Deciding where to have a baby is often intensely personal for new parents: Do you want to go to a hospital or give birth at home? Are you comfortable with the doctor? Is it close enough to make it in time if complications arise?
These choices — a decision about where and how to bring new life into the world — are dwindling for some expectant parents across Washington. Labor and delivery units, particularly in rural areas, have been among the first services to be cut as Washington hospitals face financial turmoil.
When Yakima County resident Emma Argo became pregnant with her third child last summer, she hoped to deliver at Astria Toppenish, a community hospital less than 10 minutes from her home in Zillah. She was taken aback when the hospital abruptly closed its labor and delivery unit in December, four months before her due date. After the closure, Argo said she felt an "emotional toll."
"The time I should be spending packing a hospital bag or washing baby clothes is spent sorting this out," she said a few weeks before giving birth. "It just feels like one more thing."
Labor and delivery units have been on the front lines for cuts because they're expensive for hospitals to operate. They require specialized staff, services like neonatal intensive care units are particularly costly, and government-paid insurance plans often don't reimburse hospitals for the full cost of care.
At the same time, hospitals are desperate: Hospitals in the state had collectively lost about $2.1 billion by the end of 2022, largely due to dried-up federal pandemic relief, rising costs and low Medicaid reimbursement rates. But as labor and delivery units close, parents in those areas are left with fewer options — and the possibility that it could take them longer to access obstetric care in an emergency, when every second counts.
Reducing options for expectant parents in Southeast King County, MultiCare Covington Medical Center shuttered its birth center in September. The same happened at Forks Community Hospital on the Olympic Peninsula last December, about 60 miles from the nearest hospital birthing center in Port Angeles, though the hospital is working to restaff the unit.
Washington health care leaders have warned of hospitals' financial problems for at least a year now, and other services have been cut in recent months: At Providence Everett, admissions to its pediatric inpatient unit have been paused since last fall. Astria Sunnyside lost its cardiology services in the winter. But the labor and delivery cuts may have sparked the most public pushback.
Some relief for pregnancy care is on its way after the state Legislature, which recently wrapped up its 2023 session, boosted Medicaid rates and funded a new doula program. At the same time, communities are scrambling to prevent these losses.
"Losing hospital services is something every Washingtonian should be concerned about," Cassie Sauer, CEO of the Washington State Hospital Association, said in a news conference in November. "When these resources leave a community, it's nearly impossible to get them back."
How we got here
Apple orchards, hops farms and rolling hills stretch over more than 4,000 square miles of Central Washington. At the northeast edge of the Yakama Reservation, the town of Toppenish is home to about 9,000 people in the lower Yakima Valley, with farmland surrounding a small downtown dotted with murals. The town's hospital, Astria Toppenish, has been a community staple for decades, and its maternity center was well-loved.
The December 2022 closure came as a shock, said Dr. Jordann Loehr, an OB-GYN who used to deliver out of Astria Toppenish.
"I still don't understand this decision," she said. "It's heartbreaking to our community, many whose mothers, grandmothers and great grandmothers had their babies at Toppenish."
According to the hospital, however, its labor and delivery unit had struggled all year. Astria Toppenish reported it brought on nearly 200% more travel nurses, contracted workers who typically move from hospital to hospital in response to demand and often get paid more than staff nurses. The hospital also saw increases in supply costs due to inflation. Efforts to hire permanent pediatricians, who also worked in the unit, were unsuccessful, the hospital said.
Astria Toppenish's reimbursement rates for Medicaid services, temporarily boosted in 2020 thanks to a one-year budget provision, were slashed by a third the following year when lawmakers denied an extension, according to the hospital. The drop meant providers were not getting reimbursed for the complete cost of their services by federal Medicaid programs, and would ultimately lose money when treating Medicaid patients, who made up more than 75% of Astria Toppenish's obstetrics clients.
For example, while a standard vaginal delivery, usually a one-day stay, costs about $8,000 to $10,000 per day, the hospital was only getting reimbursed about $3,765 for Medicaid patients, said Jane Winslow, an Astria Toppenish spokesperson.
