By Rachel Crumpler
Ellen Chetwynd, a long-time Chatham County resident, has already seen labor and delivery shut down once at Chatham Hospital.
She gave birth to her daughter at Chatham Hospital in 1988 when it was at its old location on West Third Street in Siler City. Shortly after, motivated by her own positive birthing experience, she went to work as a nurse in the same maternity unit.
But she didn’t stay long. She actually never got off orientation as a labor and delivery nurse because Chetwynd said the unit was beginning to shut down.
Chetwynd said the maternity unit’s closure in 1992 was devastating — a significant blow to the community.
“How can this be?” she recalls thinking at the time. “This is such a good service. This is such an integral part of the community.”
Now she’s wondering if history will repeat itself.
It’s a fate she and a coalition of others want to see avoided.
Amid the COVID-19 pandemic, in September 2020, Chatham Hospital in Siler City opened its new Maternity Care Center, ending a decades-long hiatus of not having a place to give birth near home for thousands of Chatham County families. Chatham Hospital is a 25-bed Critical Access Hospital that is part of the UNC Health System.
UNC Health invested $2.6 million to build the five-bed Maternity Care Center specifically designed to serve low-risk mothers and newborns. The unit is mostly staffed by primary care physicians trained in obstetrics and surgery, rather than OB/GYNs, to lower the cost of operations.
“What we’re trying to prove … is that this could be a sustainable model for maternal care in more rural communities across the state,” Jeff Strickler, president of Chatham Hospital, told NC Health News in November 2019 ahead of the opening.
But resuming this service has come with challenges — many anticipated — that could jeopardize the long-term sustainability of the Maternity Care Center. Meetings and discussions are underway to determine the unit’s future, said UNC Health spokesperson Alan Wolf in a statement.
Wolf said no decision has yet been made but the maternity center’s two largest issues are the ongoing nursing shortage and the low volume of deliveries at the hospital.
“The Chatham maternity center delivers one to three babies a week, and is currently only staffed five days a week,” Wolf said. “That makes it difficult to recruit and retain staff, and maintain high proficiency.”
Need for rural maternity care
When the Chatham Maternity Care Center opened over two years ago, it bucked national and statewide trends of rural maternity unit closures.
Between 2014 and 2019, 13 maternity units or entire hospitals that contained maternity units closed in rural North Carolina counties. When a closure occurs, alternatives are hard to come by, often resulting in maternal health care deserts.
Maternity care deserts are counties without a hospital or birth center offering obstetrics care and without any obstetrics providers. Nationwide, 2.2 million women of childbearing age live in maternity care deserts and more than 146,000 babies are born there, according to a 2022 report by March of Dimes. Twenty-one counties in North Carolina are designated as maternity care deserts and another 17 counties have low access to maternity care, according to March of Dimes. This affects an estimated 342,738 women of childbearing age living in those counties.
Lack of access to rural maternity care can lead to poorer maternal and infant health outcomes.
When Chatham Hospital decided to open a maternity unit, Stephanie Terry, co-founder of Chatham Organizing for Racial Equity (CORE), saw it as a value proposition to serve the community — a decision based on more than finances. After all, it’s well-documented that obstetrics units in rural areas often lose money due to low delivery volume. Nonetheless, there remains a need for care.
Throughout the state, maternal and infant outcomes are worse than the national average. North Carolina women had a pregnancy-related mortality rate of 21.9 deaths per 100,000 live births in 2021 — above the national average of 17.3. North Carolina also ranks 40th in babies born low birthweight and 42nd in neonatal mortality, according to 2021 data from America’s Health Rankings.
Compared to the rest of North Carolina and the United States, Chatham County fares worse in maternal and infant health indicators and outcomes, and Black and Hispanic communities in particular are disproportionately affected by infant mortality and low birthweights.
In 2020, Chatham County had an infant mortality rate of 12.4 percent, compared to the state’s rate of 6.9 percent. Additionally, 21.3 percent of Black babies were born low or very low birthweight in the county from 2016 to 2020 — several points above the state’s rate of 17.7 percent.
