OB Nurse Speaks Out About ACMC OB Closure

With real-life experience and mounds of research, Heather Virant, an OB nurse at ACMC, is speaking out about the risks associated with closing Ashtabula’s OB unit:

 

Just under a week ago, the staff at Ashtabula County Medical Center learned that as of August 1st our Labor and Delivery unit would be permanently closing.

This means that in roughly 30 days, the largest county in Ohio will lose the sole maternity services unit left within its over 1,300 square mile borders.

As devastating as this news is for our OB unit family ( some of whom have spent 10-20 years on the unit – and as heartbreaking as it is for other parents like myself, who have welcomed children into the world there, these feelings pale in comparison to the fear that many have of the potential impacts to the community that this closure could likely impart…

Since the news was made public, we have heard numerous accounts from patients, co-workers, and families within the community who attribute the good outcomes they have experienced, despite some very urgent situations, largely to the care they received on ACMC’s L&D unit…

With each recollection comes the sobering reality that the outcome could have been devastatingly different if access to maternity services were delayed, even by mere minutes…

In this setting sometimes every precious minute counts…

The decision to close seems sudden and ill advised to most of us, however, sadly it seems to be increasingly common across the US…

“Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services, according to a study published last year in the Journal of the American Medical Association. By 2014, a 2017 Health Affairs study noted, more than half of all rural counties had no hospital that offered maternity care.” (https://bit.ly/2Vz4KAm)

Despite the scale of these closures across the country, there seems to be a considerable lack of information on their impacts on the health and well being of mothers and babies as well as the affected communities as a whole… Of the information that is available, much of it adds merit to growing concerns… Linked at the end is a handful of  interviews, studies and articles found that could offer insight on the possible implications we may see in the coming future. Some more relevant and others that just raise interesting questions…

But first, I wanted to talk about 2 things that really stuck out in the publicly shared information about the closure ( https://bit.ly/2NCnBGe). One being discussed among the reasons given for the closure, and the other is in the plan going forward.

I quoted the first when the article came out because I found it so difficult to read: “Of the approximately 1,000 births to Ashtabula County residents each year, a five-year average shows that only 34% of those were delivered at ACMC. This amounts to less than one baby per day being born at ACMC. The other 66% of births to Ashtabula County residents take place at hospitals outside of Ashtabula County.”

One baby per day may be meant to seem like a small number but it doesn’t feel that way to me and this statistic discounts numerous other services provided by the unit encompassed in the term “maternity services.” ACMC L&D often provides time sensitive and local access to care for patients who may not inevitably deliver there, but still benefit from its availability. We administer medications to slow preterm labor, speed fetal lung development, stabilize maternal vital signs, and more to help improve outcomes while preparing for transport to higher levels of care. We often perform labor checks, rule out rupture of membranes, and perform fetal monitoring for patients that are then discharged, and may even return multiple times before delivery- but without local access to these services, mothers may delay them or ignore warning signs for fear of “wasting a trip” traveling and then being discharged, which could contribute to out of hospital births, or missed risk factors and poorer outcomes. This can be especially problematic in areas like Ashtabula county where families are often below the poverty line, making transportation and related expenses that could be incurred that much more difficult.  And these are just a few examples.

This also leads into the other part of the statement that was concerning: “The plan is for expectant moms to be seen by an obstetrician at ACMC for office visits – including high-risk OB visits currently offered – then be referred to Hillcrest for their delivery.”

Hillcrest hospital is roughly 52 miles from ACMC, and some of our patients live even farther than that.

Travel distances that far can increase adverse outcomes on their own. They can also contribute to higher rates of scheduled deliveries in fear of not being able to make it in time if natural labor occurs, which can in turn contribute to increased need for medical interventions complicating deliveries… But as discussed above, these distances can also place a large burden on patients below the poverty line that already face numerous problems with available support systems and access to reliable transportation. Ashtabula County is in the top 3rd of the state of Ohio for highest poverty rates, ranking number 8 out of 88 counties. This is a very real issue for a large portion of our patients.

This is just a small portion of growing concerns. We are at a loss on how to proceed as we watch access to care decline in our vulnerable population. The nurses and healthcare team are worried for our community and it’s hard to believe that this fear is unwarranted.

