CPAT

Stay Informed

As hospitals close labor wards, large stretches of California are without maternity care

Cal Matters
November 15, 2023
BY KRISTEN HWANG, ANA B. IBARRA AND ERICA YEE

IN SUMMARY

As maternal mortality rates are steadily worsening across California, a CalMatters analysis finds that maternity wards are closing at an alarming rate.

 

El Centro Regional Medical Center delivered the last baby at its 67-year-old maternity ward in early January. Then it closed its obstetrics department, leaving just one other hospital to deliver the approximately 2,500 babies born every year in Imperial County.

A month later and 625 miles north, Sonoma County residents lambasted the health system Providence for its decision to cease labor and delivery services at Petaluma Valley Hospital despite promises to keep it open through 2025.

Last month, Tri-City Medical Center in northern San Diego County and Centinela Hospital in Inglewood joined the growing list of hospitals nixing their labor and delivery wards.

These closures are among the latest in an accelerating trend: At least 46 California hospitals have shut down or indefinitely suspended labor and delivery since 2012, according to a CalMatters analysis of hospital records submitted to the state. This includes seven hospitals that closed entirely.

Twenty seven of the maternity ward and hospital closures have taken place in the last three years.

These rapid-fire closures leave huge swaths of California with dwindling access to obstetrics services, leading to longer travel times and additional barriers to care. Twelve counties, most of them rural, do not have any hospitals delivering babies. Latino and low-income communities have been hit hardest by losses, according to a CalMatters analysis of census tract data. The wave of closures is among the largest reduction of medical services in California since 23 hospitals closed in the late 1990s.

The closures come as the country and state grapple with a maternal mortality crisis. Pregnancy-related deaths reached a 10-year high in 2020, according to state data. The state estimates nearly 60% of maternal deaths are preventable.

“At a time where we are finally recognizing that there are disparities within our health care system, when we are recognizing that there are disparities in the outcomes of our pregnant patients and their infants…we’re also at the same time increasing those disparities with these maternity ward closures,” said Assemblymember Akilah Weber, an obstetrician and Democrat from La Mesa.

In contrast, very few new maternity wards have opened in the past decade. CalMatters identified eight new maternity wards since 2012, driven almost exclusively by the construction of new hospitals. In total, the number of hospitals delivering babies in California has dropped from at least 250 in 2012 to 214 today.

Maternity ward closures are often controversial and followed by community uproar. For example, Petaluma Valley Hospital’s suspension of services spurred local protests and heated discussions during public meetings. News reports showed nurses and other picketers carrying signs saying “Nobody wants to deliver a baby on the road!” and “Keep moms & babies safe.”

Sometimes closures happen more quietly. Hospitals are required to notify the California Department of Public Health when they reduce or eliminate services. CalMatters requested that information seven months ago, and the state has still not provided it.

CalMatters identified the closures by analyzing hospital financial reports and utilization data between 2011 and 2022, as well as from news reports and interviews.

Hospital administrators cite a myriad of reasons for the closures: High costs, labor shortages and declining birth rates. In the past 30 years, the number of births in California has dropped by half, and the birth rate is at its lowest level on record. The trend is not unique to California; labor and delivery units are shuttering across the country. But experts say the rapidly increasing number of closures the state has seen, especially in just the past three years, is concerning.

“Understanding that communities need a place where their residents can go and safely deliver a baby is not something that is a luxury,” Weber said. “It is a necessity.”

Limited choices for maternity care

Homes and agricultural fields in Calexico on Oct. 25, 2023. Photo by Adriana Heldiz, CalMatters

These maternity ward closures have disproportionately impacted California’s low-income and Latino populations as well as communities where access to maternal care is already limited.

According to a CalMatters analysis of census tracts where closures have occurred, the median household income was about $12,000 less than in communities where maternity wards remain open.

Case in point: Imperial County on the U.S.-Mexico border.

The Imperial Valley is a sprawling agricultural region. About 86% of the county’s population identifies as Hispanic or Latino and close to 23% lives under the poverty line.

Even before the closure of El Centro’s maternity ward, Imperial County was designated a “low access” area for maternity care.

The number of births in Imperial County has been slowly declining, but the birth rate there is higher than the state average. In 2021, Imperial County saw 66.3 births per 1,000 women compared to California’s average of 53.5.

The closure of the maternity ward at El Centro means pregnant patients now either give birth at the sole other hospital in the county, Pioneers Memorial in Brawley, or they travel to neighboring counties, like San Diego or Riverside.

On its website, El Centro Regional Medical Center directs labor and delivery patients to hospitals as far as Yuma, Arizona and Palm Springs, one and two hours away by car. The hospital notes that in the case of an emergency, patients can still give birth in its emergency room, which experts say that while not life-threatening, is not an ideal scenario.

