked to greater infant mortality.
Those are the stakes in each of these decisions. Hospitals can try to ameliorate the consequences by offering transportation and other services and by working to make sure the community is prepared for that transition.
But if those efforts falter, as Kozhimannil told me, there can be long-term damage.
Windham’s community leaders fear they are facing such a future. They worry what the hospital’s maternity ward closure will mean for both expectant parents and the community at large. Reyes said she believed the town would not be able to live up to its full potential and its 10-year economic development plan would end up squandered.
“The residents of the community are actually astonished,” Leah Ralls, head of the local NAACP and one of the members of the Windham coalition, told me. “What do you mean you can’t have a baby in Windham? Where are we supposed to go?”