Obstetrics Story Archives - West Virginia Public Broadcasting

Diminishing OB Care In Rural America

For struggling rural hospitals, obstetric and prenatal services tend to be some of the first on the chopping block. Over the past decade, 89 rural hospitals across the country closed their obstetric units. And when medical options shrink — rural families have to make hard decisions about how and where to get care.

Children are the future — it’s a common refrain. However, in isolated, rural communities across America, there are people traveling many miles from their home to deliver babies.

Since 2010, nearly 150 rural hospitals have shut down — a victim of the financial stresses facing U.S. health care. One survey finds that about 40 percent of rural hospitals lose money offering obstetric care, since it costs $18,000 on average to have a baby.

So, when small hospitals look at cost-cutting measures, delivery and obstetrics units are often casualties. Just under 10 percent of rural hospitals have shut down their delivery services.

For this Us & Them episode, host Trey Kay hears from families facing that change, and how it’s affecting prospects for their rural cities and towns.

This episode of Us & Them is presented with support from the West Virginia Humanities Council and the CRC Foundation.

Subscribe to Us & Them on Apple Podcasts, NPR One, RadioPublic, Spotify, Stitcher and beyond.

Amy and Jacob Staton live in Williamson, West Virginia — population 3,000. They love living in the southwest corner of the state. It’s a quiet community for raising their family. They had their first kid in 2014. Two years later, Amy was pregnant again with twins. That made her healthcare a lot more complicated — before and after birth. She faced a greater chance of emergencies — such as possible problems with the placenta or miscarriage. Twins tend to be born premature.

In all of these scenarios — minutes matter.

And in the handful of years between her first and second pregnancies, Amy’s access to obstetric care changed. Williamson Memorial Hospital — five minutes away from her house — stopped offering OB services. The only hospital in the area with a neonatal ICU is located around forty minutes away from the Staton home.

Amy and Jacob are presently expecting their second set of twins.

Credit: Trey Kay/West Virginia Public Broadcasting

Dr. Dino Beckett is the CEO of Williamson Health And Wellness Center and a practicing family physician in Williamson, West Virginia. He says when rural hospitals struggle financially, obstetric and prenatal services tend to be some of the first on the chopping block. That’s exactly what happened to Williamson’s hospital in 2014.

“None of us were happy,” Beckett told Us & Them host Trey Kay about the closing of Willamson Memorial Hospital. “Two of my children were born at that hospital. So it was something that we didn’t want to do — but you know, we weren’t the ones calling the shots. And I mean, when you look at it financially, it was just one of the things that — they couldn’t provide other services if they continue to do those and then it would put us at further risk of closure.”

In the following years, 89 rural hospitals across the country closed their obstetric units. And when medical options shrink — families have to make hard decisions about how and where to get care.

Learn more about the Williamson Health and Wellness Center.

Credit: National Rural Health Association

Carrie Cochran-McClain has focused on rural health care for 20 years. She’s the policy chief for the National Rural Health Association. And these days, her work puts a spotlight on the medical reality for places like Williamson, West Virginia.

“One of the things about rural health is that it is a microcosm for what we see in our larger healthcare delivery system,” Cochran-McClain explained to Us & Them host Trey Kay.

It’s not like rural America was once overflowing with high-tech labor and delivery units. Cochran-McClain says diminishing access to rural health care fractures something essential to small communities.

Learn more about the National Rural Health Association.

Birthing Facilities Continue to Close in W.Va., Decreasing Access to Care

Fifty years ago there were around 65 birth facilities in West Virginia. Now, there are only 24, which means pregnant women have to travel farther to give birth and, often, for prenatal care.

Take Deana Lucion, for example. Lucion was 20 weeks pregnant when the last remaining obstetrician in McDowell County retired, effectively closing Welch Community Hospital’s birthing services.

In addition to being pregnant, Lucion has a number of preexisting health conditions, including a heart problem — making consistent access to care particularly important for her.

“I went a month with struggling with getting my Lovenox shots, which is a blood thinning shot, I struggled with that and then I didn’t see a doctor for one full month,” she said.

