Rural Patients Lose Options as Birth Facilities Shut Down
WINNER, S.D. — Sophie Hofeldt planned to receive prenatal care and give birth at her local hospital, 10 minutes from her house. Instead, she's driving more than three hours round trip for her appointments.
The hospital, Winner Regional Health, recently joined the increasing number of rural hospitals shuttering their birthing units.
'It's going to be a lot more of a stress and a hassle for women to get the health care that they need because they have to go so much further,' said Hofeldt, who has a June 10 due date for her first child.
Hofeldt said longer drives mean spending more on gas — and a higher risk of not making it to the hospital in time. 'My main concern is having to give birth in a car,' she said.
More than a hundred rural hospitals have stopped delivering babies since 2021, according to the Center for Healthcare Quality and Payment Reform, a nonprofit organization. Such closures are often blamed on shortages of staff and money.
About 58% of South Dakota counties have no birthing facilities, the second-highest rate among states, after North Dakota, according to March of Dimes. And the South Dakota health department says pregnant women and infants in the state, especially those who are Black or Native American, experience high rates of complications and death.
Winner Regional Health serves rural communities, including parts of the Rosebud Sioux Indian Reservation, in South Dakota and Nebraska. It delivered 107 babies last year, down from 158 in 2021, said CEO Brian Williams.
The nearest birthing hospitals are in rural towns an hour or more from Winner. But several women said driving to those facilities would take them through areas without reliable cellphone service, which could be a problem if they have an emergency along the way.
KFF Health News spoke with five patients from the Winner area who planned to deliver at Avera St. Mary's Hospital in Pierre, about 90 miles from Winner, or at one of the large medical centers in Sioux Falls, 170 miles away.
Hofeldt and her boyfriend drive every three weeks to her prenatal appointments at the Pierre hospital, which serves the small capital city and vast surrounding rural area. She'll have to make weekly trips closer to her due date. Neither of their jobs provides paid time off for such appointments.
'When you have to go to Pierre, you have to take almost the whole day off,' said Hofeldt, who was born at the Winner hospital.
That means forfeiting pay while spending extra money on travel. Not everyone has gas money, let alone access to a car, and bus services are scarce in rural America. Some women also need to pay for child care during their appointments. And when the baby comes, family members may need to pay for a hotel.
Amy Lueking, Hofeldt's doctor in Pierre, said when patients can't overcome these barriers, obstetricians can give them home monitoring devices and offer phone- or video-based care. Patients can also receive prenatal care at a local hospital or clinic before connecting with a doctor at a birthing hospital, Lueking said.
However, some rural areas don't have access to telehealth. And some patients, such as Hofeldt, don't want to split up their care, form relationships with two doctors, and deal with logistics like transferring medical records.
During a recent appointment, Lueking glided an ultrasound device over Hofeldt's uterus. The 'woosh-woosh' rhythm of the fetal heartbeat thumped over the monitor.
'I think it's the best sound in the whole wide world,' Lueking said.
Hofeldt told Lueking she wanted her first delivery to be 'as natural as possible.'
But ensuring a birth goes according to plan can be difficult for rural patients. To guarantee they make it to the hospital on time, some schedule an induction, in which doctors use medicine or procedures to stimulate labor.
Katie Larson lives on a ranch near Winner in the town of Hamill, population 14. She had hoped to avoid having her labor induced.
Larson wanted to wait until her contractions began naturally, then drive to Avera St. Mary's in Pierre. But she scheduled an induction in case she didn't go into labor by April 13, her due date.
Larson ended up having to reschedule for April 8 to avoid a conflict with an important cattle sale she and her husband were preparing for.
'People are going to be either forced to pick an induction date when it wasn't going to be their first choice or they're going to run the risk of having a baby on the side of the road,' she said.
Lueking said it's very rare for people to give birth while heading to the hospital in a car or ambulance. But last year, she said, five women who planned to deliver in Pierre ended up delivering in other hospitals' emergency rooms after rapidly progressing labor or weather made it too risky to drive long distances.
Nanette Eagle Star's plan was to deliver at the Winner hospital, five minutes from home, until the hospital announced it would be closing its labor and delivery unit. She then decided to give birth in Sioux Falls, because her family could save money by staying with relatives there.
Eagle Star's plan changed again when she went into early labor and the weather was too dangerous to drive or take a medical helicopter to Sioux Falls.
'It happened so fast, in the middle of a snowstorm,' she said.
Eagle Star delivered at the Winner hospital after all, but in the ER, without an epidural pain blocker since no anesthesiologist was available. It was just three days after the birthing unit closed.
The end of labor and delivery services at Winner Regional Health isn't just a health issue, local women said. It also has emotional and financial impacts on the community.
Eagle Star fondly recalls going to doctor appointments with her sisters when she was a child. As soon as they arrived, they'd head to a hallway with baby photos taped to the wall and begin 'a scavenger hunt' for Polaroids of themselves and their relatives.
'On both sides it was just filled with babies' pictures,' Eagle Star said. She remembers thinking, 'look at all these cute babies that were born here in Winner.'
Hofeldt said many locals are sad their babies won't be born in the same hospital they were.
Anora Henderson, a family physician, said a lack of maternity care can lead to poor outcomes for infants. Those babies may develop health problems that will require lifelong, often expensive care and other public support.
'There is a community effect,' she said. 'It's just not as visible and it's farther down the road.'
Henderson resigned in May from Winner Regional Health, where she delivered vaginal births and assisted on cesarean sections. The last baby she delivered was Eagle Star's.
To be designated a birthing hospital, facilities must be able to conduct C-sections and provide anesthesia 24/7, Henderson explained.
Williams, the hospital's CEO, said Winner Regional Health hasn't been able to recruit enough medical professionals trained in those skills.
For the last several years, the hospital was only able to offer birthing services by spending about $1.2 million a year on temporary physicians, he said, and it could no longer afford to do that.
Another financial challenge is that many births at rural hospitals are covered by Medicaid, the federal and state program serving people with low incomes or disabilities. The program typically pays about half of what private insurers do for childbirth services, according to a 2022 report by the U.S. Government Accountability Office.
Williams said about 80% of deliveries at Winner Regional Health were covered by Medicaid.
Obstetric units are often the biggest financial drain on rural hospitals, and therefore they're frequently the first to close when a hospital is struggling, the GAO report said.
Williams said the hospital still provides prenatal care and that he'd love to restart deliveries if he could hire enough staff.
Henderson, the physician who resigned from the Winner hospital, has witnessed the decline in rural maternity care over decades.
She remembers tagging along with her mother for appointments before her sister was born. Her mother traveled about 100 miles each way after the hospital in the town of Kadoka shuttered in 1979.
Henderson practiced for nearly 22 years at Winner Regional Health, sparing women from having to travel to give birth like her mother did.
Over the years, she took in new patients as a nearby rural hospital and then an Indian Health Service facility closed their birthing units. Then, Henderson's own hospital stopped deliveries.
'What's really frustrating me now is I thought I was going to go into family medicine and work in a rural area and that's how we were going to fix this, so people didn't have to drive 100 miles to have a baby,' she said.
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