LOS ANGELES — Simone DeRoche, anticipating her fourth youngster in December, had her beginning plan set: delivering at USC Verdugo Hills Hospital, the place her three different youngsters have been born.
However when she acquired the textual content from her OB-GYN final week that the hospital can be closing its maternity ward and NICU in November, DeRoche felt a wave of disappointment and disappointment. She’d loved the expertise of giving beginning on the Glendale, Calif., hospital, calling it “a particular place.” DeRoche stated she has choices, together with giving beginning at Huntington Hospital in Pasadena, a mere 10- to 15-minute drive from her residence in La Crescenta. However she’s unsure the place she’ll find yourself, or what the expertise can be like — she’s just lately heard tales about overcrowded space hospitals the place deliveries are occurring within the ER. The information about Verdugo Hills hit residence: She knew about rural hospitals closing maternity wards, however not city space hospitals.
California has been a longtime national beacon in setting the agenda for complete maternal and youngster well being care. Maternal loss of life charges within the state are about half the national rate — though pre-term birth rates are solely barely under the nationwide common and sharp disparities persist for Black maternal and youngster well being outcomes. Now, suppliers and sufferers alike are dealing with a rash of maternity ward closings like people who have occurred across the nation, creating what have been referred to as “maternity deserts.”
These deserts typically are present in rural areas, however additionally they are popping up in city areas. An investigation accomplished by CalMatters, a nonprofit newsroom based mostly in Sacramento, discovered that since 2021, 29 hospitals within the state stopped delivering infants. Nearly 50 obstetrics departments have closed over the previous decade, and 17 have been in Los Angeles County.
For pregnant folks within the county, particularly Black and Hispanic folks whose communities are most affected by closures, the uncertainty and challenges are sometimes larger than these dealing with DeRoche. Not solely is their continuity of care affected, however the affect is amplified by being pressured to journey nice distances, doubtlessly with out transportation or youngster care, or the monetary assets to acquire them. Some hospitals gained’t settle for sufferers’ insurance coverage, and insurance coverage firms are gradual to make selections about prior authorization for sufferers to provide beginning out-of-network. Suppliers and community-based advocates work onerous to search out companies and fill in all of the gaps for pregnant individuals who have had their beginning plans upended.
“The state of affairs is slightly chaotic” for sufferers and suppliers proper now, stated Yohanna Barth-Rogers, chief medical officer of UMMA Group Clinic in Los Angeles. Sufferers might discover {that a} new hospital, unsure of who might include a possible high-risk being pregnant, is reluctant to take them on. Some sufferers are in the dead of night about who their constant supplier can be after they ship. That’s a paramount concern in the event that they or their infants expertise issues, and within the crucial six weeks postpartum, extending out to the primary yr after giving beginning.
“A variety of ladies are scared, notably ladies of colour, to ship their infants as a result of the outcomes are simply worsening on this nation,” Barth-Rogers stated. “It’s scary proper now to ship, it’s scary to not have your voice be heard.”
Suppliers, public well being consultants, and legislators instructed STAT they’ve been flummoxed by the alarming variety of maternity ward closures. The culprits cited in California, as elsewhere, embrace a declining beginning fee, staffing challenges (particularly since Covid-19 arrived in 2020), and the fixed lack of income to maintain labor and supply companies open. One other oft-cited motive is poor Medicaid reimbursement ranges for maternity care. Medi-Cal, California’s medical insurance program for low-income residents, has the nation’s fifth-lowest reimbursement fee for obstetrics, in keeping with CalMatters.
“The choice to shut maternity service is an agonizing one which our hospitals don’t come to simply,” stated Peggy Broussard Wheeler, vp of coverage for the California Hospital Affiliation, the trade advocate for the 400-plus hospitals statewide.
There are a number of elements that may make sustaining a labor and supply division that’s prepared for births year-round unsustainable, Broussard Wheeler stated. The pandemic put monetary stresses on hospitals usually. And maternity service bills specifically are excessive, typically solely second to that of emergency rooms.
