While working in large, urban hospitals, Tracy Ryan has seen 25 to 30 babies delivered a day.
“I call those places baby factories. They provide incredible care — there’s incredible expertise because they do so much volume,” said Ryan.
“But I couldn’t tell you…I can’t tell you one family that I remember both the parents’ names and their baby’s name,” Ryan said. “I know that’s supposed to be one of the most intimate, fabulous events of your life, right? And I don’t remember any of those people.”
That’s a far cry from her current job at Jefferson Healthcare in Port Townsend, a rural hospital that delivered only 78 babies last year. Ryan started her job in May — but even though she’s been there for less than a year, she already feels like she’s caring for her neighbors.
“I know that kind of sounds cheesy, but in small communities, you are caring for your neighbors,” Ryan said. “You do see these people in the community. You do see them at dinner. I’ve seen people at the movie theater, for crying out loud, and it’s so fun. It feels like they’re part of your family. So I definitely love working in a place like this.”
Places like Jefferson Healthcare are in a precarious position. Rural maternity wards are almost always financial black holes, a reality that has forced several in Washington to close in recent years, including one in Toppenish last year and at Naval Hospital Bremerton, which stopped delivering babies in 2022.
It’s something lawmakers are trying to solve, both on the state and federal level. Washington lawmakers approved $1.6 million for low-volume birthing hospitals during the 2024 legislative session, which has kept some wards from closing, said Beth Zborowski of the Washington State Hospital Association — but rural hospitals say they still need more help.
That’s why they’re supporting a bill, co-sponsored by Democratic U.S. Sen. Maria Cantwell of Washington and Democratic U.S. Sen. Ron Wyden of Oregon, to increase Medicaid reimbursements for rural hospitals and provide other support.
“We shouldn’t penalize families for living in small communities,” Ryan said. “If we don’t do something about maternity deserts and keeping maternity care a viable option for young families, our rural communities are going to die because they can’t be only populated with retiring people.”
Running a rural maternity ward
Keeping a rural maternity ward fully operational at all hours of the day requires a lot of creativity.
“We’ll go days, sometimes weeks, without having a single birth,” said Dunia Faulx, chief planning and advocacy officer at Jefferson Healthcare. “Yet we have to be fully staffed and ready for any kind of emergency.”
At Jefferson Healthcare, labor and delivery nurses are always “cross-trained,” meaning they’re trained across different departments. There are two nurses staffed on every shift trained for labor and delivery — but when the maternity ward is empty, those nurses might be in the emergency department, assisting with surgery or working on the “medical-surgical” floor, which involves patients with a wide range of medical conditions.
“It’s this constant, ‘What’s our backup plan?’” said Karah Ealy, director of inpatient services at Jefferson Healthcare, explaining the push and pull of moving nurses around when a pregnant person arrives at the maternity ward.
For Ryan, that meant being trained to work on the medical-surgical floor. Ryan has been a nurse for 29 years — but this is her first time working outside of the labor and delivery unit.
“I’m a novice in other areas of the hospital,” Ryan said. “I’m learning from the certified nursing assistants. Sometimes the housekeepers teach me things, the physicians teach me things, and it’s keeping me fresh.”
Training new nurses, too, with such a low volume of births, can be difficult. Rural hospitals often use drills and virtual or life-like birth simulations to ensure nurses are trained on high-risk deliveries and difficult births. Many rural hospitals are also dealing with staffing and recruitment challenges.
“All of the challenges of health care are magnified in rural areas,” said Jenica Sandall, director of clinical excellence at Washington State Hospital Association.
Maternity ward deserts
Nationwide, nearly one in four rural hospitals have stopped delivering babies from 2011 to 2021.
In Washington, there are still 19 rural hospitals with birthing units. While that’s much better than some states, Washington’s geography means it’s more difficult for a person in labor to travel further distances than in other areas of the country.
As many Washington residents know, depending on where you’re going in the state, an hour-long drive can become much longer due to bridge closures, stormy weather and windy backroads. Areas like Chelan, Omak and Snoqualmie Pass are particularly difficult for neonatal transport.
“You make that drive when you’re bleeding and you’re in pain, or you don’t know if you’re okay or not, and there’s a bridge that will close and you’ll be sitting on the side of the road for half an hour waiting for it to open again — yeah, it can be a tremendously long distance away depending on the circumstance,” said Dr. Stephen Erickson, a family medicine practitioner at Jefferson Healthcare.
Erikson used to practice in rural Alaska, where the hospital would fly him out to villages.
“That’s real frontier medicine, right?” said Erickson. “I feel we’re almost more in line with that Alaska isolation, compared to when I was in New Mexico.”
“We were an hour away from Albuquerque, but it was a wide open, flat, straight road all the way there. There was never traffic, there was never bridge closures, there was never bad weather that might ground the helicopter,” Erickson added.
Sometimes, Jefferson Healthcare will put expectant mothers up in a nearby hotel because they might go into labor at any minute and live too far away for the drive to be safe — but not every health insurer covers lodging.
Closures can also have a ripple effect on the remaining hospitals, which struggle with an influx of patients. Katie McClymonds, a former travel nurse, used to work at a hospital in Silverdale. When Naval Hospital Bremerton closed its maternity ward, the hospital was “totally overwhelmed,” she said.
“It’s scary, to be honest with you,” McClymonds said. “You don’t have all the resources. You don’t have enough OB providers.”
Financial realities of a rural maternity ward
Jefferson Healthcare loses between $1.2 million to $1.4 million a year operating its rural maternity ward, said Faulx — but even if the hospital only cared about its finances, shutting down the ward might be a losing prospect for them, too.
“In order for us to be able to hire people who want to start families in this community, in order for us to have a thriving family-based community here, we need to have this service,” Faulx said, pointing out that Jefferson Healthcare is the largest employer in the community.
It would take around 200 births a year for the hospital’s labor and delivery unit to be financially solvent, Faulx said.
“We’d have to almost triple our births, which is not possible in our community,” Faulx said. “There’s only 150 births in Jefferson County every year.”
Jefferson Healthcare received about $200,000 from the $1.6 million state lawmakers gave out to rural maternity wards in 2024 — about a fifth of what they lose each year.
“Those kinds of one-time grant programs are lifesavers,” Faulx said. “But there needs to be a look at more ongoing financial sustainability for these programs.”
Faulx said Cantwell and Wyden’s legislation is “incredibly comprehensive.” It would increase Medicaid payments for labor and delivery services for eligible rural and high-need urban hospitals, impacting about a quarter of Washington’s hospitals, among other various Medicaid reforms. Current payments from Medicaid, said Zbrowski, don’t come close to covering the cost of maintaining a rural birthing unit.
It will also provide “standby” payments to cover staffing and maintenance costs for hospitals with few births, allow hospitals to request emergency obstetrics providers from the United States Public Health Service Commissioned Corps and mandate states study and report the costs of providing labor and delivery services to the federal Department of Health and Human Services.
“A lot of these folks that are pregnant in labor and delivering babies out here, they have nowhere else to go,” Faulx said.
“It is critical to our community and rural communities across the state and the country that this service is offered,” she added.
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