She said she didn’t know the doctor would be leaving until she went in for an appointment one day.

“[The doctor] basically tells all of his patients, gives our records to us, and [says] we have to go,” she said.

As it turns out, Lucion still could have been seen at that facility. She didn’t realize Welch would continue to provide prenatal and non-delivery services with help from a physician group in Beckley, even though delivery was no longer supported births.

So, it took her about a month to find and get in to see a doctor in Bluefield — about an hour away, which is where she’ll deliver.

“We know that accessing transportation is a huge issue for many West Virginians,” said Amy Tolliver, director of the West Virginia perinatal partnership.

Lucion’s hour-long travel time to obstetric care is not unusual in West Virginia. As of August of 2017, 30 of West Virginia’s 55 counties lack a birthing facility, meaning the majority of West Virginia women have to drive more than 30 minutes — sometimes as far as a couple hours — to access care.

“Without access to transportation or being able to get off of work, it takes nearly an entire day for some expecting mothers who would have to drive an hour and a half each way to their provider — which has a huge impact on compliance of care and attending their prenatal visits,” said Tolliver.

According to the National Institutes of Health, prenatal visits can help prevent complications in pregnancy and assist with a healthy birth.

Prenatal visits are particularly encouraged for women considered “high risk.” This term encompases a variety of conditions including obesity, smoking while pregnant and women with preexisting health conditions.

But Lucion doesn’t have a driver’s license and her husband works the night shift in a coal mine. So when she has an appointment, he has to take her.

“I’d have to call in at the mines,” she said when asked what happens if she goes into labor while her husband is at work.

“The outside man would have to radio in to him, which takes about 25-30 minutes for him to get out of the mines himself. Then, more than likely I would have to get in the vehicle and drive up to him to get there.”

Asked about her lack of a license Lucion simply replied: “I got to do what I got to do.”

Tolliver said there’s a variety of reasons for birth centers closing.

“So, one is, yes if you have diminishing populations within certain counties and certain areas you would have lower numbers of births,” she said.

Birth is an expensive service to provide since you need staff on call 24-hours a day. When a hospital or center sees low volume it can be too expensive to continue offering services.

Additionally, small hospitals and facilities consistently struggle to recruit specialized providers to rural areas.

“West Virginia is not in this by itself. This is a rural health issue that the rest of the nation is really experiencing as well,” Tolliver said.

And Tolliver said the problem is unlikely to get better without creative policy solutions and more dollars for recruitment.

Lucion said she is done with childbearing after this baby, but that for other women in her community, having access to local prenatal care would make all the difference in the world.

Appalachia Health News is a project of West Virginia Public Broadcasting, with support from the Benedum Foundation, Charleston Area Medical Center and WVU Medicine.

Home Birth in Appalachia

A couple listens to Sarah (holding her newborn) talk about her home birth experience with Joanna Davis.

In a tiny basement living room in southwestern Virginia, two women and their husbands listen to Joanna Davis talk about what might go wrong during their births.

“So this is an Ambu bag, and if your baby was in trouble and needed help breathing this is what we would use,” she begins.

Davis is a home birth midwife based in southwestern Virginia, but serves a significant swath of central Appalachia. Several months ago, she held a birthing class for two families interested in using her services.

During the class, Davis and an apprentice went over every instrument and scenario – both good and bad – that could possibly occur during a birth. Davis says she requires all families to attend the classes so they know exactly what they are getting into.

Despite a nationwide increase in home births in the last few years, the percentage of women choosing this option remains less than 1 percent throughout most of Appalachia. But many who turn to home birth, like the two women in Davis’ living room, cite the desire to control their birthing experience and eliminate what they perceive as unnecessary medical interventions.

“Most of my philosophy of practice is that moms and dads do a great job of getting babies in there and they do a great job of getting babies out,” said Davis. “I really love when the dads catch the babies, when they are super in-tune and involved and all of that. I’ll step in when they need me to, but most of the time I feel like my job is to create a safe place where they can do their work.”

This is Sarah’s sixth baby and the first that was born at home. She said if she has a seventh she will not return to a hospital.