Filling a community need
After completing her medical training and a surgical fellowship, Fareedat Oluyadi moved from Illinois to Chatham County to work as a family medicine physician at Chatham Hospital’s Maternity Care Center.
“Chatham County and the MCC were the perfect fit,” Oluyadi said. “It allowed me to provide care and use my skills to the highest level of competence but also provide care to a community that needs it the most. That’s where I get my job satisfaction, my sense of value and worth knowing that I’m in a place where I’m most needed.”
Over 210 babies have been delivered at the Chatham Maternity Care Center since its opening. Oluyadi said about 80 to 90 percent of those giving birth on the unit are people of color, primarily Latina.
Chatham Maternity Care Center Evaluation Data From First Cohort of 99 births from September 2020 to June 2021:
- 71 birthing people were Hispanic and 28 non-Hispanic.
- 47 percent of patients preferred Spanish and 53 percent English.
- 37 percent of patients had an unmedicated birth, 52 percent had an epidural, 7 percent only had narcotics, and 3 percent had general anesthesia for C-section.
- 92 percent of the cohort were doing at least some breastfeeding at hospital discharge, with 50 percent exclusively breastfeeding.
- About half of the people in the first cohort lived between 2 to 7 miles away, so lots of folks from Siler City and fewer from farther away in the county.
Before the Chatham Maternity Care Center opened in 2020, Oluyadi said many Chatham residents in labor had to drive at least 45 minutes to the nearest hospital or birthing center. Traveling long distances during labor is associated with increased perinatal morbidity, including preterm birth and out-of-hospital births.
Now, care is closer to home for many. That’s a good thing because Chatham County’s population grew by over 20 percent from 2010 to 2020, according to the North Carolina Office of State Budget and Management, and the increase is projected to continue for years to come as the new Chatham Park housing development is built. Two major economic development projects — Wolfspeed’s manufacturing facility for silicon carbide chips and VinFast’s electric vehicle and battery production facility — will also spur growth, bringing thousands of jobs and likely families to the county.
Signs of trouble
The Chatham Maternity Care Center opening against trends of closures won Oluyadi over. It was an initiative she wanted to contribute to. Still, she knew the same factors challenging rural maternity care elsewhere were at play in Chatham, too.
She’s been aware of the unit’s vulnerability from day one, and it’s been both a propellant and a background fear, said Oluyadi, who has worked on the unit since its opening.
For Oluyadi, a turning point putting the unit’s sustainability issues front and center came last November when the Chatham Maternity Care Center first had to limit its hours of operation due to nursing shortages. The reduced hours, including being closed on the weekend, lasted months.
After returning briefly to 24/7 operating hours in June, three nurse resignations in July forced the unit to reduce its operating hours again due to insufficient staffing. The unit is currently open around the clock from 7 a.m. Monday until 5 p.m. Friday.
Sensing a tipping point about the unit’s future, Oluyadi wrote a letter co-signed by close to 100 community members in August to Chatham Hospital President Strickler expressing concern about what felt like an “impending closure.” The letter was read at Chatham County’s Board of Health meeting on Aug. 22 during the public comment period.
“We’ve shown resilience through the staggering impacts of the COVID-19 pandemic that undoubtedly catapulted staff attrition, burnout and financial loss,” the letter read. “Despite all these seemingly insurmountable obstacles, we’re still standing doing what we came here to do. We maintain a hope that we will continue to be able to provide this service to our community.”
In response, Strickler emphasized at the meeting that no decision has been made about the unit and that he remains committed to providing the highest quality care to mothers, though he said the challenge is real.
“Just to reiterate the critical nature of this, we are one resignation away from not being able to safely maintain the program,” Strickler said at the meeting.
With reduced hours, the unit saw a decrease in delivery volume, slowing to an average of one delivery per week in May.
Lesley Starke, who lives in Pittsboro, gave birth to her son at the Chatham Maternity Care Center on June 15. Fortunately, his birth occurred during the weekday hours of operation. She said the unit’s hours were a big stressor as she waited to go into labor.
