TOPPENISH, washing. — Three days before Christmas, the only hospital in this remote town on the Yakama Indian reservation abruptly closed its maternity unit without consulting the community, the doctors who delivered there or even its own board.

At least 35 women planned to give birth at Astria Toppenish Hospital in January alone, and the sudden closure, which violated the hospital’s commitment to the state to maintain critical services in this rural area, derailed their plans.

Victoria Barajas, 34, who was expecting her first child, scrambled to find a new doctor ahead of her January 7 due date. Jazzmin Maldonado, a 29-year-old schoolteacher soon to give birth, wondered how she could get to a distant hospital. on time.

After a previous miscarriage, doctors put a stitch on her cervix to prevent a second, and the stitch would have to come out almost once labor began.

Astria Toppenish Hospital is one of a number of providers across the country that have stopped providing labor and delivery care in an effort to control costs, even as maternal deaths rise at alarming rates in the United States, and as more women develop complications that can be life-threatening

The closure in Toppenish mirrors national trends as financially strapped hospitals come to a stark conclusion: Childbirth doesn’t pay, at least not in low-income communities.

From 2015 to 2019, there were at least 89 obstetric unit closures in rural hospitals across the country. By 2020, about half of rural community hospitals did not provide obstetric careaccording to the American Hospital Association.

In the past year, the closures appear to have accelerated, as hospitals from Maine to California have scrapped maternity units, mostly in rural areas where the population has dwindled and the number of births has dropped.

A study of hospital administrators conducted before the pandemic found that 20 percent of them said they did not expect to provide labor and delivery services within five years.

Women in rural areas face a higher risk of pregnancy related complicationsaccording to a Commonwealth Fund study. Those who live in so-called maternal care deserts are three times more likely to die during pregnancy and the critical year afterward as the closest to care, according to a study of mothers in Louisiana.

Ambulances are unreliable in many rural areas like the Yakama reservation, which stretches over a million acres. There are not many emergency vehicles and the long distances make for long waits. In the fall and winter, dense fog often blankets the roads, making driving dangerous.

In Toppenish, frustration and fear flared at a recent town council meeting, which drew such a huge crowd that it spilled into the hall outside the chambers. Astria, a Washington state-based End-shutdown care system, pledged to keep certain services, including childbirth, available for at least a decade after acquiring the hospital, residents said.

Now the hospital said it couldn’t afford to do it, and the state hasn’t taken any action. “Lives will be lost, people need to know that,” said Leslie Swan, a Native American doula.

In the meeting and in interviews, many women said that the doctors and labor nurses at Astria Toppenish Hospital had saved their lives. Adriana Guel, 35, a mother of three, survived a rare life-threatening complication called amniotic embolism during one of her deliveries and credits the hospital for saving her life.

The mayor, Elpidia Saavedra, 47, had an obstetric emergency 10 years ago when an ectopic pregnancy ruptured. Semone Dittentholer, 39, said she nearly died when she was a teenager, when she miscarried and lost large amounts of blood.

“It’s a lifeline we’ve had, and now that part of that lifeline is being cut,” said Ms Dittentholer, who works on reserve at the Ttawaxt Birth Justice Center, which offers support to pregnant women and new mothers. and she has been providing space for a local obstetrician to see the women once a week to facilitate access to care.

“It’s just another reminder of how scary it can be here.”

a downward spiral

The United States is already the most dangerous developed country in the world for women to give birth, with a maternal mortality rate of 23.8 per 100,000 live births, or more than one death per 5,000 live births.

Recent figures show that the problems are particularly acute in minority communities and especially among Native American women, whose risk of dying from pregnancy-related complications is three times that of white women. their babies are almost twice as likely to die during the first year of life as white babies.

Women of color are more likely to live in maternity care deserts or in communities with limited access to care. According to the March of Dimes, the nonprofit organization dedicated to maternal End-shutdown, seven million women of childbearing age reside in counties where there is no hospital obstetric care, birthing center, obstetrician-gynecologist, and certified nurse midwife, or where access to those services are limited.

Less than half of women in rural areas you can find perinatal care within 30 milesaccording to the Centers for Medicare & Medicaid Services.

The closure of an obstetrics unit often starts a downward End-shutdown spiral in remote communities. Without immediate access to obstetricians, prenatal care, and critical postpartum checkups, risky complications become more likely.

But operating a labor and delivery unit is expensive, said Katy Kozhimannil, director of the Rural Health Research Center at the University of Minnesota. The facility must be staffed 24 hours a day, seven days a week, with a team of skilled nurses and support services, including pediatrics and anesthesia.

