Tag: Hospitals

Patients and Doctors Trapped in a Gray Zone When Abortion Laws and Emergency Care Mandate Conflict

Each week, Dr. Kim Puterbaugh sees several pregnant patients at a Cleveland hospital who are experiencing complications involving bleeding or infection. The OB-GYN has to make quick decisions about how to treat them, including whether to remove the dead or dying fetus to protect the health and life of the mother. Leaving in place a fetus that has no chance of survival dramatically increases the chance of maternal infection and permanent injury.

But now her medical decisions are complicated by Ohio’s new abortion law, which generally prohibits abortions after six weeks of pregnancy if cardiac activity is detected in the embryo or fetus — which can persist for hours or days even if a pregnancy has no chance of progressing. Given the new law, University Hospitals Cleveland Medical Center has streamlined its system of having an administrator and legal team on call for Puterbaugh and other physicians if anyone questions whether the planned treatment is allowed under the law.

Since the Supreme Court erased the constitutional right to abortion in June, Puterbaugh said these cases put her and doctors like her in an impossible position — squeezing doctors between anti-abortion laws in Ohio and other states and the federal Emergency Medical Treatment & Labor Act. That 1986 law requires hospitals and physicians to provide screening and stabilizing treatment — including abortion, if necessary — in emergency situations.

“It’s a challenge to balance both those two things,” said Puterbaugh, president of the Society of OB/GYN Hospitalists. “But it’s not really a challenge to me because, in my mind, the life and health of the mother always comes first.”

The Biden administration argues that EMTALA trumps state abortion bans in emergency situations. On Aug. 2, the U.S. Department of Justice filed a federal lawsuit challenging an Idaho law that bans abortion in nearly all circumstances. The suit claims the law would make it a criminal offense for medical providers to comply with EMTALA’s requirement to provide abortion, if needed, for women experiencing emergency pregnancy complications.

In a July policy guidance and letter, the U.S. Department of Health and Human Services reaffirmed that EMTALA requires hospitals and physicians to offer life- or health-saving medical services, including abortion, in emergency situations. The letter refers to situations such as ectopic pregnancies, severe blood pressure spikes known as preeclampsia, and premature ruptures of the membrane causing a woman’s water to break before her pregnancy is viable.

The guidance stressed that this federal requirement supersedes any state laws that bar abortion, and that hospitals and physicians who don’t comply with the federal mandate could face civil fines and termination from the Medicare and Medicaid programs.

There are no known reports so far of EMTALA investigations arising from denial of emergency care in pregnancy situations.

But elected officials in states that have sharply restricted abortion disagree with the federal judgment. Texas Attorney General Ken Paxton sued the Biden administration last month to prevent the federal government from using the EMTALA law to require abortions in emergency cases. The suit claims that EMTALA doesn’t specifically mandate particular medical procedures such as abortion.

Abortion foes argue that state anti-abortion laws already include adequate exceptions when a pregnant woman’s life or health is in danger. John Seago, president of Texas Right to Life, said one of Texas’ laws specifies that treatment for ectopic pregnancies or miscarriages is not prohibited. In addition, the law defines a medical emergency allowing abortion as a condition in which a woman is at serious risk of a “substantial impairment of a major bodily function.”

Seago blamed the news media and medical associations for deliberately sowing confusion about the laws. “The law is very clear,” he said.

Legal wrangling aside, in practice, physicians and hospital lawyers say much depends on the interpretation of vaguely worded exceptions in state abortion bans, and that’s further complicated by the existence of contradictory laws, such as those banning abortion based on cardiac activity. And medical providers don’t want to risk criminal prosecution, fines, and loss of licensure if someone accuses them of violating these confusing laws.

Louise Joy, an attorney in Austin, Texas, who represents hospitals and other health care providers, said her clients perhaps are being overly cautious, but that’s not surprising. “I try to encourage them to do the right thing, but I can’t assure them they’ll be risk-free,” she said.