Despite living in the county, if her prenatal doctor hadn’t mentioned that Chatham Maternity Care Center was an option for delivery, Starke said she could have easily gone her whole pregnancy and not been aware of it. Lack of awareness of the labor and delivery unit in the county may be keeping delivery volume low, she said.
“People in this community have spent over 20 years knowing that the hospital did not have that facility anymore,” said Starke, who said the birthing experience at the maternity center exceeded her expectations. “It’s more than just neutral. It’s like people had a negative association with that option there.”
The lower volume of deliveries has contributed to some staff attrition, said Strickler at the meeting. If the unit doesn’t have any patients, then the nurses are floated to another area of the hospital to provide support until a laboring patient arrives. Strickler also said staff have left to take other nursing jobs or even travel assignments, even as some of those high-paying assignments are starting to dry up.
Despite the turnover, Chetwynd who is now a researcher evaluating the Chatham Maternity Care Center and has conducted staff exit interviews, said overwhelmingly the staff who have left are still committed to the mission of the unit.
“Even though they’re stepping away from the unit, they say very positive things about the service that is being offered and the value of what’s being offered and the need for it in the community,” she said. “One nurse told me that even though she was an experienced labor and delivery nurse who had worked at multiple hospitals — both large and small — she had some of the most touching, important-to-her birth experiences as a labor and delivery nurse at Chatham Hospital.”
Eric Wolak, chief operating officer and chief nursing officer of Chatham Hospital, said that he’s working to hire more nurses so the unit can resume 24/7 operating hours with the needed two nurses per shift, but he’s up against a tough hiring landscape as hospitals across the state and nation are looking for nurses to fill positions.
“We’re at a very important time in the history of maternal health in our country, for reproductive justice in our country, and it’s at this point that a local, rural critical access maternity care center is kind of on the brink,” said Jen Medearis Costello, a member of the operational leadership team of Equity for Moms and Babies Realized Across Chatham (EMBRACe), which seeks to ensure successful and equitable birth outcomes for women and babies in the county.
At the August meeting, Strickler also announced the creation of a 17-member community task force that will examine the long-term viability of the unit and brainstorm solutions designed to ensure the quality, safety and sustainability of the center.
The community task force is led by Audrea Caesar, UNC Health’s chief diversity, equity, and inclusion officer, and Margaret Helton, chairperson of UNC’s Department of Family Medicine. Community groups focused on achieving equitable outcomes like CORE and EMBRACe are represented on the task force.
The task force’s work includes examining nurse retention, patient volume, community engagement, and health and safety. The work is expected to take months and several meetings have already occured, Wolf, a UNC Health spokesperson, said in a statement.
“We need all the viewpoints from the operation side of it to the patient care facing side of it, to the community facing side,” Oluyadi said. “I think together, we all have the solution, and that’s why I keep going back to the task force being such a powerful avenue to solving this.”
Community members are hopeful about the potential of the task force, pleased to see that a decision on the unit’s future has not been made purely internally. They also said abandoning plans for the maternity center after two years, especially when COVID has exacerbated the unit’s challenges, would not be fair to people of childbearing age across the county since there has not been enough time to really evaluate the unit’s impact on health outcomes and disparities.
Last week, on Oct. 17, a mid-point meeting was held in which task force members presented proposed solutions to get feedback about their feasibility, said Costello, a task force member. Three UNC Health executives were expected to attend — Caesar and two others — but only Caesar attended.
Wolf said in a statement that leadership at UNC Health remain fully engaged in the discussions regarding the Chatham Maternity Care Center and were briefed by Caesar, Strickler and others after the meeting.
“I think that if this community task force is engaged in the way that it could be, where solutions are truly considered and where political will and finances are put behind those solutions, that we might make a new course and an even more positive course forward for the MCC because it will be a course that has been designed together and has been centered on the experiences of the people in Chatham County,” Costello said.