The Growth of Maternity Deserts

Women in many areas have nowhere to go...

This appeared first in Emergency Medicine News last June. I have edited it slightly.

https://journals.lww.com/em-news/fulltext/2024/06000/the_growth_of_maternity_deserts.8.aspx

We had a call from a rural EMS crew a few weeks ago letting us know that a young woman had delivered her fourth baby in the back of a basic EMS unit and that they were on their way. Reports varied from “Mom and baby are fine,” to “Mom is fine, but baby had a little bit of CPR.”

(A little bit of CPR…that’s not reassuring.)

We fortunately had 45 minutes to prepare. It was a little confusing at first because we weren't sure if both could go directly to labor and delivery (where all the fancy machines, beeping things and smart people are located) or if they would stop in the ED.

The ruling was ultimately to stop in the ED. (And why wouldn’t it be?) Fortunately, labor and delivery nurses arrived, a pediatrician slipped quietly into the room speaking in hushed tones, and all was well. Mom wasn't bleeding much, and baby was a perfect little peanut of normal baby color and respirations. (I'm still not sure where the CPR came into play.)

I've had some obstetric interactions that didn't go nearly as well. Things got particularly ugly during the pandemic. I remember one EMS unit bringing in a 26-week pregnant mom in labor. Rather than go the extra 10 minutes to a large hospital with labor and delivery and a newborn nursery, they brought the patient(s) to me at my woefully inadequate critical access hospital.

“Well, doc, we just thought it was safer to come here.”

“No,” I thought, “you just thought it was a bit faster.”

We ultimately got mom settled and transferred to the right location but not without me losing at least one of my nine lives to anxiety.

In another instance, a woman with an ectopic pregnancy (see my last post for more detail on the topic) needed to be transferred to an OB/Gyn, which we didn’t have. But we had no ambulances available. I sent her with her family, in their car. She didn’t go directly to the hospital and the receiving surgeon was furious at me. But you do the best you can in the midst of national chaos.

The painful truth is that obstetric complications and long transports will become more common as rural labor and delivery units continue to close. A web search for “rural labor and delivery unit closure” yields a lot of links. (Like this one from CNN: https://tinyurl.com/4ty7m65t.)

Maternity deserts are growing across the country, according to CNN, because Medicaid pays for 42 percent of U.S. births—even more in rural areas—and it reimburses poorly for delivery. About half as much as for non-Medicaid patients, it turns out. So, hospitals will continue to deep-six their maternity wards, and these patients will go to the only place they know to go, which is the ED. The hard reality is that we in hospital ERs remain, for better and worse, the backup plan for every American health crisis.

Whether managing the terrors of COVID with limited equipment, bunking down the mentally ill for weeks due to lack of options, holding the sick due to insufficient inpatient rooms, or bearing the brunt of the fentanyl crisis, when planning goes bad, the default is “Look at the time! The ED will figure it out.” And we generally do. But not because it's the best option. We usually do it because it's the only option for the people who come to us in grave need.

I really don't like delivering babies. I didn't deliver many during medical school, and the labor and delivery nurses would occasionally let us close during residency. Mostly they looked at the emergency medicine residents the way a sheep dog would eye a coyote: “Grrr, stay back, grrr.” So, I have a certain lack of comfort with the events surrounding a small human being emerging from a larger, screaming human being.

Fortunately, it didn't matter for most of my career. I worked in hospitals with labor and delivery and passionate obstetricians, and God bless them all for their dedication and endlessly sleep deprived lives.

It was later in my career when I started working in locums and at rural critical access hospitals in particular that I realized just how fragile and how precious a resource is obstetric care. I obviously never understood this fully before I had children of my own and saw how a thing so wonderful and natural can also be so frightening and potentially dangerous.

We emergency physicians, nurses, medics and all the rest will be there; but increasingly, rural citizens are facing closure of labor and delivery units, requiring them to travel long distances for problems and delivery. What’s worse, due to poverty and distance, some don’t get much prenatal care; it can be hard for some of our patients to afford a tank of gas.

This is a critically important issue. Reproductive health has to be about helping pregnant women flourish and healthy children be born. A nation survives or falls based on its population. This nation is currently in steep demographic decline like so many others. And it's a dangerous thing.

We should advocate for women and children, not only for the good and survival of our patients but for the entire country. (And for dads too, by the way, who also want the best for their women and children.)

Every now and then I pull out a book chapter or video on difficult deliveries. I listen to refreshers when I'm at meetings. I want to know what to do even though it makes me viscerally unhappy to contemplate and causes me to break out in a slight cold sweat.

I expect that we in emergency departments will end up being the last best hope for mothers and babies, whether or not we have labor and delivery units. I fear that it will increasingly be “not” in much of the land outside of large cities.

Back to my story, the obstetrician was a little incensed that the mom arriving at our ED had no IV. “Why did she come in a BLS ambulance?” (That is, one with basic medics who can’t start IVs or give most medications.)

“Well, sir, I think that's just all that they had in her county.”

And what they will continue to have is less and less unless things change.