As well as, the declining beginning fee, each in California and nationwide, signifies that “the employees functionality, employees competency for these high-risk deliveries shouldn’t be there and employees start to be involved that they’re not ready for a high-risk supply as a result of they’re not seeing sufficient deliveries,” Broussard Wheeler stated. “When employees begin coming to hospital management to say that they’re anxious about their capabilities, it’s one more reason these selections are on the desk.”
The concern that ‘one thing unhealthy goes to occur’
UMMA Group Clinic, in south Los Angeles, has 4 places serving principally Black and Hispanic sufferers. Barth-Rogers stated lots of the sufferers obtain care below Medi-Cal or they’re uninsured, complicating their seek for new hospitals if that they had been planning on delivering at one which closed.
Sufferers’ decisions could also be additional constrained in the event that they need to give beginning vaginally however beforehand delivered by cesarean part or in the event that they need to even have a bilateral tubal ligation — known as “getting their tubes tied” — to stop future pregnancies. Barth-Rogers identified that if a affected person has a high-risk being pregnant, it’s troublesome to ship them to someplace like Martin Luther King Jr. Group Hospital, simply exterior the L.A. metropolis limits, as a result of the hospital doesn’t have a neonatal intensive care unit and sometimes prefers taking up lower-risk pregnancies.
Some sufferers are selecting to ship at birthing facilities as a result of they’re not proud of the hospital choices out there to them in Los Angeles County, stated Barth-Rogers. She additionally stated her sufferers have expressed concern that “one thing unhealthy goes to occur” whereas they offer beginning, as a result of they’re anxious they won’t be listened to in new, unfamiliar settings.
However suppliers are doing one of the best they’ll below the circumstances, Barth-Rogers stated: With out the correct info handed on to them a few affected person who’s been transferred from one other well being system, they could not all the time know how one can present one of the best or most secure care doable, particularly if a affected person is high-risk. Sufferers are caught within the center between hospitals, docs, and insurance coverage firms — all whereas experiencing the stress of being pregnant.
“Not understanding what kind of care they’re going to be given after we ship them off to the hospital to ship, relying on who could be the supplier that day or what the state of affairs could be or how full the labor and supply division is, is absolutely difficult,” Barth-Rogers stated.
When Centinela Hospital Medical Middle introduced a yr in the past that its labor and supply unit would shut by Oct. 25, 2023, the hospital cited a declining demand for companies. However the hospital was being investigated by the state for neglect within the therapy of a Black girl, April Valentine, who died throughout childbirth there in January 2023, and her household filed a wrongful death suit in opposition to the hospital in August of 2023. Centinela, positioned in Inglewood near Los Angeles Worldwide Airport, was fined $75,000 by the state of California for “poor practices” in reference to Valentine’s loss of life.
The Centinela supply ward’s closure resulted within the suspension of 17 perinatal beds, 9 NICU beds, and the new child nursery, and 72 staff have been reassigned. The for-profit hospital, owned by Prime Healthcare, delivered about 800 babies yearly. Centinela transferred maternity companies to St. Francis Medical Middle in Lynwood, certainly one of its associates, and in its public discover additionally cited two different hospitals lower than 10 miles away with labor and supply companies, Martin Luther King Jr. Group Hospital and Windfall Little Firm of Mary Medical Middle Torrance.
Hospital executives “perceive the crucial want for maternal healthcare,” Brian O’Dea, a spokesperson for Centinela Hospital Medical Middle, stated in an e-mail assertion, and noticed that the state’s declining beginning fee created challenges for well being care suppliers. He stated the partnership with St. Francis Medical Middle would guarantee “continued entry to high quality maternity companies for our communities to assist anticipating moms welcome their youngsters into the world with the very best care.”
Pulling out a map
But it surely’s not so easy, stated Raena Granberry, director of maternal and reproductive well being for the California Black Ladies’s Well being Undertaking, for a pregnant individual to “simply go elsewhere to obtain care.”
At any time when Granberry will get a name that somebody must rapidly discover a new hospital to provide beginning at, she takes out a map that exhibits all of the hospitals within the state of California. She peppers the affected person with questions: What medical insurance do you have got? The place have been you initially going to provide beginning? What sort of supplier — an OB-GYN, a midwife, if any — did you have got?
