By Liora Engel-Smith
The mural at the corner of Siler City’s Chatham Avenue and Beaver Street describes what was.
Created to depict life in the town in 1910, it shows several one- or two-story buildings and a wide dirt road. One building in the mural has a visible sign, an ode to what was the town’s longest-running business: the Farmer’s Alliance.
But that business closed last year after a 130 year run leaving a vacant storefront in its wake. The downtown is covered in a patina of grime, featuring many such vacant storefronts. But there are also signs of economic shifts. An art studio near a pawn shop that offers Christmas layaway. A sandwich board for a local cafe shop urges passersby to try nitro coffee. Across the street, a bodega covered in colorful posters sells tamales and peanut butter.
There are other signs, too. A chicken processing plant recently opened in Siler City, bringing 1,250 new jobs to the economically depressed area. The town fire department announced it will soon hire enough professional firefighters to serve the city around the clock. And the local hospital announced it will begin delivering babies again next year after a 20-plus year hiatus.
In the challenging health care landscape of North Carolina, rural hospitals such as Chatham rarely expand, much less into obstetrics, a service that typically loses money. Since 2017, at least five hospitals across the state stopped offering maternity services.
But Jeffrey Strickler, who heads the hospital, plans to buck that trend with an unusual model: he wants to staff the unit almost entirely with primary care physicians.
“Most of the expenses [for a maternity unit] come with the staff in place and particularly the physician staff and obstetricians, their market rate is higher than a family medicine physician,” he said. “That’s why we’re interested in really showing that this can be a safe, effective model for a large percentage of the deliveries.”
‘Sustainable model of maternal care’
Strickler’s office at Chatham Hospital is all desk and chairs and almost nothing else. By next year, that office and surrounding rooms will become part of the five-bed maternity unit. Renovations will cost roughly $2.5 million, according to Strickler, who said the hospital has secured just under $900,000 in grants for the project. Chatham Hospital’s parent, UNC Health Care will also support the hospital by making up losses from operating the new unit.
Primary care physicians trained in obstetrics and surgery will provide the bulk of the care at the maternity ward, Strickler said. Staff at the unit will assist on “low-risk” deliveries — cesarean sections or vaginal births on women who are generally healthy. An obstetrician will be available to consult, according to Strickler, who said high-risk patients, such as women carrying twins and breech babies, will be transferred to UNC Medical Center in Chapel Hill, roughly 45 minutes away.
Rural hospitals with maternity and neonatal services are green. Rural hospitals that have either discontinued or will discontinue their maternity services are red. Urban hospitals are blue. Chatham Hospital is in purple.
Note: This map has been updated thanks to feedback from our readers on an additional labor and delivery unit closure.
This map collates N.C. hospitals which had 25 or more deliveries in FY2017. We updated names of hospitals that have since changed, with the old name in parentheses. The data come from the North Carolina Healthcare Association, which surveyed hospitals for the information. When hospitals didn’t respond to the survey, fields remained blank.
Urban/rural designations are based on definitions from the Centers for Medicare and Medicaid Services.
The American College of Obstetricians and Gynecologists define OB level 1 as basic care, OB level 2 as specialty care, and OB level 3 as subspecialty care.
Data source: N.C. Healthcare Association. Map credit: Liora Engel-Smith
With cost savings that come from employing primary care physicians, rather than obstetricians, the unit’s overhead cost will be lower. The hospital will need to deliver roughly 350 babies a year for the unit to remain financially viable, a number that Strickler said is within reach since Chatham County residents had roughly 700 babies last year.
“What we’re trying to prove … is that this could be a sustainable model for maternal care in more rural communities across the state,” he said.
Riding the population wave
Though the CMS classifies the 25-bed hospital in Siler City as rural, there are signs that at least part of Chatham County may not remain that way for long. The county is in the midst of a population boom. According to the Census Bureau, Chatham’s population grew from roughly 50,000 residents in 2000 to more than 70,000 in 2017. That growth will likely continue, as a massive development in the town of Pittsboro, roughly 16 miles east of Siler City, plans to erect 22,000 new homes in the county.
Chatham Hospital opened satellite medical clinics in the new development, known as Chatham Park, in 2016. But Strickler said the new development has nothing to do with the maternity unit.
“[The] decision was based solely on the needs for the entire county,” he wrote in an email.
And those needs are significant, according to a 2018 county health assessment that the hospital helped create. One in 10 babies born to Chatham County residents in 2016 had low birth weight, the assessment said. And though the county is close to the Triangle, with its abundant maternity units, expecting mothers have to travel an average of 25 miles to reach a hospital that delivers babies.
“We’ve gone without OB services for a number of years — more than 20 years — and so especially on the western side [of the county] you’re a little bit farther away from Chapel Hill and Durham that have those resources,” said Michael Zelek of the Chatham County Public Health Department. “It’s about access for a segment of our population and the region beyond our borders.”
A return to primary care
The idea of having primary care physicians in obstetrics units is not new, said Greg Griggs, executive vice president and CEO of the North Carolina Academy of Family Physicians. Primary care physicians who practice obstetrics are commonplace in many rural hospitals across the United States. Fewer of them do so in North Carolina, he said, mainly because the number of obstetrics units in the state declined.
According to the American Academy of Family Physicians, almost 30 percent of rural primary care physicians practice obstetrics. But out of North Carolina’s 2,800 family physicians, Griggs said, only about 11 percent — or 300 — practice obstetrics.
Maternity units staffed almost entirely by primary care physicians are unheard of in North Carolina, Griggs said. If Chatham Hospital’s model works, he added, it could address part of the primary care shortage in the state while ensuring that more rural obstetrics units in the state remain open.
“We’re closing OB units across the state and we actually at the same time are losing family medicine residents when they graduate who want to do OB and can’t find jobs doing OB in the state,” he said.
And as the health care market moves to value-based care, in which insurance payments are tied to health outcomes, not to specific services, Griggs said, the roles of family physicians will only expand.
“That doesn’t mean we don’t need specialists,” he said. “And it certainly doesn’t mean we don’t need OBs. We need both, but we need a better balance than we’ve had in recent years.”