A lot hinges on when a pregnancy-ending complication is deemed an emergency, a moment that is hard to define. Some Missouri women have come to the hospital emergency department with mild cramping and bleeding and were found to have an ectopic pregnancy that hadn’t ruptured yet, colleagues have told Dr. Alison Haddock, a Houston emergency physician who chairs the board of the American College of Emergency Physicians. The standard treatment is to provide the drug methotrexate, which can terminate a pregnancy.

“You’re stable until it ruptures, then it becomes unstable,” she said. “But how unstable do you need to be? The woman’s life is not clearly at risk yet. It’s not clear if EMTALA applies. There will be a lot of gray areas that make it really tough for emergency physicians who want to do what’s right for patients without violating any laws.”

Physicians and hospital attorneys are hoping for clearer federal guidance and guarantees of protection from state prosecutors who might oppose their medical judgment on political grounds.

“This is when we need the federal government to step up and say, ‘Doctors, you must provide the standard of care, and we will prevent the prosecution of anyone who is following appropriate medical practices and doing the right thing for patients,” Joy said.

They are also hoping that the federal government will proactively investigate without waiting for complaints from individuals whenever appropriate emergency medical care might have been withheld because of the new laws. The New York Times reported last month that a 35-year-old woman in the Dallas-Fort Worth area was denied a dilation and evacuation procedure for her first-trimester miscarriage, despite severe pain and bleeding. The hospital reportedly sent her home with advice to return if she was bleeding heavily. The hospital did not respond to a request for comment for this article.

“If a hospital has a policy saying that when the correct medical procedure for a woman in the emergency department is abortion but physicians can’t do that, that’s a violation of EMTALA that CMS should find actionable,” said Thomas Barker, a former general counsel for the Centers for Medicare & Medicaid Services who advises hospitals on EMTALA compliance issues.

In another potential EMTALA case, Dr. Valerie Williams reported that after Louisiana implemented its near-total ban on abortion with criminal penalties last month, her hospital in the New Orleans area blocked her from performing a dilation and evacuation procedure on a pregnant patient whose water broke at 16 weeks. The patient was forced to go through a painful, hours-long labor to deliver a nonviable fetus, with heavy loss of blood.

“This was the first time in my 15-year career that I could not give a patient the care they needed,” Williams wrote in a court affidavit as part of a case seeking to block the state’s abortion law. “This is a travesty.”

But CMS often relies on state agencies to investigate alleged EMTALA violations. That raises questions about how seriously those investigations will be conducted in states where officials have embraced strict limits on any medical services they deem abortion-related.

Last month, the Texas Medical Association warned that hospitals are pressing doctors to send pregnant patients with complications home, to wait until they expel the fetus — known as expectant management — rather than treating them at the hospital to remove the fetal remains, according to The Dallas Morning News. In a letter to the Texas Medical Board, the medical association said delayed or denied care risks patients’ future reproductive ability and poses a serious risk to their immediate health.

A study published last month in the American Journal of Obstetrics and Gynecology found that after Texas implemented its tight abortion restrictions in September, patients with pregnancy complications experienced much worse outcomes than similar patients in states without abortion bans. Of those treated with expectant management at two major Dallas hospitals, 57% suffered serious complications such as bleeding and infection, compared with 33% who chose immediate pregnancy termination in other states.

OB-GYNs and emergency physicians say they expect to be on the phone frequently with lawyers to get advice on complying with state anti-abortion laws while they are seeing pregnant patients with emergency and near-emergency complications.

“This will endanger women’s lives, no question about it,” Puterbaugh said.

Patients and Doctors Trapped in a Gray Zone When Abortion Laws and Emergency Care Mandate Conflict

Each week, Dr. Kim Puterbaugh sees several pregnant patients at a Cleveland hospital who are experiencing complications involving bleeding or infection. The OB-GYN has to make quick decisions about how to treat them, including whether to remove the dead or dying fetus to protect the health and life of the mother. Leaving in place a fetus that has no chance of survival dramatically increases the chance of maternal infection and permanent injury.

