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November 29, 2021

Rural birthing options dwindle as hospitals slash labor and delivery services

Photo | CT Mirror Preparation for a rally in favor of access to safe birthing in rural Connecticut communities.

People in some of the more rural parts of the state face fewer birthing options as three hospitals move to suspend labor and delivery services.

Executives at Windham Community Hospital, Sharon Hospital and Johnson Memorial Hospital plan to halt their hospital’s birthing services, citing a mix of financial challenges, patient safety concerns and difficulty recruiting OB-GYN healthcare providers.

In the past decade, only two labor and delivery units in the state have closed. Now, three birthing units are suspending services, and they all service rural areas. If all the closures become permanent, the state would be left with only one rural labor and delivery unit: Day Kimball Healthcare in Putnam.

A 2017 study found that, between 2004 and 2014, 9% of rural counties lost labor and delivery services, and more than half of rural U.S. counties do not have any delivery services at all. The lack of services comes down to financial challenges that birthing units present. 

“Labor and delivery is a loss leader when it comes to hospital revenues,” explained Sarah Benatar, a principal research associate at the Urban Institute whose work includes a study on the effects of rural labor and delivery units in New Hampshire. 

Not all rural communities are equally affected. Rural counties with higher rates of Medicaid coverage, poverty, and Black and indigenous residents are the most likely to face reductions in birthing services.  

In Connecticut, before a hospital can make any major changes to its service offerings, it must apply for a certificate of need and receive approval from the Office of Health Strategy. As part of that application process, the institution must provide evidence supporting the proposed changes, answer questions from OHS officials and listen to comments from the public. 

Windham Hospital, owned by Hartford HealthCare, is furthest along in this process. 

OHS held a public hearing on Nov. 10, where Windham executives cited patient safety concerns and difficulty recruiting health care providers as their main reasons for the proposed closure. In 2015, the hospital lost a major OB-GYN practice, making it more difficult to keep the unit fully staffed. In 2017, an outside consultant, hired by Windham, recommended closing labor and delivery due to low birth volumes. In 2020, Windham had the fewest births of any hospital in the state.

Members of the community question the validity of the claim regarding the number of births. 

Several years ago, the hospital stopped offering to perform certain types of births, like vaginal births after c-sections, driving down the number of births at the hospital. They’re also concerned that Windham’s announcement of its intent to close further diverted potential deliveries. 

“It comes down to both sides saying it’s unsafe. We say it’s unsafe for people to have to travel down Route 32 or up Route 6. They say it’s unsafe because there’s a low number of births. We say, there’s a low number of births because you made that happen,” explained John Brady, a registered nurse and the executive vice president of AFT CT, a union that represents 30,000 members, including nurses and healthcare professionals. 

Experts agree that concerns about patient safety are valid but that it has become a common reason hospitals give for closing labor and delivery units, often without sufficient evidence.

“That’s an important consideration, but there are also ways around it. And it’s sometimes used because it’s easier to say than ‘We just can’t make it work financially,’” said Katy B. Kozhimannil, a professor of public health policy at the University of Minnesota. 

Kozhimannil added that the relationship between patient safety and birth volumes isn’t clear.

“The work that we have done looking at the relationship between birth volume and quality of care in rural hospitals has shown a mixed bag. There are a lot of ways in which low-risk childbirth is very well done in low birth volume settings,” she said. 

OHS officials requested additional data from Windham regarding how the closure would affect driving times for the area’s birthing population and a demographic breakdown of the people giving birth at Windham, including socioeconomic status and English language proficiency, so they could better understand the population that the closure would affect.

Of the three hospitals, Windham serves as the most typical example of the rural hospitals across the country that are most at risk of losing labor and delivery. 82% of Windham’s OB-GYN patients are on Medicaid, and a significant portion of the population does not speak English as a primary language. The Willimantic community, in particular, has high poverty rates, low rates of vehicle ownership, and poor public transportation options. 

Ilda Ray, a member of the Willimantic Board of Education and chairperson of the Windham/Willimantic NAACP’s education committee, said it’s difficult to understand how residents are supposed to get to Backus Hospital in Norwich, the Hartford HealthCare facility where most of Windham’s births have been done since the suspension of services.

Ray gave birth at Windham Hospital and said that one of her main concerns is transportation for family and friends of people who will now have to give birth at Backus. 

“Some of the folks that came to visit me while I was [at Windham] don’t have transportation to Norwich. The bus lines are very, very few and far between in these small towns,” said Ray. 

Windham Hospital has said it would take care of ambulance transportation for deliveries but did not respond to request for comment regarding how it would support transportation of family or for any prenatal or postpartum appointments.  

In the case of Sharon Hospital, owned by Nuvance Health, executives claim that, even though the birthing unit maintains high levels of quality and patient safety, it’s just no longer commercially viable. 

In a statement, Nuvance Health spokesperson Andrea Rynn said, “Underutilization, continuing low birth rates, the challenge of attracting and retaining clinical talent and year-over-year program losses are the primary reasons for the planned closure.”