Davis worked for about ten years as what’s called a direct entry midwife – she didn’t have official training – but learned through careful studying, researching and shadowing other midwives. In January of 2015 she decided to pursue licensure and passed the necessary requirements to become a certified professional midwife – a designation recognized in Virginia, but not in Kentucky and West Virginia, although both Kentucky and West Virginia are currently working on legislation that would change that.

She said when she first started, the women she served were “super conservative on one end and super ultra liberal hippie, crunchy (‘those people’), and now we really are finding people that [are along that] whole spectrum [who] are much more interested in owning the experience of their own birth and wanting to be more comfortable and in control of their own births.”

Stereotypes May No Longer Fit for Families Choosing Home Birth

Cassandra Harvey holds her daughter at her Morgantown home.

At a pretty, upper-middle class Morgantown home, Cassandra Harvey’s baby is gurgling happily.

“My husband is a physician – he’s trained to deliver babies – but most OBs that work in a hospital setting, they’re actually surgeons, so they are trained to deal with things that come up that are not part of the normal birthing process,” she said.

Harvey has three children – the first was born in a birthing center, the second in a hospital, and the third at her Morgantown home. Harvey did later clarify that her husband is a general practitioner, not an obstetrician, and that his training in birth occurred as part of an obstetrics rotation in medical school.

Angel holds her daughter in Harvey’s Morgantown home. After a traumatic hospital birth with her second child, Angel choose to pursue home birth. Angel and Harvey’s daughters were born within six weeks of each other using the same home birth midwife.

“I will say that at first he was a little unsure about the whole home birth process, which is why we had a midwife even though he’s a doctor and could have handled it on his own,” she said. “But he said it was important to him that he get to just play the dad and not have to play the medical provider as well.”

Harvey was adamant that having a homebirth doesn’t mean she’s uneducated or reckless – two accusations she heard over the course of her pregnancy – but rather that she was hyper-educated – she knew exactly what she wanted, what the risks were and how to choose a provider who would help her achieve her goals.

“Most women, if they are low risk, can have a healthy delivery without any kind of intervention,” she said. “But in a hospital they are looking for those things. So when you have a intervention it can snowball and when I say on my terms I want it to be completely the way nature intended it to be without someone looking for a reason to create or have an intervention.”

This is not to say that all home births always go well or that everyone has a good experience with it. Almost all the mothers I talked to I met through the midwives who served them. So consequently, the population sample was enthusiastic about home birth.

Obstetricians Urge Caution

Doctor Dara Aliff is a Charleston-based OB/GYN. “I currently have in my practice two women who have documented PTSD from home births gone awry and are seeking care for that,” she said. “And so I think the idea that it can’t go wrong just because it’s in your house is completely false.”

Eva Gutierrez stands at the window of her home in Thomas, West Virginia. In this photo Gutierrez is just ten-weeks pregnant with her first child, but had decided to pursue home birth because it felt like a more holistic path.

While Aliff says she isn’t totally against home birth like some of her colleagues, she strongly cautions against what she calls “home birth at all costs,” and urges women to choose their providers carefully.

“I can’t think of a situation where I would say to someone, ‘Gosh you are just an ideal candidate to do that,’ because you never know who’s going to be the one, who’s going to be the one who all of a sudden isn’t. And that can happen quickly.”

The official viewpoint of the American College of Obstetrics is that “hospitals and birthing centers are the safest setting for birth.” However, the College “respects the right of a woman to make a medically informed decision about delivery.”

A little data to further muddy the waters. According to the Committee on Obstetric Practice, women who have planned hospital births are twice as likely to have a C-section as those who have chosen to give birth at home. However, planned home births are also associated with a two to threefold increased risk of neonatal death when compared with planned hospital birth.

Midwife Joanna Davis, whom we talked to at the beginning of this story, says she attends 12-24 births a year. This past year was her busiest year on record. Still, home births in the three states that she serves – West Virginia, Virginia and Kentucky – account for fewer than 1 percent of all births, according to the Centers for Disease Control and Prevention.

Appalachia Health News is a project of West Virginia Public Broadcasting, with support from the Benedum Foundation.