By Liora Engel-Smith
The maternity unit in Macon County has been closed for almost three years, but as Jennifer Garrett sees it, nothing took its place.
Garrett, clinical services administrator and director of nursing at Macon County Public Health, said having a maternal ward in town meant that pregnant women could go there right away in a medical emergency.
“We referred all our clients there for delivery or most of our clients just basically chose to deliver there anytime we had a problem,” she recalled. “Our patients just walked onto the unit and were seen right away for complications or problems.”
In the rural Appalachian county, where winters are harsh and narrow dirt roads make driving difficult even when the weather is clear, the maternity unit at Angel Medical Center was an important asset. But then in July 2017, Mission Health, which owns the hospital, closed the unit for financial reasons, leaving women in the community without an in-county option for childbirth.
The closure forces women to travel 20 miles south over a mountain to Harris Regional Hospital in neighboring Jackson County, or even to Asheville, an almost 70 mile trek northeast, to give birth. In some cases, women may even have to venture as far as Charlotte, more than 180 miles away, Garrett said.
“People are just having to make it work, you know,” Garrett said. “When we don’t have any alternatives, they’re just doing the best they can with what we have.”
Many of North Carolina’s rural women find themselves in similar situations as more maternity units have shuttered. Since 2013, at least nine rural communities lost their labor and delivery services either through hospital or maternal unit shutdowns, according to James DeVente, an obstetrician and gynecologist at East Carolina University’s medical school. Seven of those units were in the west.
Last month, Lexington Medical Center, an urban hospital in Davidson County, announced that by the end of June, it too will discontinue its labor and delivery services.
And once they close, rural maternity units rarely reopen, leaving communities such as Macon County with a gaping, difficult-to-address need.
“There’s no easy answer,” said Brock Slabach, senior vice president of member services at the National Rural Health Association, a nonprofit advocacy and research organization. “I mean, if we could just take something off the shelf and apply it we could have done that a long time ago.”
But in a state that grapples with disparities in maternal and child health outcomes, finding an answer — easy or not — has become even more urgent. As the need grows, experts from across the state have been considering everything from telehealth to creative collaborations between clinics and hospitals.
And Macon County is poised to become testing grounds for one of those experiments.
‘A hub and spoke’ vision
Suzanne Dixon has been caring for patients in Macon County since early 2018. Dixon, an obstetrician and gynecologist with the nonprofit Mountain Area Health Education Center, travels to Franklin once a week and sees women at Mission Women’s and Children’s Center on Wednesdays and Thursdays.
Even with a full schedule of 20-25 patients a day and surgeries every other week, Dixon says her work can’t fully address the needs of the community. She estimates that the patient load is enough for one, even two, full-time obstetricians. Two other clinics in town — the health department and a satellite clinic operated by Harris Regional — also care for women in the county, but Dixon said, some patients are likely falling through the cracks.
Her first couple of months at the Mission clinic made that need abundantly clear: eight of the women she treated during that time needed referrals to Asheville for various cancers.
“The patients out there do feel a fair amount of stress,” Dixon said. “Like, I am asked almost every week ‘Please don’t go. How can we be sure that you’re going to be able to stay here?’”
When she isn’t seeing patients, Dixon thinks about the big picture: How can providers in western North Carolina care for women in rural communities where maternity units are long gone? What should players in the region do to stabilize the remaining units? What tools do providers in the region need to address an access to care crisis that has become an “urgent catastrophe” in many rural women’s lives?
Part of the answer, Dixon says, is in reforming the system through a “hub and spoke” model that transcends hospital networks in the region. In that model, Mission Hospital in Asheville could become a hub for more clinically demanding cases. Community hospitals, family practices and other clinics would be the “spokes” or points of entry into a coordinated system with numerous connections and relationships.
Rural hospitals with maternity and neonatal services are green. Rural hospitals that have either discontinued or will discontinue their maternity units are red. Urban hospitals are blue. Chatham Hospital, which has plans to open a maternity ward in 2020, is purple. Lexington Medical Center, which plans to shut down its unit in summer 2020, is orange.
