Los Angeles County: the epicenter of urban maternity ward closings

Maternity Ward Closures in California Create Uncertainty for Pregnant People

LOS ANGELES — Simone DeRoche, expecting her fourth child in December, had her birth plan set: delivering at USC Verdugo Hills Hospital, where her three other kids were born.

But when she received the text from her OB-GYN last week that the hospital will be closing its maternity ward and NICU in November, DeRoche felt a wave of disappointment and sadness. She’d enjoyed the experience of giving birth at the Glendale, Calif., hospital, calling it “a special place.” DeRoche said she has options, including giving birth at Huntington Hospital in Pasadena, a mere 10- to 15-minute drive from her home in La Crescenta. But she’s uncertain where she’ll end up, or what the experience will be like — she’s recently heard stories about overcrowded area hospitals where deliveries are happening in the ER. The news about Verdugo Hills hit home: She knew about rural hospitals closing maternity wards, but not urban area hospitals.

California has been a longtime national beacon in setting the agenda for comprehensive maternal and child health care. Maternal death rates in the state are about half the national rate — although pre-term birth rates are only slightly below the national average and sharp disparities persist for Black maternal and child health outcomes. Now, providers and patients alike are facing a rash of maternity ward closings like those that have occurred around the country, creating what have been called “maternity deserts.”

Those deserts often are found in rural areas, but they also are popping up in urban areas. An investigation done by CalMatters, a nonprofit newsroom based in Sacramento, found that since 2021, 29 hospitals in the state stopped delivering babies. Nearly 50 obstetrics departments have closed over the past decade, and 17 were in Los Angeles County.

For pregnant people in the county, especially Black and Hispanic people whose communities are most affected by closures, the uncertainty and challenges are often greater than those facing DeRoche. Not only is their continuity of care affected, but the impact is amplified by being forced to travel great distances, potentially without transportation or child care, or the financial resources to obtain them. Some hospitals won’t accept patients’ insurance, and insurance companies are slow to make decisions about prior authorization for patients to give birth out-of-network. Providers and community-based advocates work hard to find services and fill in all the gaps for pregnant people who have had their birth plans upended.

“The situation is a little chaotic” for patients and providers right now, said Yohanna Barth-Rogers, chief medical officer of UMMA Community Clinic in Los Angeles. Patients may find that a new hospital, uncertain of who may come with a potential high-risk pregnancy, is reluctant to take them on. Some patients are in the dark about who their consistent provider will be after they deliver. That’s a paramount concern if they or their babies experience complications, and in the critical six weeks postpartum, extending out to the first year after giving birth.

“A lot of women are scared, particularly women of color, to deliver their babies because the outcomes are just worsening in this country,” Barth-Rogers said. “It’s scary right now to deliver, it’s scary to not have your voice be heard.”

Providers, public health experts, and legislators told STAT they have been flummoxed by the alarming number of maternity ward closures. The culprits cited in California, as elsewhere, include a declining birth rate, staffing challenges (especially since Covid-19 arrived in 2020), and the constant loss of revenue to keep labor and delivery services open. Another oft-cited reason is poor Medicaid reimbursement levels for maternity care. Medi-Cal, California’s health insurance program for low-income residents, has the country’s fifth-lowest reimbursement rate for obstetrics, according to CalMatters.

“The decision to close maternity service is an agonizing one that our hospitals don’t come to easily,” said Peggy Broussard Wheeler, vice president of policy for the California Hospital Association, the industry advocate for the 400-plus hospitals statewide.

There are several factors that can make maintaining a labor and delivery department that’s ready for births year-round unsustainable, Broussard Wheeler said. The pandemic put financial stresses on hospitals generally. And maternity service expenses in particular are high, often only second to that of emergency rooms.

In addition, the declining birth rate, both in California and nationwide, means that “the staff capability, staff competency for those high-risk deliveries is not there and staff begin to be concerned that they’re not prepared for a high-risk delivery because they’re not seeing enough deliveries,” Broussard Wheeler said. “When staff start coming to hospital leadership to say that they’re worried about their capabilities, it’s another reason those decisions are on the table.”

The fear that ‘something bad is going to happen’

UMMA Community Clinic, in south Los Angeles, has four locations serving mostly Black and Hispanic patients. Barth-Rogers said many of the patients receive care under Medi-Cal or they’re uninsured, complicating their search for new hospitals if they had been planning on delivering at one that closed.

Patients’ choices may be further constrained if they want to give birth vaginally but previously delivered by cesarean section or if they want to also have a bilateral tubal ligation — referred to as “getting their tubes tied” — to prevent future pregnancies. Barth-Rogers pointed out that if a patient has a high-risk pregnancy, it’s difficult to send them to someplace like Martin Luther King Jr. Community Hospital, just outside the L.A. city limits, because the hospital doesn’t have a neonatal intensive care unit and often prefers taking on lower-risk pregnancies.

Some patients are choosing to deliver at birthing centers because they’re not happy with the hospital options available to them in Los Angeles County, said Barth-Rogers. The closure of maternity wards in urban settings, such as Centinela Hospital Medical Center, has had a significant impact on health equity, according to patient advocates and experts. The closure of Centinela’s labor and delivery unit, which was announced to shut down by October 25, 2023, resulted in the suspension of 17 perinatal beds, nine NICU beds, and the newborn nursery. This closure left many pregnant individuals in the area scrambling to find alternative places to give birth.