A cesarean, or C-section, usually costs about $35,000 for a three-and-a-half-day stay in the hospital, while the Medicaid reimbursement amounted to about $4,933, Winslow said, using an example of a "snapshot in time" from December 2022.
By the end of the year, Toppenish's labor and delivery services had lost $3.2 million, the hospital said.
"It is a very challenging service line to keep open when you're facing the financial losses that many of the hospitals are right now," said Chelene Whiteaker, senior vice president of government affairs at the Washington State Hospital Association. "You're thinking, 'If you keep that open, what else are you going to have to close instead?'"
Historically, obstetrics is considered a particularly resource-intensive field, said Dr. Tanya Sorensen, a maternal and fetal medicine doctor at Providence Swedish in Seattle, one of the more popular delivery units in the state.
The field requires significant hands-on nursing, Sorensen said. Labor and delivery nurses usually spend more one-on-one time with their patients compared, for example, to a nurse caring for someone gradually recovering from surgery.
Obstetrics also has become more specialized over the years, Whiteaker added: In the past, babies were commonly delivered by doctors who worked as general practitioners or family physicians. Now, it's more typical for hospitals to employ doctors and other staff who are trained specifically in infant and pregnancy care and are prepared to address the wide variety of challenges that can arise in deliveries.
That means labor and delivery units need to have larger staffs with specialized experience — which costs more money. At the same time, hospitals, especially those in rural areas, are struggling to retain and recruit a limited number of health care workers, which means staffing costs overall have increased dramatically.
"We're in a spot now where we're using travel nurses, which are far more expensive, costing millions of dollars compared to our [permanent] nurses," Sorensen said. "Swedish is able to cope with that ... but if you're a little community and trying to staff for a small labor and delivery unit, that becomes super challenging and super expensive."
She's particularly worried about the growing lack of obstetric care in Yakima Valley, she said, noting Swedish's transfer rate from rural areas rose about 8% between 2021 and 2022.
"There's a huge amount of concern about these obstetric deserts where there's limited local care for pregnant women," Sorensen said.
The fight back
Since several hospitals closed their labor and delivery units, few have provided updates on plans to bring services back. In the Yakima Valley, residents are determined to keep the issue from being forgotten.
At a town hall meeting in Toppenish in early January, the room was crowded with former hospital employees and patients hoping to voice their concerns about the labor and delivery closure.
"I was a senior in high school and pregnant with my first child when I suffered a miscarriage and almost died," Semone Dittentholer, a Wapato resident and Yakama tribal member, said at the podium, recalling her experience at Astria Toppenish more than 20 years ago. She knew her community suffered disproportionately worse birth outcomes, adding to her fear.
"I was minutes from bleeding out," she said. "There was no way I was going to make it to Yakima [Memorial]," the largest hospital in the county, about twice as far from her home as Astria Toppenish.
When Dittentholer arrived at Astria Toppenish, she couldn't stop shaking and her skin was almost translucent. She was told she might not make it through the night.
After hours in the maternity center, Dittentholer woke up, but her baby didn't.
"If it wasn't for Toppenish labor and delivery, I wouldn't have made it," she told City Council members. "It makes me stressed and sad to think about all the women who couldn't — and won't be able to — make it out to Yakima."
Since the closure of Toppenish's maternity center, community members have continued to brainstorm ideas on how to return obstetric care to their area. They held community gatherings. They wrote to their City Council members. They advocated for new legislation.
Then, last month, a group working on maternity solutions in Washington stumbled on an old state law that mentions "maternity care distressed areas." Ears perked up.
According to the law, enacted in 1989 and revised in 2011, the Washington state Health Care Authority would pay for contracted maternity care providers, if an area is considered to be maternity care distressed — which could mean a higher-than-average percent of people in the area received late or no prenatal care or had to travel out of the area to receive maternity care.
"We're not sure if this is going to apply to us yet," Loehr said, "but if this ends up working in our favor and we could get some state relief, that would be big."
