Bethany Rodgers, Pocono Record
Some days, Tiffany Rodriguez’s hands swelled up so badly she could barely make a fist, and simple tasks like hooking her bra or putting on her pants seemed to take forever.
Because of the soaring hypertension she experienced during the second half of her pregnancy, the 31-year-old from Montrose, was also coming down with pounding headaches and noticing spots or blurry patches in her field of vision. As her blood pressure continued to tick upward, doctors were growing concerned about the health of her pregnancy. But Rodriguez was determined to do whatever she could to carry her baby, Carter, until his scheduled delivery in mid-August.
She asked for shorter shifts at the local supermarket deli, a job that keeps her on her feet for hours at a time. She also hustled to a battery of prenatal checkups to make sure her hypertension didn’t worsen into preeclampsia, a serious condition that can cause preterm birth and endanger the life of the mother. Every week, she was supposed to go in for her standard doctor’s visit, plus sit through tests to monitor her baby’s heart rate, a process that could take hours at a time. And with a 30- or 45- minute drive between her rural township and these medical services, these visits could consume half of her day.
There was little choice considering the lack of specialized maternity services in her community, a small northeastern Pennsylvania town ringed with bluestone quarries and soaring old-growth hemlock forests. Rodriguez’s hometown — where she recently returned for a fresh start after leaving a marriage she says was unhealthy — also boasts a brewery, an annual blueberry festival and a handful of fast-food options. But there are no obstetricians working at its local hospital. And there are none at Susquehanna County’s only other hospital, which shut down its maternity unit in the 1990s. A wave of other small-town hospitals in Pennsylvania have followed suit, forcing Rodriguez and many other rural women to seek services and give birth in facilities farther and farther from where they live.
In 2020, six Pennsylvania counties, Cameron, Forest, Greene, Juniata, Sullivan and Wyoming, met the criteria for a maternity desert because of the absence of delivery hospitals or obstetricians in those areas, according to the March of Dimes. These deserts are only expected to multiply, experts say. In some cases, women are so far away from the hospital where they’ll give birth that they have to schedule their deliveries, according to one obstetrician. These deserts can also hinder them from accessing the prenatal care that can keep them and their babies healthy during their pregnancies.
For Rodriguez, several overlapping challenges made it tough to get to appointments. She’s a single mother of a 10-year-old daughter, and finding childcare can be difficult. And it wasn’t always easy to clear space in her schedule at the deli, work she’s banked on to secure an apartment for her, her daughter and her new baby. Then, there are the fuel costs to consider. Rodriguez said one week she spent six days in a row driving to medical appointments in Scranton, Wilkes-Barre and Tunkhannock. “It was like $120 almost in gas just for those days to go to the doctor’s,” she said during an early August interview.
Rodriguez, health workers and Pennsylvania policymakers agree these rural communities need more maternal healthcare resources. But experts say there’s no quick fix to the financial pressures and staffing shortages that are driving delivery rooms and clinics to close, especially with aging populations and declining birth rates.
“Some of the smaller facilities are going to feel (the demographic changes) and then really struggle to be able to keep the lights on,” said Dr. Amanda Flicker, an OB/GYN and chair of the Pennsylvania section of the American College of Obstetricians and Gynecologists. “We just have to decide … that the health of mothers and the safe birth for newborns is something we need to prioritize.”
Expanding deserts
Money is one major driver in the closure of delivery rooms and even entire hospitals across Pennsylvania, health experts say.
Since 2005, nine rural Pennsylvania hospitals have closed or transitioned to specialty care as it’s become increasingly difficult to keep these types of medical facilities operating in the black. Another 17 have chosen to eliminate their labor and delivery units, according to a Hospital and Healthsystem Association of Pennsylvania analysis.
“The fact that we see fewer labor and delivery units in rural communities is not in any way a statement about the dedication of those hospitals to providing comprehensive care,” said Lisa Davis, who directs the Pennsylvania Office of Rural Health. “It just means they may not be able to afford it.”
One issue: Medicaid, which covers about half of all rural births nationwide, fails to provide adequate reimbursement rates for obstetric care, according to a 2022 U.S. Government Accountability Office analysis. Doctors say there are issues with private insurance as well, noting that carriers often offer a bundled payment for obstetrics, regardless of how much care a particular woman ends up needing.
“No matter how many times I see them, whether they get a vaginal delivery or a C-section, I’m getting paid by the insurance company one flat fee for all of their care,” said Dr. Stacy Beck, an OB/GYN at UPMC Magee-Womens Hospital in Pittsburgh and co-chair of the Pennsylvania Maternal Mortality Review Committee.
In addition, obstetricians and gynecologists deal with high liability insurance costs because of the number of malpractice claims they face.
In 2020, insurance premiums for OB/GYNs in Philadelphia totaled almost $120,000 each, about $30,000 more than general surgeons and $95,000 more than internists, according to an American Medical Association analysis of selected insurance companies. The staffing demands of a labor and delivery unit make it even harder to keep them open.
