Ten of Oregon’s 34 rural hospitals have no labor and delivery units, and even more are at risk of shutting their doors. This raises concerns for those seeking maternal healthcare in rural areas as residents face high drive times to the remaining providers, limiting their access to prenatal visits and increasing risk in cases of emergency.
Late last month, Oregon Governor Tina Kotek announced $15 million in funding for maternity care in rural hospitals across the state. This will provide payments to rural hospitals with labor and delivery units that have “fewer than 50 beds and may or may not be within 30 miles of another hospital.”
Jeanna Romer is an obstetrician and gynecologist at Grande Ronde Hospital in La Grande. Nora Hawkins is a direct-entry midwife in Wallowa County. They both join us to give us a sense of what that funding might mean, and the general state of obstetric care in Northeast Oregon.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Ten of Oregon’s 34 rural hospitals have no labor and delivery units, and even more are at risk of shutting theirs down. This raises concerns for people seeking maternal health care in rural areas as residents face increasingly high drive times to the remaining providers and limited access to prenatal visits. Meanwhile, Oregon Governor Tina Kotek recently announced $15 million in funding for maternity care in rural hospitals across the state. Jeanna Romer is an obstetrician and gynecologist at Grande Ronde Hospital in La Grande. Nora Hawkins is a certified professional midwife in Wallowa County. Her private practice is called Wallowa Mountain Midwifery. She is the only licensed midwife in Oregon east of Bend who is currently practicing. They both join me now. It’s good to have both of you on Think Out Loud.
Jeanna Romer: Thanks for having us.
Miller: Jeanna, first. How many OB-GYNs are there at your hospital?
Romer: Currently we have two full-time OB-GYNs practicing here and then we have locums who come and cover for us. So we kind of practice at about a one in three call model.
Miller: Locums meaning temporary people who are being brought in?
Romer: Correct.
Miller: So what is an average week like for you these days?
Romer: Busy. We kind of hit the ground running. We work four days a week, and those are all clinic days, but typically one of those days is an operating day in the OR where we’re doing GYN surgery. Then throughout that we’re on call, like I said, equivalent to slightly under one in three, where we’re doing deliveries throughout the day, including during our clinic schedule, and then also overnights and on weekends.
Miller: How many babies might you deliver in the course of, I don’t know, pick your time period?
Romer: It really varies. When I first started here, we were doing about 250 deliveries a year. Now we’re doing over 350 a year. Some weeks things are calmer, other weeks we’ll have 10 to 15 babies a week.
Miller: Did you see an increase in births at your hospital when St. Alphonsus in Baker City closed their obstetrics department and birth center? That was in August of 2023.
Romer: Initially, in 2023 our hospital did about 250 deliveries, and the following year we did about 330. So we saw our numbers go up about 40% after St. Alphonsus closed.
Miller: Am I right that you’re also seeing local birth rates increase, so it’s not just that you’re taking in more patients from a wider area, but there are more births even within your own area?
Romer: Correct, the birth rates from our patients who are located within Union County have also increased, but we do see patients, quite a few from Baker County, a few from Wallowa County, a few, just a handful from Umatilla, and then some from John Day.
Miller: I want to hear a lot more about those distances and what they mean, but Nora Hawkins, as a certified professional midwife in Wallowa County, how many babies do you deliver in the course of a year?
Nora Hawkins: Quite a bit less. I generally am about 12 to 15 a year, and I don’t travel to Union County anymore, I did when I started my practice. My babies are either in Wallowa County or folks that either have relatives or friends, or come and rent a hotel or an Airbnb from somewhere further than I feel comfortable traveling.
Miller: And then if they were going to do that, they would rent an Airbnb or an RV or something around the time when they’re assuming they’ll go into labor?
Hawkins: Yes, that is generally the case. Some people have relatives or family that they can come over, some will come in labor. The distance is no greater than… already they’re driving around to various hospitals regionally, and some will get Airbnb’s at 39-ish weeks. Some feel more comfortable doing it right a few days before. Occasionally people can swing it and do it for a month, so it depends what everybody’s scenario is, what they’re leaving behind, and how long they can stay.
Miller: What you’re describing, it sounds like the costs, especially if they don’t have family in the area, that the costs could really add up very quickly.
Hawkins: I think they could, depending on insurance, the kind of co-pay you would have, would still be far greater than a few days or even a week in an Airbnb and out of pocket for a midwife.
Miller: How far away might your patients, then, be coming from?
Hawkins: I also had an increase with St. Alphonsus closing. I do think there’s, you know, we can chat more about what informed consent and choice looks like for why some of that increase was happening. Generally, I would say most of my Airbnb folks are Umatilla County, Union County, and Baker County.
Miller: Jeanna, how far away might your patients be traveling to see you? You mentioned the county names, as Nora did just now, but some of these are pretty large geographic areas. In terms of minutes or hours, how far away are some of your patients?