Increased travel times coupled with data discussed below indicating unanticipated deliveries outside of hospitals with dedicated maternity service increases after unit closures like this, could lead to a large strain on our emergency department. In the ER where these patients will inevitably end up, emergency medicine is in the forefront, but specialty services like obstetrics are not commonly practiced. This issue is further complicated by findings that nearly 29% of low-risk births may experience unexpected complications and require non-routine interventions, which demonstrates how important expert care is for these patients. All of this together makes it seem very unlikely that in the next 30 days the community, the hospital and the local services will be able to form an effective plan to begin to bridge the gap to mitigating the possible consequences.

 

Resources:

 

The rate of pregnancy-related deaths has risen steadily in the U.S. in recent decades, and a lack of access to quality health care – before, during and after pregnancy – may be putting rural women at greater risk.

 

“Maternal health is in crisis in communities across the United States,” Katy Kozhimannil, director of research at the University of Minnesota’s Rural Health Research Center, said this week at a rural maternal health forum hosted by the Centers for Medicare and Medicaid Services.

 

“We are talking a lot about maternal mortality and maternal morbidity, but it’s not just about how mothers die, but how rural women live and access care in rural America,” she added.

https://www.usnews.com/news/healthiest-communities/articles/2019-06-13/what-happens-when-rural-communities-lose-their-hospital-maternity-care

A travel time of 30 min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.

https://www.sciencedirect.com/science/article/abs/pii/S1353829213001226

“Loss of hospital-based obstetric care in rural counties not adjacent to urban areas was significantly associated with increases in births in hospitals without obstetric units (3.06 percentage points), and preterm births (0.67 percentage points), compared with counties with continual obstetric services.”

> “Global data indicate that lacking this care exposes pregnant patients to greater risk of morbidity, mortality, and poor infant outcomes.”

> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885848/

A travel time from home to hospital of 20 minutes or more by car is associated with an increased risk of mortality and adverse outcomes in women at term in the Netherlands. These findings should be considered in plans for the centralisation of obstetric care.

https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2010.02816.x

Evidence suggests the closure of maternity units is associated with an increase in babies born before arrival (BBA).

During 1992–2011, the absolute numbers (N = 22,814) of women having a BBA each year in Australia increased by 47% (N = 836–1233); and 206% (n = 140–429) in Queensland. This coincided with a 41% reduction in maternity units in Australia (N = 623–368 = 18 per year) and a 28% reduction in Queensland (n = 129–93).

The closure of maternity units over a 20-year period across Australia and Queensland is significantly associated with increased BBA rates. The distribution is not limited to rural and remote areas. Given the high risk of adverse maternal and neonatal outcomes associated with BBA, it is time to revisit the closure of units.

 

https://www.sciencedirect.com/science/article/abs/pii/S1871519215000396?via%3Dihub

“Importantly, accredited birth centers and hospitals that offer basic and specialty maternity services provide needed obstetric care for most women who are giving birth in the United States 15. Furthermore, they often provide maternity care in rural and underserved communities, which offers the benefit of keeping women with low- or moderate-risk pregnancies in their local communities. Closing hospitals with low-volume obstetric services could have counterproductive adverse health consequences 16 17 and potentially increase health care disparities 18 19 by limiting access to maternity care.”

“Rather, these data, combined with the fact that 59% of hospital births in the United States occur at hospitals where fewer than 1,000 newborns are delivered annually 15, underscore the importance of adequately staffed and equipped level I and II hospitals; regionalized care with defined relationships between different level facilities; continuous risk assessment; and the potential benefit of caring for women with high risk of maternal morbidity in centers with higher level, acuity-focused resources and specialty and subspecialty personnel.”

https://www.acog.org/en/Clinical/Clinical%20Guidance/Obstetric%20Care%20Consensus/Articles/2019/08/Levels%20of%20Maternal%20Care

“Of births, 29% identified to be low risk had an unexpected complication that would require nonroutine obstetric or neonatal care. Additionally, for select outcomes, risks were higher in the low-risk group compared to the group with identified risk factors. This information is important for planning location of birth and evaluating birthing centers and hospitals for necessary resources to ensure quality care and patient safety.”

“low-risk pregnancies had higher risks of vacuum delivery, forceps delivery, meconium staining, and chorioamnionitis compared to high-risk pregnancies.”

https://pubmed.ncbi.nlm.nih.gov/26042957/