Because babies can arrive at any hour, these units require the round-the-clock presence of nurses and physicians, but it’s becoming increasingly challenging for hospitals to fill these shifts.
The medical field in general is facing labor shortages, and the taxing nature of a job in the maternity ward can make it even harder to retain specialists, according to health experts. As many as three-quarters of OB/GYNs experience professional burnout, an American College of Obstetricians and Gynecologists report found.
“It’s really just, where have the doctors gone?” said Flicker, chair of obstetrics and gynecology in the Lehigh Valley Health Network.
Many are taking early retirements, she said, or moving out of direct clinical care. The same thing is happening with nurses in maternity units, Flicker added.
Even outside hospitals, obstetricians are in short supply in many rural parts of Pennsylvania, and of those who are practicing, a higher percentage are over age 75 compared to other areas of the commonwealth, according to a report by the Center for Rural Pennsylvania.
The number of OB/GYNs in Pennsylvania is expected to flatline between 2018 and 2028, with 0% growth forecasted by analysts at Projections Central, a federally-funded program that makes state and local projections. And that prognostication doesn’t take into account the rural-urban divide.
New physicians are sometimes reluctant to leave urban areas where they have more professional support and community amenities, so reversing that trend could be challenging, experts say. The erosion of robust health systems in some rural communities can also discourage health providers from moving into them, creating something of a vicious cycle, said Davis, director of the rural health office.
In the meantime, services continue receding. Wilkes-Barre General Hospital is among the latest medical facilities to stop delivering babies.
Erica Acosta, director of diversity initiatives at Wilkes University, was one of the women who’d been planning to give birth there. But about halfway through her pregnancy, when the hospital announced it would close its maternity ward, she had to make a quick pivot to another medical center and another physician.
Acosta said she’d chosen her original provider carefully; as a woman of color, she’s intentional about seeking physicians who look like her, although that’s not always easy because of the lack of diversity in the medical field, she said. And though her pregnancy has been free of complications so far, she said it was still difficult to lose an OB/GYN who’d been with her since she started contemplating having a second child.
“It’s very traumatic because you build trust. I told them I want to have a baby. They already knew my life story,” she said. “So now I have to start over and be vulnerable with people I don’t know.”
The importance of maternity care
For many young and healthy pregnant women, prenatal visits mostly provide reassurance that their babies are developing normally and everything is on track, Beck said.
But with increasing obesity rates and the number of women who are having babies later in life, she explained, more pregnancies are no longer in the low-risk category, and these medical appointments can play an essential role in addressing pre-existing diseases and other health concerns.
During early visits, physicians check a pregnant patient’s general health and monitor her for signs of preeclampsia. In certain cases, it might have been years since a person has seen a medical professional.
“Sometimes pregnancy is the only time we get the opportunity to take care of decades of diabetes or high blood pressure that somebody has not been controlling,” Beck said.
Prenatal care is also vital in screening for substance-use disorders, medical experts say. Accidental or intentional overdoses are the leading cause of maternal death in Pennsylvania, and Flicker said it’s scary to see hospitals closing and providers leaving in rural communities where at-risk women live.
Researchers have linked fewer pregnancy appointments to preterm birth and low birth weight. Still, in rural Somerset County, roughly one of every 20 babies is born without any prenatal care, according to the Center for Rural Pennsylvania. And the number of women in southcentral Pennsylvania who are forgoing a first-trimester doctor’s visit is on the rise, said Kim Amsley-Camp, a Chambersburg-based midwife with Keystone Health.
Getting to these appointments can be challenging for many women, especially those who live far away from the nearest hospital or clinic. Women who don’t have their own cars or who share one with a partner struggle to travel to their appointments, especially considering the lack of robust public transportation options in many rural areas, experts say.
Others already have kids and don’t have anyone to watch their children while they’re away at a doctor’s office or can’t afford to take time off from their jobs. Particularly in the aftermath of the COVID-19 pandemic, some people distrust the medical profession, Amsley-Camp said, and many don’t have adequate insurance coverage.
Davis said some pregnant women access services in their local emergency rooms, which she said is an important option but is also expensive and deprives the patient of the ability to form a long-term relationship with prenatal providers. Distance can also create complications when it’s time to give birth, experts say.
For women who aren’t sure if they’re in labor, heading over to the hospital might not be a big deal if they live a few minutes down the road. The decision looks much different when someone is an hour or more away and doesn’t want to make an unnecessary trip, Amsley- Camp said.
Davis has been hearing about paramedics in rural areas delivering babies in the back of ambulances rushing to the hospital but unable to make it in time. Between 2010 and 2020, the number of live births that happened in Pennsylvania homes and doctor’s offices (or other locations outside of a hospital or birthing center) shot up by roughly 50%, even as the overall number of deliveries declined, according to state health department data, though these figures are not broken down between rural and urban counties. Amsley-Camp knows of one woman who gave birth to twins in her driveway.