Some relief is on the way for Toppenish. Gov. Jay Inslee last week approved legislation that will raise the hospital's Medicaid rates starting next year. In the meantime, the hospital will receive a short-term grant this summer to "bridge the gap until that reimbursement kicks in," Winslow said.
Still, it likely won't be enough for the hospital to reopen its maternity center, Winslow said, adding that it's an "exceptionally expensive service" and the extra funding will likely go toward maintaining existing services, like behavioral health, instead.
Loehr is also leading efforts to introduce a public hospital district to the area, a fairly common designation in Washington. The state has 56 public hospital districts, community-created entities authorized by the state to deliver health services.
"We're like a library district or a school district," said Matthew Ellsworth, executive director of the Association of Washington Public Hospital Districts. "Local constituents voted to draw a circle around themselves and ultimately they can choose to tax themselves for revenue."
Most public hospital districts in the state have hospitals, while a handful provide specific care, like emergency services, urgent care and nursing homes. Once a district is created, residents elect a board of commissioners to govern the district and decide which health-related projects to fund.
"To have health care decisions executed on a policy basis by elected officials is a big benefit," Ellsworth said. "Ultimately, the people running your hospital are accountable to you. ... But I don't want it to be viewed as a panacea."
For example, he said, "If you want to build a billion-dollar hospital, that's not going to happen." Tax revenue from public hospital district levies don't come close to the amount needed to run a health care facility, he said.
But in places like Vashon Island, the state's newest public hospital district, residents were able to raise enough funds to preserve some clinical services.
What's at risk
Across the Puget Sound, similar challenges have complicated the search for pregnancy care.
As of this year, only one hospital in Kitsap County — St. Michael Medical Center in Silverdale — is staffed to deliver babies. The Naval Hospital, near a base in Bremerton, closed the doors to its labor and delivery unit in April 2022, citing staffing and resource shortages. Peninsula Community Health Services, also in Bremerton, followed suit a few months later.
Because of the growing gap in care, many patients have started to rely on local midwives, said Ashley Jones, a licensed midwife and executive director of True North Birth Center in Poulsbo, the only out-of-hospital birth center on the peninsula. The practice has seen a huge influx in patients since last July, Jones said.
"The unfortunate thing is that I know there are those who do qualify (for a low-risk birth) who may actually choose our option and just don't know about us," Jones said. "We're a big military community, so some people are coming from states like Virginia and Texas, or somewhere where midwifery is not as common may not even know that we're an option."
She's hoping to continue to spread the word about her practice in case St. Michael's obstetric unit does fill up. In the last year, many of Jones' new patients transferred to her practice after experiencing or hearing stories of long waits at St. Michael, she said.
Because of recent changes to the state's landscape of labor and delivery care, patient numbers have fluctuated at different hospitals, making clear trends in demand difficult to identify.
While the number of MultiCare Yakima Memorial's monthly deliveries has slowly increased since Astria Toppenish's unit closure, signaling some absorption of patient volume, St. Michael hasn't necessarily seen the same rise on the Kitsap Peninsula.
St. Michael's president, Chad Melton, says its unit does have room and staffing has "stabilized" in the past four to five months, though it still does partially rely on contract travel nurses. Demand has actually dropped from an average of about 200 deliveries a month during most of the pandemic to now about 130 per month.
"It's a service we need to provide," Melton said.
Meanwhile, patient demand at Kitsap OB-GYN, one of the few independent practices on the peninsula, has been growing for months, said administrator Megan McDermaid.
"There's not a lot of choice in the county," McDermaid said.
Morgan Runge, 27, a mother of two who lives on Chinook Pass, said she's concerned for other new parents in the Yakima area who now may be far from the nearest hospital, or may no longer have a choice in where they deliver their baby.
She said she felt fortunate to have options: She delivered her son at Astria Toppenish just days before its maternity center closed, instead of MultiCare Yakima Memorial. While Yakima was much closer to her home — about 30 minutes, compared to an hour's drive to Toppenish — she was willing to make the hourlong trip because of a traumatic experience delivering her first child at Yakima Valley.
She was in labor the entire drive, she said.
"It's a terrifying thought that these types of services are drying up in some parts of our state," she said.
