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Cailee and Tanner Wenger live in Water’s Edge, a picturesque development north of Washington, Iowa, that has residents trading in lake life for “pond life,” thanks to a large pond across the street where neighbors swim and fish.
Cailee thinks the couple, who married in 2016, eventually might have three children. Tanner, a teacher at the Keota Community School District, has one sibling, and Cailee grew up as one of four — so she said she hopes they’ll meet in the middle.
But for now they are focusing on their first child, a daughter born on June 29 named Hayden Rose — a nod to the Hawkeye’s Hayden Fry and a great-grandmother named Rosella.
Although they live 10 minutes from the hospital in Washington, Cailee was traveling about 35 minutes for every checkup, ultrasound and birthing class. That’s because their hospital no longer has a labor and delivery and postpartum unit.
“The biggest barrier for us was travel,” said Cailee, who teaches at Washington Middle School. “We have to go 35 minutes to go to the hospital, so there was a worry — what if we can’t get there fast enough?”
The Wengers’ story is a familiar one for parts of Eastern Iowa and other regions of the state. They have joined a population that’s in the direct path of what Dr. Stephen Hunter, a high-risk obstetrician at the University of Iowa Hospitals and Clinics in Iowa City, describes as “a perfect storm” of circumstances that can cripple health care access across the state and the rest of the country.
In recent years, rural hospitals have struggled to stay afloat, meaning departments with low patient volumes and high costs, yet low reimbursement rates — such as an obstetrics unit — are the first to be cut. In some cases, and in ever-increasing numbers, hospitals close entirely, leaving area patients with a long drive to the nearest specialist.
That commute is even longer in some areas because obstetricians-gynecologists can be few and far between. Iowa stands as second to last nationwide for the number of these specialists in the state.
Both are factors experts say limit options for those who already face economic barriers and will cost Iowans more in the long run.
And, unfortunately, long-term solutions are difficult to find, Hunter said.
“Pregnancy is very hard. All this does is make it harder and riskier, which is where we do not want to be,” said Elizabeth Nash, senior state issues manager at the New York-based Guttmacher Institute, a policy organization.
A TALE OF TWO HOSPITALS
Compass Memorial Healthcare is changing in a big way.
The 25-bed critical access hospital in Marengo, an Iowa County city of about 2,500, is in the midst of a $27 million expansion that will renovate the existing facility and add 33,000 square feet of new space. The project, among other objectives, will appropriate two suites to a labor-delivery and postpartum unit.
“From a community service standpoint, we felt doing the right thing for the community was important,” said Compass CEO Barry Goettsch. “If we can do it, and we can do it at a high level, then that’s a service we should be offering these communities.”
Marengo is planning for 70 deliveries in the first year. Officials have set a goal of 150 births down the road.
Compass Memorial, which has an affiliation with UnityPoint Health, will be wrapping up the two-and-a-half year project at the end of November.
There is no hard open date for the labor-delivery-postpartum unit, as officials continue to seek a specialty physician “to complement the existing team we have to date,” Goettsch said.
Marengo is a rarity in Iowa, and across the country.
As the population and health providers continue to migrate to urban centers, more Level 1 hospitals increasingly are closing down departments and services to maintain stability — or be forced to shut their doors completely.
“Those are big issues,” Goettsch said. “They lead to a whole new set of questions.”
The recent trend of rural and small community hospitals closing departments, eliminating staff and taking other measures so they remain financially stable is not likely to improve in the near future. In fact, it has worsened significantly in Iowa, according to the Iowa Rural Health Association.
In 1973, 140 hospitals provided maternity services in Iowa.
In 2018, that figure has dropped to 70 hospitals — with two dozen closures in the past 15 years. According to the association, seven of those closures occurred in 2018 alone.
It’s a trend seen nationwide.
According to a study by the University of Minnesota Rural Health Research Center, 45 percent of rural counties had no hospital obstetric services between 2004 and 2014, affecting as many as 18 million women.
In addition, during that study period, the report found another 9 percent of rural counties nationwide experienced the loss of all hospital obstetric services.
One critical access hospital in Eastern Iowa, almost 55 miles south of Marengo, faced this very reality.