As people move to rural areas with the telework boom, healthcare access could be one factor as they choose a small-town home, says Abby Weaver, a mother and business owner in Schuylkill County. As Weaver recently navigated a complicated pregnancy, she says she appreciated the proximity of her town’s hospital, which is part of the Lehigh Valley Health Network. A recent Center for Rural Pennsylvania report found that more people were moving into rural counties than out of them in 2019 and 2020. But Weaver, who has been part of Pottsville’s revitalization efforts for the past six or seven years, said new arrivals often expect big-city amenities and services to follow them. “You have to be able to match things like what you see in bigger cities, like a coffee shop, like good health care, like good school systems, for people to choose you,” she said.
What are the solutions?
There aren’t any simple ways to halt the expansion of Pennsylvania’s maternity deserts, but analysts and experts are full of ideas about where to start.
Increasing Medicaid rates — which are set at a state level — could make a dent in the problem, but Davis said because of policymakers’ reluctance to drive up healthcare costs, the chances of that happening in the near future seem remote. The commonwealth’s leaders could also look at expanding transportation services in rural communities, working with the Pennsylvania Department of Transportation to add ride programs, she said. Doing more to recruit health professionals and opening more standalone birthing centers — which now operate only in Pennsylvania’s urban counties — could also make a difference.
Christine Haas, executive director of the Midwife Center in Pittsburgh, said the proliferation of facilities like hers could definitely be part of closing service gaps. But she said various barriers stand in the way: There are steep startup costs for opening a birth center, and these facilities sometimes struggle with state requirements, such as needing to have a physician serve as a medical director. Even the Midwife Center, which Haas said is one of the nation’s largest birth centers, opted against opening a second location because of the challenges involved, she said.
However, change could be on the horizon as congressional lawmakers consider legislation that would aim to improve reimbursement for services offered by freestanding birth centers, Haas said. This bipartisan legislation, called the BABIES Act, has been introduced in both the U.S. House and Senate. The Center for Rural Pennsylvania report also suggests the commonwealth could make more of the midwives, doulas, lactation consultants and other medical professionals to help close some of the provider gaps.
For example, nurse-midwives must now have an established collaborative agreement with a physician in order to practice to the full extent of their training, and many times that means they must affiliate with a large medical system, according to Amsley-Camp. These restrictions can prevent midwives from being able to open their own smaller practices in underserved areas, she said. “To have a practice out of these outlying counties would be fantastic,” she said. “But if the (midwife) is not working for one of these big organizations, the physician is not going to sign on. It’s an unknown entity.”
With the expansion of telehealth, medical providers can also look at handling some prenatal visits virtually rather than making women come into the practice every time. In more remote areas, maybe it makes sense to send pregnant people home with a scale and a blood pressure cuff to use during online appointments so they can avoid a few long drives to the clinic, Flicker said. In order for that to work, though, many rural communities would need better access to broadband.
And with nonprofit groups already targeting rural underserved populations, state lawmakers could consider making more investments in programs that already exist, according to the Center for Rural Pennsylvania report. Federally-qualified health centers, or federally-funded nonprofit clinics that target underserved populations, are one important resource for rural communities, experts say. One of them, Primary Health Network, runs about 50 sites in 16 Pennsylvania counties, providing care regardless of a patient’s insurance status or ability to pay, according to George Garrow, the organization’s chief executive officer. These centers don’t have delivery rooms, but they do provide prenatal and postpartum services and help patients confront any barriers to accessing care, Garrow said.
Rodriguez, the expectant mother in Montrose, said she isn’t sure how she’d have managed if not for Elizabeth Cassidy, a nurse who works for a Pennsylvania nonprofit called Maternal and Family Health Services. While she has to navigate winding rural highways to most of her appointments, Cassidy comes to Rodriguez, spending time chatting on her living room couch or in the local Dunkin’ Donuts. She was the first to help Rodriguez identify her blood pressure as a concern, and the pregnant woman says she’s come to consider the nurse a friend. “I would probably fight somebody if they were mean to her,” joked Rodriguez, who ended up delivering her son Aug. 18.
The nurse-family partnership, a program within Maternal and Family Health Services serving lower-income mothers, assigns nurses like Cassidy to meet with clients throughout their pregnancy and in the first two years of their child’s life. Through the program, Rodriguez has also gotten access to educational resources, baby supplies and sessions with a trained counselor. While Maternal and Family Health Services operates in eastern Pennsylvania, different organizations run nurse-family partnerships in other parts of the commonwealth. However, about 20 counties fall outside the program’s scope, and because it targets first-time mothers and includes income restrictions, not all families are eligible.
Cassidy says the challenges Rodriguez faces in accessing medical care are not uncommon for the women she serves. “Nothing is closer than 40 minutes, 45 minutes for any of these clients,” she said.
The USA Today Network is covering health care access issues in rural parts of the commonwealth. As part of this reporting, we’re interested in hearing from Pennsylvanians in these communities who have struggled to access medical, dental and mental health care. Fill out the form at bit.ly/pa-maternity and your response will go directly to a USA Today Network reporter. You may be contacted for further details about your story.