HANOVER — As birthing facilities in the Twin States continue to struggle, a New Hampshire report has put data to the trends that have been dragging providers down for years.
11 hospital labor and delivery units, nearly half of those in the state, and five freestanding birth centers have closed since 2000, including birthing wings at Alice Peck Day Memorial Hospital, Cottage Hospital, New London Hospital and Valley Regional Hospital in the Upper Valley.
Across state lines, Brattleboro Memorial Hospital announced last month that it plans to close its birthing center amid severe budget shortfalls, sending shockwaves through the region.
The planned closure follows the closures of Copley Hospital in Morrisville, Vt., in November and Springfield Hospital in 2019.
“There’s just fewer and fewer and fewer places for women to have babies safely without putting themselves or their babies at risk on the side of the road or at home unattended,” said Katherine Bramhall, midwife and owner of Gentle Landing Birth Center in Hanover, in a recent interview.
Researchers at the University of New Hampshire found in a June study that high medical malpractice insurance rates, low insurance reimbursements, and low patient volumes are the main factors forcing freestanding birthing centers to close.
There are four independent birth centers in New Hampshire, including Gentle Landing and three others south of Concord.
To compile the study, researchers conducted surveys and interviews with current and former midwives and reviewed state birth data, birth center finances, and literature and policy from New Hampshire and surrounding states.
Bramhall said she provided data to the researchers, including years of financial documents from her practice that opened in 2018.
She said she has dealt with the issues in the report firsthand and faced potential closure this year due to insurance reimbursement challenges.
Bramhall said she has resolved issues with Anthem insurance that left her with about $60,000 in unpaid reimbursements thanks to an outpouring of community support. She is optimistic that the report will continue to help birth centers, including Gentle Landing, become more stable.
“A problem with access”
With the compounding closures, more women “are delivering, unfortunately, in [emergency rooms] where they may not have an obstetrics provider, there’s delivering by the side of the road, they’re delivering anywhere they can think of,” said Dr. Ilana Cass, chief of obstetrics and gynecology for Dartmouth Health. “This is just a reality in our region.”
In the Upper Valley, there are open birthing wings at Dartmouth Hitchcock Medical Center in Lebanon and Gifford Medical Center in Randolph, in addition to the Hanover freestanding birth center.
“It’s not just do you have somewhere to have a baby,” Bramhall said of the situation. “It’s what is best for your family. Options in care are really limited.”
While she could not provide an ideal distance for pregnant people to travel for obstetric care, Cass said there is clear evidence that longer drives lead to a higher risk of complications and both pregnant people and babies ending up in intensive care units.
The declining birthing options in Vermont and New Hampshire are part of a larger national problem, with about 60% of women in rural counties living more than 30 minutes from a hospital, she said.
Dartmouth Hitchcock Medical Center may see an increase in patients from the Brattleboro closure, but Cass said she expects to see much more of an impact at Cheshire Medical Center in Keene. Cheshire is the closest hospital to Brattleboro with a labor and delivery unit.
Gifford Medical Center, in Randolph, is also keeping an eye on the Brattleboro proceedings, but Birthing Center Nurse Manager Jenny Davis said while the medical center is willing and able to absorb more pregnant patients, she expects the hour-and-a-half drive will curb any influx.
“I don’t think it’s going to be realistic for most people because of the distance,” Davis said. “I really hope that they don’t close. I hope they can work something out because I think it’s so extremely important to have maternity care in a reasonable distance.”
To remain open, Brattleboro would have to find a way to cover estimated annual losses of $4.8 million, VTDigger reports.
Gifford’s small birthing suite delivers about 210 babies per year, with most patients living within half an hour of Randolph, Davis said. Gifford has not been insulated from threats to its own birthing center, but has managed to make cuts in other areas to keep the beloved facility open.
“I’m just really grateful that our administration is committed to keeping our birthing center open so we can serve our community,” Davis said.
