Where in Alabama

By 2014, just 29 of Alabama's 67 counties have a hospital that offers obstetrical services. More rural hospitals are closing their labor and delivery departments as a way to save money.

(Anna Claire Vollers / avollers@AL.com)

The day before Sommer Curry was scheduled to deliver her baby in early September last year, she got in her car and drove to the hospital.

Two hours away.

"Really, there are no other options," said the mom of three, who lives with her husband and children in Camden, Ala., located in rural Wilcox County. "I guess we've gotten used to it. You just have to plan."

Curry, who has lived in Camden for the past 12 years, delivered all three of her children - ages 10, 7 and 5 months - 102 miles away in Tuscaloosa at DCH Regional Medical Center.

Montgomery is a bit closer - an hour and a half drive to the northeast - and Selma is about an hour north, but Curry said she liked her OBGYN in Tuscaloosa and wanted to deliver at a bigger hospital with more sophisticated emergency services.

"There's just nowhere local," she said. "So you're forced to go to the larger cities."

Curry is one of a growing number of women in rural Alabama who are having to drive 50, 60, 70 miles or more to reach a hospital that has labor and delivery services and to see an obstetrician for prenatal care.

Back in 1980, 46 out of the 54 rural counties in Alabama had hospitals that delivered babies.

Today, that number has fallen to just 17.

"It's not just a state problem; this is a national trend," said Dale Quinney, executive director of the Alabama Rural Health Association. "I personally consider this as the greatest healthcare threat we have in rural Alabama: the loss of obstetrical care."

Deep cuts

One of the latest hospitals to shutter its labor and delivery unit is Bryan Whitfield Memorial Hospital in Demopolis, the largest city in Marengo County.

Obstetrical services are expensive to offer, said Jay Shows, a member of the hospital board at Bryan Whitfield. There are stringent operating regulations, malpractice insurance requirements and there may not be adequate reimbursements from patients' insurance.

"There are so many challenges with rural healthcare that the (labor and delivery) component of our overall operations was costing us between $400,000 and $500,000 a year," said Shows, who has a background in small business. "If you are a huge hospital, that's maybe unpleasant, but you have other revenue streams and you can use it as a loss leader. But when you're a rural healthcare system, the board had to look at certain services we were providing, like labor and delivery, that were making the whole ship list to one side."

The decision to close Bryan Whitfield's labor and delivery department was a hotly debated topic in Demopolis for many months before it was finally shut down in February 2014.

The majority of patients at Bryan Whitfield have Medicaid insurance, which reimburses roughly 73 percent of a regular delivery; private insurance like Blue Cross and Blue Shield of Alabama reimburses roughly 74 percent, said Quinney.

"Given the current rate of reimbursement, to cover those fixed costs (of providing obstetrical care) they would have to have a minimum of 250 births a year just to break even," said Quinney. "They were losing money on each delivery."

The hospital was actually down to less than one birth per day, said Shows. They tried cutting staff, but regulations required they keep L&D fully staffed 24 hours a day. With so few births, the hospital couldn't make it work financially.

Affecting the disadvantaged

Women in rural areas who have the means will often choose to travel a greater distance to receive care in a more sophisticated hospital. "Even if our little hospital here (in Camden) delivered babies, I wouldn't go there," admitted Curry. She said she felt better knowing she was in a hospital with more specially-trained physicians and more sophisticated equipment.

Meanwhile, low-income and disadvantaged women don't have the means to make a choice, and still often have to drive an hour or more to reach a hospital - any hospital - that offers obstetrical services.

For women who can't make the long drive to a hospital with obstetrical services, their choices are limited: go to the nearest emergency room to have their babies delivered by an ER physician, or deliver at home. If they choose to deliver at home, state law forbids them from being assisted by a midwife or other skilled provider.

A void in prenatal care

The distance to a hospital with obstetrical services doesn't just affect a woman in labor. It affects her entire pregnancy, her health and that of her child.

"What's hurting more than anything is what you don't see," said Quinney. "When you lose physicians who are performing obstetrics in a county, you lose a source for prenatal care along with them."

Demopolis, for example, once had four doctors offering obstetrical care. Now there's just one.

In 2013, nearly 26 percent of expectant mothers in rural areas in Alabama received less than adequate prenatal care, according to the Alabama Rural Health Association.

Rural areas don't have public transportation or taxi services. And in an area like Wilcox County, where nearly 40 percent of the population lives below the poverty level, a ride to the doctor or the hospital can be difficult to come by.

Driving an hour or more each way for a monthly OBGYN appointment just isn't feasible for many women who work full time, who have jobs with inflexible leave policies, or those who don't have access to transportation. So they go without.

Changing the birth landscape

The lack of easy access to obstetricians and obstetrical services also impacts the kinds of births rural women are having.

"We planned an induction with all three of mine," said Curry. "I really felt more comfortable doing that, being so far away from the hospital. Most people here have either scheduled inductions or c-sections."

At Russell Medical Center in Alexander City, around 57 percent of babies were delivered via cesarean section in 2013 - much higher than the state's rate of 36.1 percent.

"(Russell Medical Center) has a number of women who come in from outlying counties that don't have hospitals that perform obstetrics," said Quinney. "Many of those women are afraid of the distance and elect to go ahead and have a planned delivery. I think that's contributing to the fact that Alabama has (one of the) highest percentage of premature births nationwide."

A 2009 study published in the New England Journal of Medicine found that 36 percent of planned cesarean births were actually performed before 39 weeks - the cutoff recommended by the American College of Obstetrics and Gynecology. Babies delivered before 39 weeks are at increased risk of birth-related complications and adverse outcomes.