“These [are] particular person individuals who get affected, after which all the things is simply occurring on this massive form of enterprise stage the place folks could make enterprise selections that don’t have anything to do with folks’s well being,” Granberry stated. “We might help them navigate [this] however… for a techniques change kind of assist, the issues they actually need and need to see and need to have entry to, [it’s] going to take years.” Granberry talks concerning the “private ache” she will be able to’t disconnect from when the incoming cellphone calls, textual content messages, emails, and even grocery retailer encounters remind her of how group members are being left behind.
It’s a “disaster,” she stated, that has sufferers immediately not understanding what to do or the place to show. The California Black Ladies’s Well being Undertaking tries to alleviate their burden by directing funds towards “filling in all these little gaps” that begin to add up for pregnant folks grappling with maternity care deserts. Granberry stated the group has paid for pregnant folks to get Ubers to get to their appointments in order that they gained’t must journey on the bus by themselves or with their youngsters; to purchase households meals in order that in the event that they get residence late they’ve one thing to eat; and to pay for lodge rooms as a result of households’ youngsters can not spend the night time within the close by hospital. Different instances, the group has given households a lump sum of money.
Since Centinela Hospital Medical Middle ended labor and supply companies, Granberry stated, pregnant persons are going to different locations in Los Angeles like Martin Luther King Jr. Group Hospital and Cedars-Sinai Medical Middle. The previous provides a midwife-led birthing mannequin, whereas Cedars-Sinai, regardless of being recognized for high-end maternity suites that draw celebrities, was additionally the topic of a federal probe in the death of Black woman, Kira Dixon Johnson, from inner bleeding hours after she gave beginning through C-section at Cedars in 2016. The medical heart at this time says it’s working onerous to reduce the Black maternal health gap.
‘De facto segregation’
There’s a transparent well being fairness affect from the closure of maternity wards in city settings, affected person advocates and consultants say. “This isn’t Cedars that’s closing down, it isn’t a spot for people with cash, or [where] numerous white persons are going to have their child, so we all the time have to start out with racism,” Granberry stated. “Racism is the rationale why we have now issues within the medical discipline on the hospitals and it performs out right here too.… We couldn’t be as dismissive [of maternity ward closures] if it wasn’t [happening in] an overwhelmingly Black and brown neighborhood.”
The fact is “if we actually care about fairness, and we care concerning the extent to which Black ladies and birthing persons are disproportionately and alarmingly impacted by this maternal well being disaster, then we have now to take a look at what’s occurring in city areas,” stated Alecia McGregor, an assistant professor of well being coverage and politics with Harvard College’s T.H. Chan College of Public Well being, who has studied city hospital closures nationwide.
A comparability of city space hospitals the place white folks and the place Black folks go to provide beginning typically demonstrates “de facto segregation,” stated McGregor. Her studies based mostly on hospital discharge knowledge have proven that at some hospitals in New Jersey there aren’t any deliveries amongst Black folks, whereas at different hospitals within the state greater than 90% of deliveries are accounted for by Black sufferers. McGregor stated this isn’t a phenomenon distinctive to New Jersey, but it surely exhibits how separate — and unequal — birthing experiences could be.
Methods to handle the issue, McGregor stated, would possibly embrace ensuring hospitals with majority Black sufferers have the tools and funding they want, and reforming the fee techniques in order that deliveries usually are not a monetary loss for hospitals. With Medicaid reimbursements so low, one route could be for the Facilities for Medicare and Medicaid Companies to undertake a reimbursement designation that’s based mostly on the fee that obstetric items serving weak communities really incur. CMS has such Critical Access Hospital designations for some rural hospitals. Whereas McGregor stated “even crucial entry hospitals proceed to shut,” there have been some instances of hospitals reopening after qualifying for such a designation.
McGregor stated it’s worrisome there aren’t extra options on the desk to assist hospitals and sufferers navigate this.
“Obstetric items are form of seen as cash losers for hospitals and that is particularly the case when these items are positioned in low-income and low-wealth communities, which, in city contexts in the US, are usually communities of colour —people who find themselves racially and ethnically marginalized,” McGregor stated. “There tends to be numerous overlap with concentrated poverty that’s been the sample of racial residential segregation on this nation in order that’s the rationale why we see maternity wards in Black and brown communities closing at a quicker fee.”
