Options for maternal care dwindle in rural Iowa

Jessica Sheridan's plan was to have her first daughter at the hospital just five minutes away from her Iowa Falls house. But when she was seven months' pregnant, that suddenly changed.

'I think October is actually when we learned that the labor and delivery unit was talking about closing,” Sheridan said, recalling the final months of 2018. 'Obviously, we were, like, kind of in a panic. We're like, ‘Oh my gosh, like, what are we going to do?'”

As her due date neared, she fought to keep the rural unit open in Iowa Falls, a Central Iowa community of just over 5,000 people. She delivered a petition with 800 signatures to hospital officials, but Hansen Family Hospital nonetheless closed the unit in November.

'I really genuinely believe that, that nobody was happy,” she said. 'Nobody at the hospital. It was ... something that was inevitable, I guess.”

The closure sent Sheridan scrambling, just two weeks before her due date. She started traveling to a hospital in Ames - an hour away.

'We had to do all of our remaining visits in Ames to kind of get to know those doctors down there,” she said, 'because there's multiple labor and delivery doctors that deliver down there.”

Sheridan delivered daughter Arya in mid-December. Though she was pleased with her experience at the Ames hospital, she and her husband worried about the winter weather leading up to the due date.

'We were lucky. It was nice weather,” she said.

‘A perfect storm'

Hansen Family is hardly the only hospital facing this tough choice. In the past two decades, nearly three dozen small Iowa hospitals have stopped delivering babies. And Hansen Family was one of eight hospitals that stopped delivering in 2018, the most in one year, according to the Iowa Department of Public Health.

Unity Point Hospital in Marshalltown was the most recent hospital to announce it will stop delivering babies.

Officials at Hansen Family decided that labor and delivery care was too expensive for an aging, rural community with a declining birthrate, said Chief Executive Officer Doug Morse.

'One of the hardest lessons that we learned as a community was to deliver those 86 babies, this hospital was losing nearly a million dollars,” he said.

After months of public meetings, hospital officials opted to use half the money they would save to start a mental health program for seniors.

'It really did become fairly clear that people recognize that this wasn't necessarily - delivering babies isn't necessarily a service that matches an elderly population,” he said.

Iowa's aging population is a key reason for these closures, said Stephen Hunter, vice chair of obstetrics at the University of Iowa Hospitals and Clinics in Iowa City.

'Some rural counties have lost as many as 40 percent of their population in the last three decades,” he said. 'That's a lot of people gone, unfortunately. That leaves a system that's not adequate for those that remain in those counties, and areas.”

Hunter said there are several other reasons that contribute to closures - what he calls a 'perfect storm.”

'Medicaid reimbursements are so low for OB that hospitals can't survive,” Hunter said.

According to numbers from the UI, Medicaid - government-funded insurance for those with low incomes - reimbursed its hospital last year about a third of what commercial insurance plans did for services like ultrasounds and deliveries.

In Hardin County, where Iowa Falls is located, 44 percent of births were Medicaid-funded in 2018, according to data from the Iowa Department of Public Health.

Hunter said the state also face a severe shortage of OB/GYNs and family practice doctors who practice obstetrics.

The state ranks 49th for the number of practicing OB/GYNs. There are only 1.49 doctors per 10,000 women, according to the American College of Obstetricians and Gynecologists.

'Most of those OBs are practicing in urban areas, not rural areas,” Hunter said.

This was one of the factors that started Hansen Family's conversation to close the unit.

The hospital's family practice doctor, who was doing most of the hospital's deliveries, left in November, Morse said.

'It became a system very much dependent on just a few people,” he said. 'As we all know - or maybe people don't know - ... being on call 24/7/365 to deliver babies in this environment is very difficult.”

Studies show there can be negative side effects when rural communities lose obstetrics units. A 2017 University of Minnesota study found that the loss of labor and delivery units in smaller, remote counties is linked to a decrease in prenatal care and an increase in out-of-hospital and preterm births.

‘Reality point of view'

At her office near downtown Iowa Falls, Diana Thies, the director of the town's Chamber of Commerce, said the hospital is one of the pillars of the local economy.

'That's one reason people do move here or decide to stay here, is because there is a hospital,” she said.

She was disappointed when hospital administrators approached her last fall with news that the labor and delivery unit would be shuttered, but she understood the financial strain the hospital was under.

'I also don't want to lose our hospital. So if taking one department out, and being able to financially - the hospital thrive financially - then I'm OK,” Thies said.

For Mayor Gene Newgaard, there is an emotional tie to losing the unit. He was born in Iowa Falls, like his mother and brother were.

'You think about the fact that, well, nobody going forward is going to - unless it's an emergency - is going to actually be born here,” Newgaard said. 'You know, they're always going to say they're born somewhere else.”

Hansen Family's Morse said the hospital decided to put a 'share care” program in place once it stopped delivering babies.

Under the plan, women receive pre- and postnatal care in Iowa Falls. As they near their due date, they start planning for their delivery at Mercy One Medical Center in Mason City by meeting with the doctor in Iowa Falls, and planning the hour drive to deliver.

'The idea is, you do as much as you can in a rural community, and then work with a referral center to partner and then come back to the rural community,” Morse said.

Morse said initial figures show that under the system, three-fourths of women are bringing their children back to the doctor in Iowa Falls, instead of sticking with the out-of-town provider.

Molly Forgy of nearby Ackley was one of the first women to use the 'share-care” program. She delivered her son in Mason City last April.

'I did not feel that I missed out on anything through having to go to two facilities and seeing two providers,” she said.

But the hour drive to deliver is a strain on others. At eight months' pregnant, Nicole Grover said she's nervous about traveling so far because, four years ago, Iowa Falls doctors delivered her daughter by emergency C-section.

'It's a little scary not knowing if I'm going to have time to get there,” she said. 'Or if something happens, I'm going to have to go by an ambulance.”

‘Right thing to do'

About two hours southeast of Iowa Falls in Marengo, Compass Memorial Hospital is bucking the trend. It's finishing a new labor and delivery unit.

Chief Executive Officer Barry Goettsch said the hospital is aiming to open the unit with two birthing suites by the end of next year. It's projecting to have between 150 and 175 births a year.

Goettsch said Compass Memorial shut its previous unit in the 1980s, and local women have to drive to Iowa City or Cedar Rapids to give birth.

'The people who live in our area deserve the best, and they shouldn't have to drive 45 minutes or further to get the perceived best from somebody bigger,” he said.

To help attract enough expectant mothers, the hospital designed birthing suites to be more upscale. Still, Compass Memorial expects to confront a lot of the same issues as Iowa Falls.

Marengo, which has about 2,400 residents, is also an aging community and Goettsch said half of the town's births will likely be Medicaid-funded. The hospital forecasts losing $1 million a year to operate the unit. Plus, he said it hasn't started searching for an OB/GYN. Still, Goettsch called opening the unit 'the right thing to do.”

'I mean, if we're not doing what's right, and we're not doing the best we can for the folks that utilize our organization,” he said, 'then we kind of missed the point of being in health care.”

Seeking a Cure: The quest to save rural hospitals is a collaborative project including the Institute for Nonprofit News and INN members IowaWatch, KCUR, Bridge Magazine, Wisconsin Watch, Side Effects Public Media and The Conversation; as well as Iowa Public Radio, Minnesota Public Radio, Wisconsin Public Radio, The Gazette, Iowa Falls Times Citizen and N'west Iowa REVIEW. The project was made possible by support from INN, with additional support from the Solutions Journalism Network, a nonprofit organization dedicated to rigorous and compelling reporting about responses to social problems. For more stories visit hospitals.iowawatch.org