But now her medical decisions are complicated by Ohio’s new abortion law, which generally prohibits abortions after six weeks of pregnancy if cardiac activity is detected in the embryo or fetus — which can persist for hours or days even if a pregnancy has no chance of progressing. Given the new law, University Hospitals Cleveland Medical Center has streamlined its system of having an administrator and legal team on call for Puterbaugh and other physicians if anyone questions whether the planned treatment is allowed under the law.

Since the Supreme Court erased the constitutional right to abortion in June, Puterbaugh said these cases put her and doctors like her in an impossible position — squeezing doctors between anti-abortion laws in Ohio and other states and the federal Emergency Medical Treatment & Labor Act. That 1986 law requires hospitals and physicians to provide screening and stabilizing treatment — including abortion, if necessary — in emergency situations.

“It’s a challenge to balance both those two things,” said Puterbaugh, president of the Society of OB/GYN Hospitalists. “But it’s not really a challenge to me because, in my mind, the life and health of the mother always comes first.”

The Biden administration argues that EMTALA trumps state abortion bans in emergency situations. On Aug. 2, the U.S. Department of Justice filed a federal lawsuit challenging an Idaho law that bans abortion in nearly all circumstances. The suit claims the law would make it a criminal offense for medical providers to comply with EMTALA’s requirement to provide abortion, if needed, for women experiencing emergency pregnancy complications.

In a July policy guidance and letter, the U.S. Department of Health and Human Services reaffirmed that EMTALA requires hospitals and physicians to offer life- or health-saving medical services, including abortion, in emergency situations. The letter refers to situations such as ectopic pregnancies, severe blood pressure spikes known as preeclampsia, and premature ruptures of the membrane causing a woman’s water to break before her pregnancy is viable.

The guidance stressed that this federal requirement supersedes any state laws that bar abortion, and that hospitals and physicians who don’t comply with the federal mandate could face civil fines and termination from the Medicare and Medicaid programs.

There are no known reports so far of EMTALA investigations arising from denial of emergency care in pregnancy situations.

But elected officials in states that have sharply restricted abortion disagree with the federal judgment. Texas Attorney General Ken Paxton sued the Biden administration last month to prevent the federal government from using the EMTALA law to require abortions in emergency cases. The suit claims that EMTALA doesn’t specifically mandate particular medical procedures such as abortion.

Abortion foes argue that state anti-abortion laws already include adequate exceptions when a pregnant woman’s life or health is in danger. John Seago, president of Texas Right to Life, said one of Texas’ laws specifies that treatment for ectopic pregnancies or miscarriages is not prohibited. In addition, the law defines a medical emergency allowing abortion as a condition in which a woman is at serious risk of a “substantial impairment of a major bodily function.”

Seago blamed the news media and medical associations for deliberately sowing confusion about the laws. “The law is very clear,” he said.

Legal wrangling aside, in practice, physicians and hospital lawyers say much depends on the interpretation of vaguely worded exceptions in state abortion bans, and that’s further complicated by the existence of contradictory laws, such as those banning abortion based on cardiac activity. And medical providers don’t want to risk criminal prosecution, fines, and loss of licensure if someone accuses them of violating these confusing laws.

Louise Joy, an attorney in Austin, Texas, who represents hospitals and other health care providers, said her clients perhaps are being overly cautious, but that’s not surprising. “I try to encourage them to do the right thing, but I can’t assure them they’ll be risk-free,” she said.

A lot hinges on when a pregnancy-ending complication is deemed an emergency, a moment that is hard to define. Some Missouri women have come to the hospital emergency department with mild cramping and bleeding and were found to have an ectopic pregnancy that hadn’t ruptured yet, colleagues have told Dr. Alison Haddock, a Houston emergency physician who chairs the board of the American College of Emergency Physicians. The standard treatment is to provide the drug methotrexate, which can terminate a pregnancy.