“The choices are limited, and so sometimes women have reported that there’s a delay in being able to get into the maternity ward,” said Adriana Ramirez, who manages maternal programs for Imperial County’s Public Health Department. “What else can they do?”

Calexico in Imperial County is home to about 38,000 people. The city doesn’t have its own hospital. Pregnant women there largely relied on El Centro’s hospital, some 13 miles away, to give birth. With the closure of that maternity ward, families now have to travel farther north. The trek from Calexico to Brawley isn’t unreasonable — it’s a 30-to 45-minute drive depending on traffic — but it’s a reminder that much-needed medical care is drifting farther away from this town.

“It creates a very troubling feeling in an area that already is medically underserved, and to move those services farther north really makes a lot of people nervous,” said Assemblyman Eduardo Garcia, a Democrat representing the Imperial Valley.  “What I understand at the moment is that it is working out because there really isn’t any other option but to make it work.”

The El Centro hospital and Pioneers Memorial released a joint statement when they announced the maternity ward closure that said one “unified” county-wide maternity ward would be a positive change. “We are confident that consolidating services will benefit all mothers and newborns,” Damon Sorenson, CEO of Pioneers Memorial, said in the statement.

Many closures and suspensions result from hospital systems consolidating maternity care into one location. Hospital representatives say consolidations can help maintain staff training and provide a higher level of care.

Yet stories of an overwhelmed maternity ward at Pioneers are circulating on social media and among residents. Some women have said they’ve experienced delays, although no one has reported being denied care.

Dr. Hamid Zadeh, an obstetrician who delivers at Pioneers Memorial, said the hospital is seeing significant demand that strains the capacity of its maternity ward.

“Sometimes we schedule inductions or deliveries for patients and they are getting put on hold because people keep coming and we have no nurse to take care of them,” he said.

Zadeh said medical staff monitor patients whose scheduled deliveries are delayed. “I understand it’s a concern that has always been there, but more recently with the closure of El Centro, it’s gotten worse.”

Calexico Wellness Founder Blanca Morales outside the clinic in Calexico on Oct. 25, 2023. Photo by Adriana Heldiz, CalMatters

Blanca Morales, CEO of Calexico Wellness Center, a community clinic, said she hears these concerns from patients.  “They’re full. That capacity is not there for our population.”

Morales grew up in the area and has seen the depletion of local medical services. After stints in other parts of the state and country, she came back home and in 2018 established the clinic. Next she’d like to open a birthing center — an ambitious goal, but a much needed service.

Bringing a birthing center and more OB-GYNS to Calexico would also open the doors for local women to get prenatal care sooner, she said.

There’s some evidence nationally that women receive less prenatal care and rates of preterm birth increase when maternity wards close particularly in rural counties. In the case of El Centro Regional Medical Center, the hospital is continuing prenatal care in its outpatient clinics.

Mothers in Imperial County receive the least amount of prenatal care in the state — only about 47% of pregnant women there receive prenatal care beginning in the first trimester compared to 83% statewide, according to the Centers for Disease Control and Prevention birth database.

Local providers say this low rate reflects a few of the area’s challenges: delayed care because of insufficient providers, a high rate of pregnant teens who are more likely to skip prenatal care, and also patients who may start receiving pregnancy care in Mexico before seeking services on the U.S. side.

Financial decisions by California hospitals

In the business of health care, perhaps nothing is more influential than the bottom line. Among the top reasons cited by hospital administrators and experts for this wave of closures is growing costs coupled with periods of financial stress.

Labor and delivery units often are the second-most expensive departments for hospitals to run, second only to emergency rooms which also require 24-hour staff, multiple administrators and health care researchers told CalMatters.

“Obstetrics units are often unprofitable for hospitals to operate,” said Caitlin Carroll, an assistant professor at the University of Minnesota whose research focuses on health economics and maternity care. “The cost of running an obstetric unit is quite high. Obstetric units have to be ready to take care of a patient 24 hours a day, they need clinical staff with specialized skills, they need specialized equipment, they need dedicated space for labor and delivery. All of that costs money.”

Jim Goerlich, president of the Petaluma Valley Hospital nurses union, said even if the maternity unit isn’t making money, the rest of the hospital is almost always profitable enough to make up the difference.

“Does that unit need to make money to be intrinsically valued?” Goerlich said.

Providence, the hospital operator, suspended maternity services indefinitely in May, maintaining that it was not a financial decision. In a statement, Chief Administrative Officer Troy Gideon said the hospital did not have enough clinicians to keep the ward running.

In San Diego County, administrators at Tri-City Medical Center said that the maternity ward closure was driven in part because of “current and expected financial losses”. Meanwhile, officials at the El Centro hospital in Imperial County said closing its maternity ward “was necessary for financial reasons.”

