The U.S. medical system, despite many nonprofit hospital systems, is a for-profit industry. We see this in many areas, but there is one in particular that affects patients in my care as an ob/gyn: the discontinuation of maternity services. Declining birth rates both decrease the financial incentive of providing maternity care and make it difficult to maintain qualified staff. In my state of Maine alone, four hospitals have announced discontinued maternity services since the year began. And this trend is not unique, but rather occurring in many areas throughout the country. Frequently, these closures occur in rural areas and significantly increase the time it takes for pregnant women to travel to their delivery hospital. We need to take innovative approaches or risk jeopardizing hospital-based obstetric care. Below, I discuss the challenges around staffing facing maternity units, as well as the consequences of discontinuing such necessary care.

The Challenges of Maternal Care

One reason for the closures of maternity units is that such units can be costly: They require around the clock staffing by a full team that is ready to respond to any emergency that presents. When faced with poor reimbursement rates via private insurers who undervalue perinatal care in bundled payments and a large percentage of Medicaid-covered care, these costs really add up. 

Another issue is that low patient volumes create challenges for maintaining qualified staff. Obstetric emergencies are often unpredictable and almost universally rapid. They require both labor and delivery nurses and physicians with the experience and knowledge to recognize the emergency immediately and to enact the necessary interventions. If these clinicians are unfamiliar with best practices, equipment, medications, or clinical skills needed to respond, the mother and baby are at risk of serious morbidity and mortality.

A final challenge is physician coverage. Community hospital ob/gyn groups often do not have the patient volume to support anything beyond a small group practice. However, the group of physicians taking these positions needs to provide 24-hour coverage for the maternity unit. While some burden can be displaced to certified nurse midwives, a physician trained in the full scope of obstetric care must also be available. This means that a small group practice can lead to an incredibly burdensome call expectation. This is difficult for any physician but is becoming increasingly so as the physician workforce evolves, with many earlier career physicians placing a larger value on their work-life balance. 

The Negative Effects of Ward Closures

And yet, despite these financial and logistical realities, maternity wards need to remain open. Though increased travel times as a result of fewer wards may seem clinically insignificant, a recent study suggests that distances of 40km and above have a negative impact on maternal and neonatal outcomes. This should be a cause of concern in the U.S., considering we have the worst maternal outcomes of any high income country. 

Furthermore, increased distances produce anxiety for patients concerned about delivering too quickly to arrive at the nearest hospital when in labor or if faced with a critical emergency. This anxiety leads to increased requests for elective induction of labor, which increases the length of hospital stay and interventions, further increasing the cost of maternity care. 

Alternatively, this anxiety has the potential to expand the number of pregnant patients seeking intrapartum care outside of hospital systems. Historically, there has not been a robust system of support between physicians and home birth clinicians in this country, nor are there uniform standards for home birth practices and allowing safety gaps in home-based childbirth. 

How We Can Rectify the Issue

Community hospitals often maintain a commitment to providing maternity care because they are part of their community and recognize the importance of maternity access within their communities. As community hospitals are increasingly encompassed in larger systems removed from the communities they serve, the fiscal realities of financial losses are more likely to supersede the needs of community members. We cannot let this happen — and there are ways to ensure that the situation improves.

First, our current medical system needs to create more sustainable staffing solutions at all levels of maternity care, both to bolster the numbers of people who provide care in community hospitals as well as to maintain safe and well-trained staff. One advantage of large hospital systems is that they foster stronger relationships between affiliated community hospitals and tertiary care centers. This should be utilized to rotate staff from lower volume institutions into higher volume and acuity centers to ensure that they develop and maintain the skills needed to provide high quality care. Low volume units should also create robust simulation training systems. This can be utilized to maintain skills, as well as complementing experiences in higher acuity settings by ensuring that staff are familiar with providing interventions on their own units and with the more limited resources available in the community hospital setting. 

Second, the model of ob/gyn clinic and call coverage by a small number of physicians needs to be abandoned. Position sharing and/or part time positions need to be embraced instead. Further, the price of call needs to be better acknowledged as a component of the compensation these obstetricians receive. This will provide the flexibility necessary to attract a group of people that can meet the appointment needs of the population while also allowing for a sustainable call schedule for each individual physician — which will enable a group of physicians to develop relationships that can support their community and each other.

Finally, if we are unable or unwilling to provide a hospital birth system that supports the needs of expectant families, U.S. obstetric clinicians should consider changing systems of collaboration and education to create a safe and robust home birth system.

I would argue that women deserve safe care through the vulnerable and life-changing process of pregnancy and childbirth. But it will take the will of the medical system to prioritize maternity care for us to be able to continue to provide safe hospital-based childbirth. The above offers solutions I see for keeping units safely staffed. However, none will make maternity units more profitable. That will not happen unless reimbursements improve. 

The U.S. medical system needs to make a decision. Will we allow fiscal concerns to decimate hospital-based maternity care? Or is this a social good that we are committed to providing? 

What solutions do you see for ensuring maternity units are well staffed? Share in the comments.

Dr. Erica Jacovetty is an ob/gyn practicing in Maine. She enjoys reading, pie making, and gardening. Dr. Jacovetty is a 2024-2025 Doximity Op-Med Fellow. 

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