“You’re stable until it ruptures, then it becomes unstable,” she said. “But how unstable do you need to be? The woman’s life is not clearly at risk yet. It’s not clear if EMTALA applies. There will be a lot of gray areas that make it really tough for emergency physicians who want to do what’s right for patients without violating any laws.”

Physicians and hospital attorneys are hoping for clearer federal guidance and guarantees of protection from state prosecutors who might oppose their medical judgment on political grounds.

“This is when we need the federal government to step up and say, ‘Doctors, you must provide the standard of care, and we will prevent the prosecution of anyone who is following appropriate medical practices and doing the right thing for patients,” Joy said.

They are also hoping that the federal government will proactively investigate without waiting for complaints from individuals whenever appropriate emergency medical care might have been withheld because of the new laws. The New York Times reported last month that a 35-year-old woman in the Dallas-Fort Worth area was denied a dilation and evacuation procedure for her first-trimester miscarriage, despite severe pain and bleeding. The hospital reportedly sent her home with advice to return if she was bleeding heavily. The hospital did not respond to a request for comment for this article.

“If a hospital has a policy saying that when the correct medical procedure for a woman in the emergency department is abortion but physicians can’t do that, that’s a violation of EMTALA that CMS should find actionable,” said Thomas Barker, a former general counsel for the Centers for Medicare & Medicaid Services who advises hospitals on EMTALA compliance issues.

In another potential EMTALA case, Dr. Valerie Williams reported that after Louisiana implemented its near-total ban on abortion with criminal penalties last month, her hospital in the New Orleans area blocked her from performing a dilation and evacuation procedure on a pregnant patient whose water broke at 16 weeks. The patient was forced to go through a painful, hours-long labor to deliver a nonviable fetus, with heavy loss of blood.

“This was the first time in my 15-year career that I could not give a patient the care they needed,” Williams wrote in a court affidavit as part of a case seeking to block the state’s abortion law. “This is a travesty.”

But CMS often relies on state agencies to investigate alleged EMTALA violations. That raises questions about how seriously those investigations will be conducted in states where officials have embraced strict limits on any medical services they deem abortion-related.

Last month, the Texas Medical Association warned that hospitals are pressing doctors to send pregnant patients with complications home, to wait until they expel the fetus — known as expectant management — rather than treating them at the hospital to remove the fetal remains, according to The Dallas Morning News. In a letter to the Texas Medical Board, the medical association said delayed or denied care risks patients’ future reproductive ability and poses a serious risk to their immediate health.

A study published last month in the American Journal of Obstetrics and Gynecology found that after Texas implemented its tight abortion restrictions in September, patients with pregnancy complications experienced much worse outcomes than similar patients in states without abortion bans. Of those treated with expectant management at two major Dallas hospitals, 57% suffered serious complications such as bleeding and infection, compared with 33% who chose immediate pregnancy termination in other states.

OB-GYNs and emergency physicians say they expect to be on the phone frequently with lawyers to get advice on complying with state anti-abortion laws while they are seeing pregnant patients with emergency and near-emergency complications.

“This will endanger women’s lives, no question about it,” Puterbaugh said.

To Retain Nurses and Other Staffers, Hospitals Are Opening Child Care Centers

When Jennifer Lucier and her husband found out they were expecting a baby in 2016, they immediately made three phone calls.

The first was to her mother. The second was to her husband’s family. And the third was to the Roper St. Francis Healthcare Learning Center.

That last call, she felt, was particularly urgent. Lucier wanted to secure a spot for her unborn infant on the day care’s long waiting list.

Lucier works as a cardiovascular ICU nurse for Roper St. Francis Healthcare, the only hospital system around Charleston, South Carolina, that operates a child care center for the children of its employees.