Romer: Up to two hours, definitely have quite a few patients coming that distance. Baker County, for reference, those patients are about one hour away, but where we are geographically located here in Eastern Oregon, we sit between a few mountain passes. So it depends on time of year and road conditions and whether freeways are open or not, in terms of them accessing us in a reasonable amount of time.
Miller: Right, Pendleton is theoretically only an hour away, and I guess this lack of a winter so far that’s remained the case. But if that pass is closed, if snow has closed it, people just can’t get to you, right?
Romer: Correct. Those Pendleton patients would then likely be traveling up to Kadlec in Tri-Cities or Hermiston to get obstetric services. But, same thing, Baker sits on the other side of a mountain pass as well.
Miller: So, obviously, birth is just the end of this process, but how do you handle prenatal visits for people who live hours away?
Romer: Typically, early on in pregnancy we see patients about once a month, and at the end that frequency gets closer. Thankfully, a lot of the family medicine physicians that are in Baker are still doing a shared care model, where they will see patients in their clinic for some of their routine prenatal care, and we see them only a handful of times throughout that pregnancy to help reduce some of their costs. So we’re really grateful for those family medicine docs in Baker who are continuing that because it provides a really good service for those patients.
But typically during these prenatal visits, these patients still need to travel at least 45 minutes to an hour to get here, then the time of their visit, potentially the time of fetal monitoring, and then traveling back.
Miller: Right, in that case, it’s basically an entire workday.
Romer: Correct.
Miller: Nora, what about you? How do you handle prenatal visits?
Hawkins: Good question. I have a clinic in Wallowa itself, so most of my clients are traveling from Joseph or Enterprise or Lostine or some of the smaller rural areas that are not in the towns, and then from La Grande. So generally, it’s between 20 minutes and 45 minutes to an hour travel for mine, and then travel home.
Miller: The only other licensed direct-entry midwife in Oregon east of Bend is in La Grande, but she’s not practicing right now. We actually called her up just to check in to make sure and she told us that she’s on sabbatical. Nora, why are there so few of you?
Hawkins: I wish I knew. I don’t know. I think the pathway to education is difficult. There’s not some of the endowment that exists with other programs. Certainly the cost of running a private practice is high, so it’s harder to stay afloat once you’re doing it, but I do really, really wish there was more out here. I turn down folks all the time from hours away, that there’s just no way I would go that far or it’s feasible for them.
So I think there is a need, and then there’s areas in Oregon that are pretty saturated and have a lot of midwives that have to compete for clients. We’re in a food desert and a maternity care desert out here.
Miller: When you’re turning down people, you say all the time, because of distance and maybe also perhaps at times because you’re full up at that moment, do you have a sense where they’re turning?
Hawkins: I think some of them will end up doing care, as Jeanna was saying, at different local clinics, and then traveling to a city during the time that they would be getting midwifery care there. I do a certain number of months off every year that I take off from call, and if I am doing that with someone and I’m doing their prenatal and postpartum care, usually it’s Boise they’ll go, sometimes Portland, also sometimes hospitals, but I think that there’s so many answers to that question.
Miller: Jeanna, I’m curious. I know that you’re obviously much more in the trenches as an OB-GYN than a finance person at the hospital, but broadly, what have you come to understand as the reasons that labor and delivery wards or birth centers are being closed down, not just in Oregon, but around the country?
Romer: I think labor and delivery units are really highly specialized units. The nurses that we have working for us have a lot of training because they are taking care of two patients at a time. It involves the whole labor process. Sometimes they’re taking care of a post-surgical patient, helping take care of newborns right after delivery, doing newborn screening, teaching women to breastfeed. A lot of the people who work on these units are really highly trained, highly capable individuals, and I think just overhead costs to maintain this type of staffing on labor and delivery units is hard, plus we have to be open 24/7. Obstetrics is not a predictable field, and as you know, the saying goes, these babies all come at 2 a.m., which is when they like to come. So we have to keep these units open 24/7, just like emergency rooms.
I think the other aspect, too, is that a lot of hospitals are already operating on really thin margins, and historically maternity care really doesn’t reimburse or pay very well. And in Eastern Oregon, a high percentage of our patients are on Medicaid, and currently that reimburses at right around 50% of the actual patient care cost.
Miller: How has the Grand Ronde Hospital been able to keep your department afloat?
Romer: You know, I think that’s a really good question. We are an independently owned hospital, which I think has provided a lot of opportunities for creativity.
Miller: Meaning not owned by some large hospital group from outside the area?
Romer: Correct. So I think that the hospital has done a really good job of trying to focus on providing local care to people within our communities and surrounding regions, and that they keep that focus really community-oriented. From my perspective, the hospital has done a really good job of prioritizing maternity care. I think, even though it doesn’t typically reimburse well, if other departments and other service lines are doing well, the hospital can absorb some of those costs that we see, where maternity units typically aren’t generating a lot of revenue.