Informational pamphlets on infant care at the Calexico Wellness in Calexico on Oct. 25, 2023. Photo by Adriana Heldiz, CalMatters

Earlier this year, the state found both El Centro and Tri-City to be in financial distress and received loans of $28 million and $33.2 million, respectively. Fifteen other hospitals in a similar situation also received loans.

Maternity ward closures are complex and finances are only one piece of the puzzle, said Carmela Coyle, president of the California Hospital Association.

“I think there are multiple whys: In some of these rural communities, they’ve lost a key member of that team, and they just can’t get them back. In other places, they simply don’t have enough births to make this safe. And in other places, it could be the finances where they simply can’t afford to support the entire team,” she said.

There’s broad consensus across the U.S. that increasing reimbursement for Medicaid, the federal insurance program for very low-income people, would help some hospitals keep labor and delivery running. In California, the state’s version of the program known as Medi-Cal pays for half of all births, but reimburses far less than private insurance, and according to hospitals, below the cost of care.

For example, for a vaginal delivery in Sacramento, commercial insurance pays hospitals about five times what Medi-Cal pays, according to an analysis by the California Health Care Foundation.

A much greater share of the population in communities that lost maternity wards rely on Medi-Cal or are uninsured than in those that gained maternity wards: 31% vs 19%, according to Census data.

The state has made concerted efforts to expand Medi-Cal coverage for more services like doulas, midwives and 12 months of postpartum care. Most recently, lawmakers brokered a deal to increase Medi-Cal rates across the board, and maternity services are some of the first in line to get more money.

“In the past five years, you’re seeing legislation and public interest that is creating positive change,” said Stephanie Leonard, an assistant professor and maternal health researcher with Stanford University. “At the same time, the statistics are still looking overall rather grim, and you’re still seeing hospital closures.”

Declining births and a vicious cycle

Caitlin Jack, a registered nurse, rallies in support of keeping the OB unit at Petaluma Valley Hospital open on Feb. 15, 2023. Photo courtesy of Chad Surmick, The Press Democrat

Seated in the northern end of the Sierra Nevada, Plumas District Hospital stopped delivering babies in 2022. The decision to do so was tumultuous, hospital CEO JoDee Read said. The next closest hospital with a maternity ward is roughly an hour and a half drive south on mountain roads to Truckee near Lake Tahoe.

“It’s been one of the most emotionally challenging and draining things that I’ve faced in my career,” Read said. “I have people in opposing positions in the leadership team who believe that we will kill people if we don’t do OB, and we will kill people if we do OB. And there’s no right answer.”

The year before Plumas District Hospital closed its maternity ward, only 64 babies were born there.

The number of babies born every year has been decreasing in the U.S., with California experiencing some of the steepest drops, according to Hans Johnson, a demographer with the Public Policy Institute of California. In the span of three decades, the number of births in the state dropped from a peak of 613,000 in 1992 to 420,000 in 2021.

“You can imagine that the recent decisions might just be an accumulation of having low births for a number of years. And finally, just, you know, throwing in the towel,” Johnson said.

For many hospitals too few births also becomes an issue of practice and general safety.

“Most of us would agree, if you’re not even doing one birth a week, there’s probably going to be a skill issue there,” said Zack Brown, director of outpatient clinics at Mammoth Hospital. The hospital, which is nestled in the remote Inyo National Forest on the eastern side of the Sierra Nevada, delivered its last baby in 2022. In the years immediately preceding closure, Mammoth Hospital delivered between 60 and 70 babies annually.

Some hospitals report difficulty hiring obstetrics staff, which is another factor they cite in closing maternity wards. Even with a declining birth rate, California is still projected to have a shortage of more than 1,100 obstetricians by 2030, according to estimates from the federal Health Resources and Services Administration.

Nursing shortages have already hamstrung some rural hospitals, and it isn’t always about pay. Read said maternity ward staff were some of Plumas District Hospital’s highest-paid employees.

“The first thing I would do when I would hear that some of these hospitals are closing or closing their OB departments is run as many ads as I could in that area about, you know, you can be a labor and delivery nurse in Quincy, and we’ll give a sign-on bonus and 90 days of housing,” Read said. “It still wasn’t enough.”

In Mono County where the population is less than 14,000 people, Brown said labor and delivery jobs went vacant for more than a year.

“It just became impossible to hire people,” Brown said. “We wouldn’t have any applicants. It was wild.”

Since Mammoth Hospital closed its maternity ward, patients travel 45 minutes south to a hospital in Inyo County for the final stages of their prenatal care and to deliver. A healthy mother should have about 20 prenatal visits over the course of her pregnancy. The time adds up, and Brown said, and providers know it’s “a huge barrier.”

“When you’re traveling 45 minutes, that’s half a day,” he said, adding in the time of the appointment. “All of us agree closing labor and delivery is a terrible thing. Losing services is not good.”

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

 

Read More at Cal Matters.