The catch is there isn’t room for everyone. Roper St. Francis employs 5,000 people, and its day care can accommodate only 130 infants and children. More than 100 children typically sit on that waiting list. Lucier’s newborn was 9 months old before an opening became available.

“We were ecstatic,” said Lucier, who also gave birth to twins in 2020. Her children are still enrolled in the Learning Center.

Roper St. Francis Healthcare opened the facility more than 30 years ago to address a perennial human resources problem: recruitment and retention. Today, it remains one of the relatively few hospital systems in the United States to operate a full-time child care center for its employees, though that appears to be changing. Some hospitals are now considering child care centers as a means of solving one of the pandemic era’s big challenges: persuading employees to stay.

Nationally, only about 1 in 10 workers have access to employer programs that cover some or all of the costs for child care services — either on the job site or off — according to a report published last year by the U.S. Department of Labor. The health sector seems to be doing more: About one-third of U.S. hospitals offer child care benefits.

But the data obscures the wide variation of those benefits. Some hospitals provide access only to backup care so parents can make last-minute arrangements for sick children. Even among hospitals that offer more robust benefits, many parents, like Lucier, end up spending time on a waiting list.

Hospitals scrambled at the beginning of the pandemic to accommodate clinical staff members who suddenly found themselves unable to both work and care for their kids. More than two years later, most do not offer permanent solutions for parents facing the country’s ongoing child care crisis. Meanwhile, thousands of child care providers, ranging from small, at-home programs to large day care facilities, have closed since early 2020, making it even more difficult for families to secure care than it was for Lucier when she first gave birth.

These challenges are felt across all business sectors. A benefits report published by Care.com this year estimated that at least 4 million U.S. workers resigned each month during the second half of 2021, nearly half of them citing that they were struggling with child care or senior care challenges.

But retention has become a particularly urgent issue when it comes to nurses, who are overwhelmingly women and who have resigned from hospitals in huge numbers during the pandemic, citing burnout, stressful working conditions, and other workplace problems. In fact, the number of registered nurses in the U.S. dropped by more than 100,000 last year — “a far greater drop than ever observed over the past four decades,” according to a report published by Health Affairs. In a recent McKinsey & Co. survey involving hundreds of nurses, 32% indicated they may leave their current position within the next year.

“People are leaving the industry because they’re not able to balance work and life,” said Priya Krishnan, senior vice president of client relations for Bright Horizons, the largest provider of employer-sponsored child care in the country.

Bright Horizons operates 82 hospital-based child care centers out of 655 centers it runs across the country. Krishnan said most of the recent conversations the company is having with potential clients have been with hospitals.

“Retention is the biggest reason they’re thinking about this,” she said.

The federal government offers businesses an annual tax credit worth up to $150,000 for providing child care to employees. Indirect financial incentives also exist. According to the 2022 “National Health Care Retention & RN Staffing Report” published by NSI Nursing Solutions, hospitals lose an average of about $46,000 when a bedside nurse resigns, which equaled about $7 million in nursing turnover costs for the average hospital in 2021.

But anecdotal evidence offered by Roper St. Francis suggests that employees whose children are enrolled in the Learning Center are much less likely to leave. The system experienced significant turnover during the pandemic, said Melanie Stith, its vice president for human resources. But during that time, she said, only two employees whose children attended the Learning Center resigned.

In a recent survey of parents who use the Learning Center, 91% indicated that the child care facility was the reason they remained in their jobs. Roper St. Francis loses money operating the Learning Center, but it’s still considering an expansion of child care services as it builds a bigger hospital in nearby Berkeley County.

That’s not to say, historically, that money hasn’t been made in child care. Bright Horizons, founded in the 1980s with an investment from Bain Capital, made hundreds of millions of dollars for the private equity firm. Now publicly traded, its shares are worth about half what they were at the peak of their value in February of last year.

Some hospitals still consider child care a good investment.