State Senator Sue Prentiss, D-Lebanon, has advocated for maternal healthcare during her years in the legislature. She sponsored one package of legislation, “Momnibus 2.0,” that funded the UNH study, which she said comes at a crucial time and will be vital to future policy decisions.
“We’re not seeing additions of places to have babies right now; we’re seeing less options,” Prentiss said. “That’s just not a good place to be in, and with continued pressure on reimbursement and some of these other factors, it’s going to continue to go like this.”
The Senator plans to take the report and work with a group of stakeholders to plan her next steps. She is most interested in looking at payment parity, or ensuring providers are getting the same insurance reimbursement rates for obstetric care regardless of where they are working, and reimbursement rates.
Problems and solutions
Marnie Cabezas, a former midwife and consultant based in Lyndeborough, N.H., provides contract negotiations, credentialing and other services for midwives and birth centers, including Gentle Landing.
Insurance billing and coding for midwifery is “an entirely different beast” from many other medical fields, Cabezas said, making it complicated and resulting in many more denials than any other type of care.
Even when insurance companies do pay, birth centers are short-changed, according to the study.
At an acute hospital, commercial insurance companies pay about $10,000, or 75%, more for normal, uncomplicated vaginal deliveries than for the same type of delivery at a birthing center, according to the study. Medicaid pays between $1,500 and $2,000 more for hospital births.
Several of the study’s recommended solutions involve insurance, including payment parity, incentivizing insurance to cover more required costs of care, like a second provider at each birth and care provided to newborns, and requiring insurance companies to offer better customer support.
“All types of midwives, they’re all catching a baby,” Cabezas said. “It’s the same skillset at that point; why aren’t they getting paid the same for that service?”
Without higher reimbursements, Cabezas said birthing centers can’t support the staffing needed to deliver more babies and reach financial stability.
When working through contract negotiations for midwives and birthing centers, Cabezas said she “can’t get anywhere with any payer” to try to get her clients the same rates offered in hospitals. She hopes that the study will encourage the state and legislators to get involved and make a change.
“We need a helping hand to become established,” Cabezas said.
Another portion of the report focuses on medical malpractice insurance, which companies require providers to have but is extremely expensive in New Hampshire. The report recommends creating a permanent grant fund to help cover medical malpractice costs.
Bramhall said a malpractice fund would be a massive help for her practice.
The midwife’s medical malpractice insurance more than doubled from $18,000 to $40,000 this year, she said. She expects the rates to go up again to about $75,000 next year based on conversations with other midwives.
“I’m just like, am I going to be able to do this?” Bramhall said.
Getting the word out
Bramhall added another recommendation: launching a statewide marketing campaign for birth centers.
“I’ve been open for five-and-a-half years,” Bramhall said. “I still hear the words ‘I didn’t even know you existed.'”
According to the study, Birth centers deliver consistently safe and satisfactory care for uncomplicated pregnancies that is less expensive than traditional maternity care. Yet, the independent facilities continue to see consistently low birth rates, delivering less than 1% of babies born in New Hampshire.
Misconceptions that freestanding birth centers are unsafe and expensive are likely driving these numbers, researchers found. A statewide marketing campaign could address some of the concerns.
“The research basically says that the safety of birth centers is optimized with collaboration with hospitals,” Bramhall said. “And we all have these amazing collaborations with the hospitals; let’s advertise it.”
The study also explicitly recommends more collaboration between birth centers and other healthcare providers, including hospitals.
DH’s Cass agreed that collaboration and communication among providers is crucial to improving local obstetric care.
“We can, and are, actively trying to develop and cultivate this network of rural obstetrics providers,” Cass said. “Including family practice, including midwives, including birthing centers.”
Bramhall is optimistic that the state of New Hampshire will take the study and use it to support freestanding birth centers and pregnant people in the state.
“We are the foundation of family and community,” Bramhall said. “Putting women’s health at this much risk basically means that they start their families from a place of vulnerability instead of empowerment.