AN EMOTIONALLY TRYING TIME
Washington County Hospitals and Clinics, located in Washington, closed its obstetrics unit June 1 this year, citing declining birthrates and increasing costs.
The hospital assisted in an average 130 births a year, but costs rose 41 percent over the past five years. At the same time, patient demand in other units continued to increase, especially in the emergency room.
“With the relatively low (number of) births, we were utilizing a lot of resources that potentially could help a greater number of people within the community,” Dr. Stephan Schomer, interim CEO of the hospital at the time of the closure announcement, told The Gazette.
In November, Schomer told The Gazette it was difficult for all rural obstetric practices to keep going. To remain as an organization, hospitals are left with a hard choice — do officials continue putting the organization in financial risk to meet a low but necessary patient need, or channel resources to other departments that are seeing high patient counts?
Hospital officials declined to speak with The Gazette for this story this summer, saying it remained an emotionally trying time.
This dilemma partially can be attributed, UIHC’s Hunter said, to low reimbursements rates from health care programs such as Medicaid.
“Medicaid reimbursement in the state is abysmal,” Hunter said. “Most Level 1 hospitals are probably losing a considerable amount of money each year for labor and delivery service.”
Hunter also pointed to the fact more patients are having children when they are older and are presenting more frequently with comorbidities — two or more chronic conditions or diseases such as heart conditions and diabetes. These patients experience a higher risk for pregnancy complications that could result in death of the woman.
“The Level 1 hospitals are not capable of taking on these types of patients we’re seeing — and unfortunately, we’re seeing a significant increase in maternal deaths across the country. Iowa is not excluded from that,” Hunter said.
In 2015, the nation’s maternity mortality rate was about 26.5 deaths per 100,000 live births, according to a study that year.
With the absence of obstetrics services in their hometown, pregnant women in Washington are left to choose between Mount Pleasant, 31 miles away, and Iowa City, a 33-mile drive.
Cailee Wenger opted to head north to OB-GYN Associates of Iowa City and Coralville, which has an agreement to deliver babies at Mercy Iowa City.
It was an inconvenience to make the drive for every birthing class and every doctor’s appointment, as Cailee had to take time off work — but there were some benefits, Tanner Wenger said.
“It would have been slick to be five minutes” from the hospital, he said. “But with any complications that might have happened and being in Iowa City with the bigger hospitals, it was reassuring.”
The Wengers, though, see these inconveniences as part of their lifestyle. They opted to live in a small town and work for small community school districts in southeast Iowa because, they said, it was the kind of environment where they wanted to raise their family.
But hospitals that do have the capability to maintain labor and delivery departments face another new challenge — finding the workforce to staff these departments.
Recruitment and retention is a challenge many small health care providers face, not just in female-centric health care. Iowa ranked 46th out of 50 states in 2016 for the total number of physicians active in patient care per 100,000 people, according to the Association of American Medical Colleges, which represents all U.S. medical schools.
For the number of OB-GYN physicians per capita, Iowa is ranked 50th among all states and the District of Columbia, according to a 2017 analysis from the American Congress of Obstetricians and Gynecologists.
And when the 227 practicing fellows in the state in 2010 is compared to the about 1.5 million women in the state, it results in about 1.5 OB-GYNs per 10,000 women.
Family practice physicians can obtain certification in OB-GYN services, but increasingly more of these doctors are not offering those services — in part due to the complexity of OB-GYN patients.
“When I started at Mercy Iowa City eight years ago, there were five family practice doctors that still delivered,” said Dr. Jill Goodman, an OB-GYN at OB-GYN Associates of Iowa City and Coralville. “Now there are zero. It’s not all because they all retired.”
Looking at access to health care as a whole, UIHC’s Hunter said solutions won’t be easy and won’t come at a low cost.
Not only can the state work to bring in more OB-GYN residents and establish them in rural parts of the state, but Iowa, he hopes, will increase its use of telemedicine services.
He also suggested improving reimbursements for health care providers, so hospitals have a better chance to stay on their feet.
Overall, though, it’s important to continue educating people on the issue of access to women’s health care in Iowa, he said.
“I hope we can get policymakers in the state to see this problem sooner rather than later, take necessary steps to halt it,” he said.
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