“I look at this as being a really, really vital piece of the benefits package, especially for families with kids who are infants to school-age,” said Rebecca Gomez, a clinical health psychologist at Wellstar Health System, based in the Atlanta area. Both of her children are enrolled in Wellstar’s Learning Academy operated by Bright Horizons.

“Everything about it has made my life so much easier,” Gomez said.

As with the Roper St. Francis Healthcare Learning Center in Charleston, Wellstar employees often end up waiting for an available spot. And Wellstar doesn’t operate child care facilities on every hospital campus, Gomez said.

Even so, the breadth of Wellstar’s child care offerings makes it an outlier. Other notable examples include Mass General Brigham in Boston and NewYork-Presbyterian, both of which have long offered child care for employees. And while providing on-site child care remains rare, hospitals are increasingly exploring options for it.

Ballad Health — a hospital system with medical facilities in Appalachian Tennessee, Virginia, and North Carolina — recently announced it will invest $37 million over the next three years to build 11 child care centers, in addition to the three it already operates. The expansion will allow the system based in Johnson City, Tennessee, to increase its child care capacity from 200 slots to 2,000.

For employees, hospital-based child care isn’t typically free. Roper St. Francis Healthcare in Charleston charges all parents who use the Learning Center a weekly rate, ranging from $200 to $220, based on the age of the child, slightly higher than the market average.

Some hospital systems create a sliding scale that takes into consideration the employee’s salary. A doctor, for example, might pay more than an X-ray tech to enroll a child. Ballad Health recently polled employees, who indicated, on average, they could afford to pay about $145 per child per week.

Like many hospital systems, Ballad has struggled to keep nurses from leaving during the pandemic. But it’s also competing with other regional employers for jobs. Tony Keck, executive vice president of system innovation at Ballad Health, said a new casino in Bristol, Virginia, recently hired 600 people. It’s expected over the next few years to hire thousands more, he said.

“We’re not just competing for doctors and nurses,” Keck said. The hospital also needs to attract housekeeping staff and other lower-wage workers whom the casino and others are targeting.

But nurses are particularly crucial. Keck said Ballad Health raised its starting nursing salary by more than 30% over the past two years, but hospitals in nearby markets such as Knoxville — which paid nurses higher salaries to begin with — raised their rates, too.

“We can’t keep up with that,” he said. Ballad Health leaders hope the new child care centers will offer the system a competitive advantage, “which is why we’re trying to move as quickly as possible,” he said.

‘American Diagnosis’: Two Indigenous Students Share Their Path to Medicine


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The transcript for this segment is being processed. We’re working to post it four to five days after the episode airs.


Episode 9: “Two Paths, Two Future Physicians”

In 1890, Dr. Charles Eastman became the first Native person to graduate from medical school in the United States. Today, one of his descendants, Victor Lopez-Carmen, is a third-year student at Harvard Medical School. He described feeling isolated there.

“I did feel alone. There wasn’t any Native person around me I could turn to,” said Lopez-Carmen.

Less than 1% of medical students in the United States identify as American Indian or Alaska Native. That’s according to a 2018 report from the Association of American Medical Colleges and the Association of American Indian Physicians.

Lopez-Carmen is working to change that. In 2021, he co-founded the Ohiyesa Premedical Program, which provides mentorship and support to Native American students as they navigate the medical school application process.

A digital illustration in pencil and watercolor. A smiling Indigenous woman wearing is wearing doctor's coat and has a stethoscope around her neck. She wears a pair of dangly beaded earrings which are orange, black, and white. The earrings appear to be radiating light, to emphasize their importance in the image.
(Oona Tempest / KHN, Little E Creations (Earrings))

While Lopez-Carmen is mentoring future medical students in Boston, in Oklahoma, Ashton Glover Gatewood has found community at the first medical school in the United States affiliated with a Native tribe. Gatewood attends Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation.