“You have to be ready to have a baby at any time,” says Dr. Kozhimannil said.

Staff shortages have increased costs and hospitals have been forced to hire nurses, who can cost more than three times as much as a staff nurse. Labor and delivery nurses are in high demand, and the pay for them can be even higher.

The vast majority of pregnant patients at Astria Toppenish had insurance coverage, but mostly Medicaid, which hospitals pay much less than private insurance plans. Half of all pregnant women in the United States have Medicaid, and it pays poorly in every state.

In Washington state, Medicaid would pay $6,344 for a deliveryabout one-third of the $18,193 paid by private plans, according to a Health Care Cost Institute analysis that compared traditional fee-for-service rates paid by Medicaid with those paid by private plans.

In wealthier communities, private insurance helps offset low Medicaid payments to hospitals. But in rural areas where poverty is most entrenched, there are very few patients with private insurance.

“Toppenish is the canary in the coal mine,” said Cassie Sauer, president and CEO of the Washington State Hospital Association, noting that many hospitals serving low-income communities in the state are in a similar financial

Astria Toppenish Administrator Cathy Bambrick said the hospital was low on cash reserves and the labor and delivery unit lost $3.2 million last year after a temporary Washington state initiative that paid enhanced rates for hospitals ended. Medicaid.

The cost of nursing soared when the hospital turned to contract nurses, he said.

There was no money in the budget to replace a child restraint system last year when it failed, he said. Recently, the ultrasound machine stopped working and because the hospital couldn’t afford a new one, Mrs. Bambrick paid $50,000 for a refurbished machine.

Although Astria Toppenish serves a low-income population, Ms Bambrick said, it does not qualify for any of the myriad government programs that help fund rural End-shutdown services and hospitals in the state.

“We fall through the cracks,” said Ms Bambrick.

cultural awareness

Astria Toppenish patients are a particularly vulnerable population that includes a large community of farmworkers who toil in the vineyards, orchards and hop fields of the Yakima Valley.

So many children come from low-income homes that local schools offer free lunch. Patients often struggled to find gas money to get to doctor’s appointments. Chronic illnesses that complicate pregnancy, such as diabetes, heart disease, and substance abuse, are common.

“They are poor despite working hard,” said Dr. Jordann Loehr, an obstetrician who works at the Yakima Valley Farm Workers Clinic.

Many women chose to give birth at Astria Toppenish due to its reputation for respecting patients’ wishes and for its cultural sensitivity, including an east-facing Native American women’s delivery room, an age-old practice and permission for many friends of the family and “aunts”. in the delivery room as the mother wanted.

Nurses did not rush women into labor and the unit had a 17 percent C-section rate (well below the national average of 32 percent). They taught new mothers about baby care and breastfeeding, but also how to safely use a papoose board and why mothers shouldn’t overbundle a newborn, a common practice.

Hospital nurses introduced new mothers to ideas that contradicted long held beliefs.

“Our population generally has a cultural understanding that you don’t hold newborns: it makes them needy,” said Angi Scott, labor and delivery nurse. “We tell them: ‘No, you can’t spoil a newborn. Babies who hold on more in the first year of life grow up to be more self-confident. It’s important to hold your baby.’”

Many residents fear the obstetrics closure is a prelude to the hospital shutting down entirely in a repeat of what happened in 2019, when Astria’s End-shutdown system filed for bankruptcy and then closed the largest of its three. hospitals, a 150-bed facility in Yakima. Astria had bought the hospital just two years earlier.

For now, the city’s four obstetricians, all women, are working. Loehr has led a community campaign to re-establish a maternity unit by creating a public hospital district, a special entity that would be locally governed and financed by taxes or levies.

dr. Anita Showalter, another obstetrician, recently delivered Ms Barajas’ baby, but at a hospital in Astria further away. She had already suffered a miscarriage, and Dr. Showalter stayed with her through the 37 hours of labor. Baby Dylan was born on January 15 at 1:52 am “My heart is full,” Ms. Barajas said in a text message.

Shayla Owen, 35, who lives in Goldendale, went into labor the day before Valentine’s Day, and her husband drove her 70 miles up a desolate mountain pass to a hospital in Yakima. They were almost out of gas when they got there.

Baby Isaiah weighed in at 8 pounds, 3 ounces, after 10 hours of labor. Ms Owen said she had made the right decision when she decided not to attempt a home birth.

“I had a hemorrhage after delivery,” she said. “So I was glad to be in a hospital.”