A invoice giving six months’ discover of closure
In California, the numerous closures have drawn the eye of legislators, who discover that their palms are nearly tied as a result of the state can not drive non-public hospitals to proceed companies, stated state meeting member Akilah Weber, an OB-GYN who represents California District 79, east of San Diego, and is chair of the meeting’s well being finances subcommittee.
She stated she and different legislators typically hear from constituents who’re touring lengthy distances to get to the closest labor and supply unit. And when Scripps Mercy Hospital Chula Vista introduced earlier this yr that it might be closing its maternity unit in June, folks exterior her district referred to as Weber, urging the state to do one thing to cease it.
“When folks take into consideration a supply, they consider this superb, great life-changing expertise, which it’s and that’s the best way it occurs most instances,” Weber stated. “After I consider a supply from an OB-GYN perspective, I perceive all the issues that might doubtlessly go incorrect and people issues can go incorrect in a matter of some seconds.” If households can’t entry a correctly staffed and geared up hospital, the outcomes “can change into disastrous not just for the mom but in addition for the kid.”
In California, hospitals are legally required to provide three months’ discover a few closure. However Weber stated it’s not sufficient time for the state to spring into motion to do what’s doable to cease it from occurring.
That’s why Weber filed a invoice that might require hospitals to inform the state if their maternity items are susceptible to closure within the subsequent six months. The invoice would additionally require the state to arrange a report concerning the closure’s affect on the group. The purpose of the laws, she stated, is to make sure entry to well timed info and knowledge about what number of infants are born on the hospital, its monetary state of affairs, and the workforce that could be affected. She stated the invoice would possibly even permit the state to supply funds to stop the closure from occurring.
Weber stated she initially wrote the invoice to require hospitals to provide one yr’s discover, however decreased it to 6 months after getting suggestions from the hospitals. For hospitals, there’s all the time a threat in getting ready not solely sufferers but in addition the well being care workforce for potential closure too far prematurely — finally reinforcing and presumably accelerating the method if, for instance, staff resign searching for new jobs.
Altering the mannequin of care
Some clinicians and public well being consultants consider that the hospital obstetrics ward closures are highlighting an inherent drawback with reliance on the hospital system.
It’s vital to think about “what a very good perinatal community of care may seem like within the state and within the nation,” stated Priya Batra, an OB-GYN and deputy director for the well being promotion bureau with the Los Angeles County Division of Public Well being. That, she stated, would imply shifting past a hospital mannequin of care to construct a various and strong community of beginning facilities, using midwives and doulas, that might result in constructive outcomes for infants and birthing dad and mom.
Altering birthing plans for households as a result of medical concerns or a maternity ward closure can typically trigger anxiousness and panic, stated Batra, and making midwives and doulas a part of the method can doubtlessly mitigate some stressors in order that households usually are not alone. However advocates word that the state of California hasn’t made it straightforward for birthing centers to function, and there have been some latest closures of such facilities as effectively.
Batra additionally works on the manager committee with the California Maternal Quality Care Collaborative, which brings state businesses, hospitals, and well being supplier associations collectively to search for methods to stop being pregnant issues and deaths. She stated the group has studied the affect of maternity ward closures, and that the journey burden has been best in rural areas of California, however exists for a lot of throughout the state.
The following steps for the group, Batra stated, embrace finding out what occurs to households in city areas the place there could also be different beginning facility choices out there however that “nonetheless could also be far sufficient away from their normal supply of care or their household networks, that it impacts the beginning expertise and beginning outcomes.”
The wrestle for suppliers dealing straight with sufferers whose lives are upended by the closures is that these sufferers want options — and instantly. UMMA’s Barth-Rogers stated she strives to assist her sufferers nonetheless she will be able to. However she worries concerning the future.
“When there was that continuity, and we have been capable of actually companion with one or two hospitals, one for high-risk and one for different sufferers, it was streamlined,” Barth-Rogers stated. “Now we’re coping with all these totally different hospitals, all these totally different techniques, totally different insurances…the panorama has simply change into far more difficult.”
This story is a part of ongoing protection of reproductive well being care supported by a grant from the Commonwealth Fund. Our monetary supporters usually are not concerned in any selections about our journalism.