“I told my husband about it, and he said, ‘That sounds like they’re building you a medical school. You have to go,’” Gatewood said.

She’s noticed a “momentum” in medical training that she said could one day lessen the health care disparities Indigenous people experience.

Episode 9 explores the barriers Indigenous people face to becoming physicians and includes the stories of two medical students working to join the ranks of Indigenous health care workers in the U.S.

Voices from the episode:

  • Victor Lopez-Carmen, student at Harvard Medical School — @vlocarmen
  • Mary Owen, director, Center of American Indian and Minority Health at the University of Minnesota, and president, Association of American Indian Physicians

Season 4 of “American Diagnosis” is a co-production of KHN and Just Human Productions.

Our Editorial Advisory Board includes Jourdan Bennett-BegayeAlastair Bitsóí, and Bryan Pollard.

To hear all KHN podcasts, click here.

Listen and follow “American Diagnosis” on Apple Podcasts, Spotify, Google, or Stitcher.

After New Abortion Laws, Some Patients Have Trouble Obtaining Miscarriage Treatment

Surgical procedures and medication for miscarriages are identical to those for abortion, and some patients report delayed or denied miscarriage care because doctors and pharmacists fear running afoul of abortion bans.

Nurse Midwives Step Up to Provide Prenatal Care After Two Rural Hospitals Shutter Birthing Centers

MUSCATINE, Iowa — Bailee Tordai, who was 33 weeks into her pregnancy, barely made it to the prenatal checkup. Her clunky old Jeep couldn’t complete the 2-mile trip from her house to the University of Iowa’s outreach clinic in her southeastern Iowa hometown. It was a hot June day, and a wiring problem made the Jeep conk out in the street.

A passerby helped Tordai, 22, push her stricken vehicle off the road and into a parking lot. Then she called her stepdad for a ride to the clinic.

Jaclyn Roman, a nurse midwife, walked into the exam room. “I heard your car broke down.”

“Yup. You want to buy it? Five bucks!” Tordai joked.

Her lack of reliable transportation won’t be a laughing matter in August, when her baby is due. She will need to arrange for someone to drive her about 40 miles northwest to the University of Iowa Hospitals and Clinics in Iowa City. She can’t give birth at Muscatine’s hospital because it shuttered its birthing unit in 2020.

Roman is part of an unusual effort to minimize the harm caused by such closures. She’s one of 11 certified nurse midwives from the University of Iowa who travel regularly to Muscatine and Washington, another southeastern Iowa town where the local hospital closed its birthing unit. The university’s pilot project, which is supported by a federal grant, doesn’t aim to reopen shuttered birthing units. Instead, the midwife team helps ensure area women receive related services. Last year, it served more than 500 patients in Muscatine and Washington.

Muscatine is one of hundreds of rural areas in the U.S. where hospitals have dropped birthing services during the past two decades, often because they lack obstetricians and other specialized staff members.

Hospital industry leaders say birthing units also tend to lose money, largely because of low payments from Medicaid, the public health insurance program that covers more than 40% of births in the U.S. and an even greater share in many rural areas.

The loss of labor-and-delivery services hits especially hard for women who lack resources and time to travel for care.

Muscatine, which is on the Mississippi River, has more than 23,000 residents, making it a relatively large town by Iowa standards. But its hospital is one of 41 Iowa facilities that have closed their birthing units since 2000, according to the Iowa Department of Public Health. Most were in rural areas. Just one has reopened, and only 56 Iowa hospitals now have birthing units.

The nurse midwife team’s work includes crucial prenatal checkups. Most pregnant people are supposed to have a dozen or more such appointments before giving birth. Health care providers use the checkups to track how a pregnancy is progressing and to watch for signs of high blood pressure and other problems that can lead to premature births, stillbirths, or even maternal deaths. The midwives also advise women on how to keep themselves and their babies healthy after birth.