She also noted that, before deciding to suspend labor and delivery, Nuvance had made significant efforts to keep the unit open, including promoting birthing services and examining other, more financially viable models.

Sharon Hospital came under the ownership of Nuvance Health in 2019, when Western Connecticut Health Network merged with Health Quest to create Nuvance. OHS approved the merger on the condition that Nuvance would keep Sharon’s maternity and obstetrics services for a period of five years. 

Now, two years later, they say that’s just not possible. 

An obstetrics unit, like an emergency room, has to be fully staffed 24/7, with OB-GYNs, nurses, anesthesiologists and surgeons who can perform c-sections. In areas with lower birth volumes, that can be difficult to sustain, from both a financial and recruiting perspective. 

“Many, many rural hospitals will keep their obstetric unit open even though it loses money because it matters to the community,” said Kozhimannil, but she added that it’s definitely “tough math.”

As for challenges in retaining health care professionals, Benatar from the Urban Institute confirms that staffing and recruitment is a major concern among rural labor and delivery units. The schedule for staff can be brutal, and there is a generational shift occurring among younger OB-GYNs who don’t want to work hundred-hour weeks. 

Johnson Memorial in Stafford suspended its labor and delivery services, among other units, in April 2020. At the time, COVID-19 was raging, and the hospital pivoted to meet the needs of the pandemic. Theoretically, it should have restarted labor and delivery when the needs of the pandemic subsided, but, in September 2021, the hospital told labor union AFT CT that the suspension would be “indefinite.” 

A spokesperson for Trinity Health, which owns Johnson Memorial, cited “steadily declining demand,” “pandemic-related staffing challenges” and “difficulty in recruitment of new, qualified staff” as reasons for the suspension but added that “to date, we do not have intentions of permanently closing the unit.” 

However, Johnson Memorial never got state approval for the indefinite suspension of these services, raising a potential loophole in the certificate of need process. The statute requires hospitals to go through the certificate of need process for any termination of services, but by calling it an “indefinite” suspension, Johnson Memorial seems to have sidestepped the process and kept its labor and delivery unit closed without permission for several months.

Just last week, OHS notified Johnson Memorial that it must either resume labor and delivery services or formally apply for a certificate of need. 

Community members also have concerns about how Windham and Sharon Hospital have handled the certificate of need process. The last delivery occurred at Windham in June 2020, but the hospital didn’t apply for a certificate of need until September 2020. Sharon announced its intent to close labor and delivery in September 2020 and still has not applied for a certificate of need. 

“That’s a big problem. The intent of the certificate of need process is not for you to do what you want and then ask permission,” said Brady of AFT CT. 

State Rep. Maria Horn, D-Sharon, added that in the case of Sharon Hospital, announcing an impending closure before actually obtaining permission naturally results in the labor and delivery staff looking for new jobs. 

“And then, by the time they apply, they can say, ‘Well, we tried, but gosh, we just can’t staff it.’” 

In a Nov. 4 meeting with community officials, Sharon Hospital President Mark Hirko said the hospital is in the process of putting together its application. 

Tina Hyde, a spokesperson for OHS, confirmed that the suspension of services before obtaining a certificate of need violates the certificate of need statute. Yet both Windham and Johnson Memorial suspended services before obtaining a certificate of need. 

Ultimately, decisions to close labor and delivery units are complex because there are no hard and fast benchmarks. 

Kozhimannil noted that there isn’t a “magic number of minimum births” from a financial or safety perspective that means the unit should close. Instead, hospitals and government officials need to assess the local conditions because, ultimately, it is the community that bears the weight of the closure.

“When the hospital closes its unit and decides that the risk is too much to bear, either financial or safety, that risk does not go away. It goes back to the community. Those families then bear that risk,” said Kozhimannil. 

When considering the closure of a rural labor and delivery unit, policymakers need to figure out, first, whether something can be done at the state level to get the hospitals back to a viable place, whether their challenges are financial, safety or staffing related. If that’s not possible, they need to put a plan in place to support the community, she said.

“We cannot have a labor and delivery unit in every community. That’s just not possible. But we know what happens when one leaves, so we need to plan for that.” 

Currently, each of the hospitals plans to retain its prenatal and postpartum care, meaning birthing patients could still have that care provided locally, but they would give birth at a different facility farther from home. 

Though many community members have voiced concerns about this model, Kozhimannil says it is common and can help ease the transition when a labor and delivery unit closes. 

One of the main effects of labor and delivery closures in rural towns near city centers, like the ones in Connecticut, is a temporary increase in emergency room births. To plan for this, health officials need to ensure communities are prepared for an increase in emergency births and that emergency rooms are trained in emergency obstetrics. 

Other measures, like an increase of investment in public health resources, transportation and telemedicine can also help. 

“I think there are lots of ways to solve the problem. I think the point is to just not drop the ball on the community,” said Kozhimannil. 

CORRECTION: A previous version of this story incorrectly reported that birthing services at Sharon Hospital have halted. The hospital plans to close the birthing unit, but it still operates.

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