Miller: Jeanna, what are the distances that we were talking about earlier, and the closures that are happening all over the country, including in Oregon, what do they mean specifically for the highest risk patients?
Romer: Nora alluded to the term “maternity care deserts,” where it’s basically these patients who are just having to travel farther to get these services, and high risk patients need to be seen at increased frequency. So in order to have that visit, they’re taking an entire day off work.
And then sometimes in our cases, it’s not appropriate for them to be delivering at a Critical Access Hospital, or they develop a serious condition while they’re still preterm and need to do a life flight to a different state sometimes, in order to get those services. So it really has put a lot more stress on our patients in terms of time off work, travel expenses, and then the unpredictability of when labor may happen, if they’re going to have family resources around or even be in a community that they’re familiar with.
Miller: Nora, has the evaporation of some obstetric services in eastern Oregon, has it changed your own calculus for if and when to transfer a patient if something does go wrong?
Hawkins: Yes, absolutely. I think the closure in Baker was pretty palpable, it sounds like for all of us, and it changes both how you do your screening, because I think without the choice that had previously been there, there were more people reaching out for home birth that maybe would not have, on their own, come to that choice but felt like they didn’t have an option anymore.
For me there was a palpable shift when screening clients to see if it’s a good fit, and of course, we’re only doing low-risk birth and transferring as needed. But if somebody was there for the reasons of feeling like that was the only choice they had, it was a new thing like, OK, we have to discuss, if this is not what you want, then it’s probably not a good fit.
Then on the other side of that, certainly where I am doing births has always impacted what regional hospital might be nearby and is easy to transfer to, and relationships there. I’ve been super grateful to have a fantastic relationship with the hospital here in Enterprise, so I feel incredibly comfortable calling for consults or transferring if something is coming up, that I feel like that would be the better place to be.
Miller: And just to be clear, that’s a hospital where there are general surgeons or internists, but not OB-GYNs. Is that correct?
Hawkins: Correct, that’s my understanding. We have great MDs in general practice. We don’t specifically have an OB-GYN in Enterprise at the Wallowa Memorial Hospital. But there is certainly a team.
Romer: Sometimes Dr. Whitaker and I will go up there and cover calls for some of the providers up there as well.
Hawkins: Yeah, we have a handful of providers that do delivery, and then when they need some time off, Jeanna and Dr. Whitaker have both come over to help cover that, which I think is that your neighbors really do impact your safety. I think it’s that positive impact of better safety for home birth that really does rely on the hospitals that we have down the street, and better staffing certainly means better safety all around.
Miller: I’m curious Jeanna, earlier Nora mentioned sometimes sending patients to Boise. This reminds me of conversations we’ve had in the last couple months about the political realities of maternal care post-Roe [v. Wade]. Have there been cases where Boise, you think would be the best option for patients medically and distance-wise, but because of politics you have not recommended that?
Romer: Yes, I mean, we have a really great relationship with some of the maternal-fetal medicine or high-risk obstetric providers in Boise, and have been super grateful for our accessibility to them and their willingness to help care and collaborate with our patients, but…
You know, a prime example is if, say we have a gestational carrier here living in our community, and the intended parents are two males, they are not both allowed to be on a birth certificate in Idaho, is my understanding. So if some type of complication develops, we are not sending that patient to Idaho because it doesn’t align with the values of the intended parents and what the overall birth plan is.
Miller: Even though they say that Boise may be the closest big city hospital for that surrogate.
Romer: Yes, correct.
Miller: So then instead, they would go to Tri-Cities or Bend or Portland?
Romer: Typically to Portland, yeah.
Miller: I mentioned in the beginning, Oregon Governor Tina Kotek announcing recently $15 million in funding for maternity care in rural hospitals across the state, including providing payments to smaller rural hospitals with labor and delivery units. Jeanna, do you have a sense for what difference this might make?
Romer: I think it is a very real difference, and I think it is a great step in the right direction. I think that we probably need some better long-term solutions when we’re looking at the state of maternity care in rural communities, but I alluded to some of our biggest issues have been in staffing needs. Again, we run 24/7, so we have to have labor and delivery nurses, we have to have anesthesia providers. We have to have pediatricians available, OB-GYNs available.
I think giving the hospital a little bit of breathing room to make sure that we’re able to have this appropriately trained staff and our hospital does a great job, we follow A-1 state staffing guidelines, but it’s a big financial burden to these rural hospitals. My hope is that some of this funding will at least allow some breathing room as we’re putting bigger and more permanent ideas into place.
Miller: Jeanna Romer and Nora Hawkins, thanks very much.
Romer: Thank you.
Hawkins: Thank you for having us.
Miller: Jeanna Romer is an OB-GYN at Grande Ronde Hospital in La Grande. Nora Hawkins is a certified professional midwife at Wallowa Mountain Midwifery.
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