Karen Jefferson, director of midwifery practice for the American College of Nurse-Midwives, said the University of Iowa team’s approach is an innovative way to address needs in rural areas that have lost hospital birthing units. “How wonderful would it be to see a provider in your town, instead of driving 40 miles for your prenatal visits — especially toward the end of pregnancy, when you’re going every week,” said Jefferson, who lives in rural New York.

Midwives can provide many other types of care for women and for babies. In theory, they could even open rural birthing centers outside of hospitals, Jefferson said. But they would need to overcome concerns about financing and about the availability of surgeons to do emergency cesarean sections, which she said are rarely needed in low-risk births.

The University of Iowa midwives focus on low-risk pregnancies, referring patients with significant health issues to physician specialists in Iowa City. Often, those specialists can visit with the patients and the midwives via video conference in the small-town clinics.

The loss of a hospital obstetrics unit can make finding local maternity care harder for rural families.

Tordai can attest that if patients must travel far for prenatal appointments, they’re less likely to get to them all. If she had to go to Iowa City for each of hers, repeatedly taking three hours off from her job managing a pizza restaurant would be tough, she said. On that June day her Jeep broke down, she would have canceled her appointment.

Instead, she wound up on an exam table at the Muscatine clinic listening to her baby’s heartbeat on a monitor and watching as Roman measured her belly.

“Nice job being perfect,” the midwife told her during the checkup.

Roman asked Tordai to describe her baby’s movements. “Constant,” she replied with a smile.

Roman asked whether she planned to breastfeed. Tordai said she didn’t have much luck with her first daughter, Aspen, now 4.

“Have you thought about a breastfeeding class?” the midwife asked.

“I don’t have time for that,” Tordai replied. Roman continued to coax her, noting where a breastfeeding class is available online.

Near the end of the appointment, Tordai asked Roman whether she could schedule an induced birth at the University of Iowa hospital. The midwife told her that, in general, letting labor begin on its own is better than artificially starting it.

But there was the matter of unreliable transportation. Tordai explained that scheduling the birth would help her arrange to have her mother drive her to the hospital in Iowa City. Roman agreed that transportation is a legitimate reason and arranged for an induced labor on Aug. 10.

The University of Iowa midwife team started offering services in 2020 in a clinic about 2 miles from Trinity Muscatine hospital. The hospital is owned by UnityPoint Health, a large nonprofit hospital system that blamed a lack of available obstetricians for the closure of the Muscatine birthing unit. At the time, UnityPoint leaders said they hoped to reopen the unit if they could recruit new obstetricians to the area.

Kristy Phillipson, a UnityPoint Health spokesperson, told KHN in June that the company has continued to try to recruit physicians, including for the Muscatine hospital. Although it has not reopened the birthing unit, the company regularly sends an obstetrician and other staff members to provide prenatal care and related services, she said.

Most pregnant patients from the area who choose UnityPoint for their care wind up giving birth at the system’s hospital in Bettendorf, a 45-minute drive to the east.

The University of Iowa midwife team has no plans to open its own birthing centers. But it hopes to expand its rural clinic service to other underserved towns. To do so, the university would need to hire more nurse midwives, which could be a challenge. According to the Iowa Board of Nursing, 120 licensed nurse midwives live in the state of 3 million people.

The University of Iowa plans to address that by starting the state’s first nurse midwife training program in 2023. The master’s degree program, which will emphasize rural service, will train registered nurses to become nurse midwives. It eventually could graduate eight people per year, said Amber Goodrich, a University of Iowa midwife helping lead the effort.

Those graduates could fill gaps throughout rural areas, where even more hospitals may shutter their birthing units in the coming years.

“This crisis is going nowhere fast,” Goodrich said.

Hundreds of Suicidal Teens Sleep in Emergency Rooms. Every Night.

With inpatient psychiatric services in short supply, adolescents are spending days, even weeks, in hospital emergency departments awaiting the help they desperately need.