The closure of Centinela Hospital Medical Center’s labor and delivery unit was met with controversy due to an investigation by the state for neglect in the treatment of a Black woman, April Valentine, who tragically died during childbirth there in January 2023. The hospital was also fined $75,000 by the state of California for “deficient practices” related to Valentine’s death. The closure of the unit led to protests and a wrongful death lawsuit filed by Valentine’s family against the hospital.

In response to the closure, Centinela transferred maternity services to St. Francis Medical Center in Lynwood, one of its affiliates. However, patient advocates like Raena Granberry, the director of maternal and reproductive health for the California Black Women’s Health Project, point out that it is not easy for pregnant individuals to simply switch hospitals. Granberry mentioned that pregnant individuals facing the sudden need to find a new hospital to give birth at are overwhelmed with questions about insurance, provider preferences, and other logistical challenges.

Granberry emphasized the personal impact of these closures on the community, noting that pregnant individuals are left with uncertainty and fear about their birthing experiences. She mentioned that the California Black Women’s Health Project has stepped in to fill gaps in care by providing financial support for transportation, meals, and accommodations for families affected by the closures.

Since the closure of Centinela Hospital Medical Center’s labor and delivery unit, pregnant individuals have been redirected to other hospitals in Los Angeles, such as Martin Luther King Jr. Community Hospital and Cedars-Sinai Medical Center. While these hospitals offer different birthing models and amenities, concerns about racial disparities in maternal health outcomes persist.

Patient advocates and experts warn that the closure of maternity wards in urban settings disproportionately affects marginalized communities and contributes to what Granberry describes as “de facto segregation” in healthcare. Addressing these disparities will require systemic changes and long-term investments in maternal health services to ensure that all pregnant individuals have access to safe and equitable care.

Racism continues to play a significant role in the disparities seen in the medical field, particularly in hospitals. The closure of maternity wards in predominantly Black and brown neighborhoods is just one example of how systemic racism impacts healthcare outcomes. Alecia McGregor, an assistant professor at Harvard University’s T.H. Chan School of Public Health, who has extensively studied urban hospital closures, highlights the disproportionate impact on Black women and birthing individuals in these communities.

McGregor’s research has shown that in some hospitals, there are no deliveries among Black patients, while in others, more than 90% of deliveries are accounted for by Black patients. This de facto segregation in hospital care demonstrates the unequal birthing experiences that Black and white individuals face. McGregor emphasizes the need for equitable distribution of resources and funding to hospitals serving majority Black populations to address this issue.

One proposed solution is to reform payment systems to ensure that hospitals serving vulnerable communities are adequately reimbursed for their services. McGregor suggests adopting a reimbursement designation similar to Critical Access Hospital designations for rural hospitals, which could help hospitals in urban areas serving marginalized communities stay afloat financially.

In California, State Assembly Member Akilah Weber, who is also an OB-GYN, has taken action to address the issue of maternity ward closures. She introduced a bill that would require hospitals to give six months’ notice if their maternity units are at risk of closure. This legislation aims to provide the state with enough time to intervene and potentially prevent closures that could have detrimental effects on communities.

Weber’s bill also mandates a report on the closure’s impact on the community, including data on the number of births at the hospital, its financial status, and the workforce that may be affected. By providing access to this information, the state can better understand the implications of these closures and take proactive measures to mitigate them.

Some experts argue that the current reliance on hospital-based obstetric care may not be the most effective model for addressing maternal health disparities. Priya Batra, an OB-GYN and deputy director at the Los Angeles County Department of Public Health, suggests reimagining a more comprehensive perinatal network of care that goes beyond hospital settings.

Ultimately, addressing the systemic issues that contribute to the closure of maternity wards in Black and brown communities requires a multi-faceted approach that prioritizes equity, access to care, and community engagement. By acknowledging and combating the role of racism in healthcare disparities, we can work towards a more just and inclusive healthcare system for all.

In an effort to improve birthing experiences and outcomes for families, there is a growing call to move beyond the traditional hospital model of care. Advocates are pushing for the establishment of a diverse network of birth centers that employ midwives and doulas, who can provide personalized and supportive care to birthing parents.

Neha Batra, a key figure in this movement, emphasizes the importance of offering families alternative options when faced with changes to their birthing plans, whether due to medical reasons or the closure of maternity wards. By incorporating midwives and doulas into the care process, the hope is to alleviate some of the anxiety and stress that families may experience during these uncertain times.

However, the road to expanding birthing centers in California has not been easy. Recent closures of such facilities have highlighted the challenges that these centers face in operating within the state. Batra, who is also involved with the California Maternal Quality Care Collaborative, stresses the need to address these obstacles in order to provide accessible and quality care for all families.

One of the key issues that the organization is looking into is the impact of maternity ward closures on families, especially those in rural areas where travel to alternative birthing facilities may be difficult. The goal is to understand how these closures affect birth experiences and outcomes, particularly in urban areas where options may still be limited for some families.

Providers like UMMA’s Barth-Rogers are on the front lines, trying to support patients whose lives are disrupted by these closures. The challenge lies in navigating a complex healthcare landscape with multiple hospitals, systems, and insurance providers, which can make it difficult to ensure continuity of care for patients.

As the conversation around birthing care continues to evolve, it is clear that a more holistic approach is needed to support families through the birthing process. By building a network of birth centers staffed by midwives and doulas, there is hope for positive outcomes and experiences for both babies and birthing parents. The work of advocates like Neha Batra and organizations like the California Maternal Quality Care Collaborative is crucial in driving these changes and ensuring that all families have access to the care they need during this important time.