Note: This map has been updated thanks to feedback from our readers on additional maternity unit closures.
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
So a pregnant patient in Franklin might see Dixon or a physician at the Harris Regional clinic for most of her prenatal care. But if that patient needs to consult with a specialist in Asheville, her doctor’s office and Mission Health would coordinate a telemedicine consult, perhaps saving a trip that takes most of the day.
Dixon knows that many obstacles stand in the way of that vision, from finding money to support the effort to reconciling data from disparate electronic medical records systems.
“We don’t have a lot of funding and we don’t have a lot of manpower but we’re going to go ahead and start,” she said. “ … We’re just going to keep trying.”
Building these relationships isn’t easy, or fast, Dixon said. It might even take several years. But as providers on the other side of the state discovered, given enough time, big visions can bear real fruit.
‘A better place to be born’
James DeVente has a wishlist he keeps on a dry erase board in his office. He calls it the “if I were king” list. On it, the ECU obstetrician and gynecologist notes items that have the potential to improve maternal and child health outcomes in eastern North Carolina.
One of the most underserved regions in the state, eastern North Carolina counties, particularly rural ones, have many challenges from food insecurity to economic stagnation. And between 2008-2012, the region had the highest infant mortality rate in the state, or 9.1 infant deaths per 1,000 live births. By 2014-18, that rate decreased to 7.9 deaths per 1,000 live births.
DeVente, who also works at Vidant Medical Center in Greenville, has credited this improvement to a deliberate effort to foster strong relationships between hospitals in the region.
“We’re trying to make all of eastern North Carolina a better place to be born whether you’re (in) a Vidant hospital or not,” he said.
And these relationships have helped DeVente implement some of the items on his list. Like a program that allows small community hospitals in the region to exchange surfactants — an expensive, but necessary agent to help premature babies breathe — before the drugs expire. Before the program began, DeVente said, community hospitals in the region did not want to purchase the medication. But now, the agent is available at every community hospital with a labor and delivery unit across the region.
Vidant also has a program that trains and supports maternity unit staff at small community hospitals in the region — whether they belong to Vidant’s network or not — on how to best support pregnant women and their infants during emergencies, such as eclampsia, a life-threatening condition that’s caused by high blood pressure.
Many of these innovations took years to implement, DeVente said. It took roughly five years to get total buy-in from hospitals for the surfactant exchange program, for example. But since the collaborations began in 2012, the region saw a marked decline in its infant mortality.
Vidant also credits the support it gives to community hospitals in the region for the relatively low rate of maternity unit closures in the region, even as economic pressures intensify.
But even collaborations have their limits. Martin General Hospital, a for-profit Quantum Health facility in the region, abruptly discontinued its labor and delivery services last year despite these safeguards. The closure, DeVente said, was out of Vidant’s control.
To address the needs of women in Martin County, Vidant sent specialists to train first responders and emergency room doctors there on responding to maternal and neonatal emergencies. Vidant also announced plans to open a satellite OB clinic in Martin County.
“It’s not the best solution,” DeVente said. “The best solution would be to keep the maternity unit open, but obviously we can’t do that.”
Vidant Health is not immune to some of the economic pressures that led to the closure of Martin’s obstetrics unit. After a budget shortfall in the first quarter of the 2020 fiscal year, Vidant told NBC affiliate-WITN that it is exploring cost-cutting options, including layoffs.
A Vidant spokesman did not directly comment on the impact of potential cuts on Vidant’s eight labor and delivery units or maternal and child health programs. But in an email statement, he attributed the deficit to “the impact of the realities of delivering rural health care.”
“Despite these challenges, Vidant will stay true to improving the health and well-being of eastern North Carolina,” the statement said. “The communities we serve depend on us to protect their health care.”
DeVente, for his part, thinks of other numbers: The number of the lives saved in the decade since Vidant began focusing on maternal and child health collaborations. In a decade, he said, the relationships they built prevented 210 infant deaths, or an average of 21 babies a year.
“That’s a kindergarten class,” he said.