When Nikki Mahar, who recently moved to Eastport from California, woke up in the middle of the night with stomach pains at 14 weeks pregnant, she and her husband rushed to the closest emergency room, in Calais. 

Seven weeks earlier, after another visit to the emergency room for unexpected bleeding, the couple had learned Mahar was pregnant with monochorionic-monoamniotic twins, identical twins who share a placenta and an amniotic sac. The condition is extremely rare and high-risk for both mother and baby and requires close monitoring throughout pregnancy.

When the couple arrived in the emergency room in Calais, which closed its labor and delivery unit in 2017, there was no one specialized in obstetrics to care for her. Her obstetrician at Down East Community Hospital in Machias was out sick; they were diverting patients to Northern Light Eastern Maine Medical Center in Bangor.

A physician in Calais did an ultrasound and told the couple it appeared there was only one twin still present. There was still a heartbeat, said Mahar, but the couple was told that, given the loss of amniotic fluid, Mahar was likely to miscarry the second twin as well. The couple was told that not much could be done at the moment and sent home.

Before they left, Mahar told staff that she was concerned about the odor of her leaking amniotic fluid, which she’d read could be indicative of an infection. Staff swabbed her and said they would get her treated right away if the test came back positive.

The couple returned home, but Mahar still didn’t feel right. She began calling hospitals in Bangor and Portland. A nurse at EMMC in Bangor called her back right away. “She said, ‘How fast can you get here? Because you need to be seen,’” Mahar recalled.

Exhausted, the couple piled into the car and drove the two hours west to Bangor. 

Another ultrasound revealed that the second fetus had no heartbeat. An obstetrician confirmed Mahar’s suspicion that she might have infection and recommended immediate dilation and curettage, a surgical procedure to clear Mahar’s uterus and prevent sepsis.

After the procedure, the couple stayed nearby at a hotel, just in case. The decision proved prescient: Mahar spiked a fever that night and returned to the hospital, where doctors found a blood clot in her uterus. They recommended Mahar undergo either another D&C or take mifepristone, a medication used to terminate early pregnancies, to help pass the clot.

Mahar, fearing additional scarring and complications for future pregnancies, took the medication.

“It was just scary,” said Mahar. “This was a miscarriage. What if I was full term and in labor? There would’ve been no one specialized in obstetrics and gynecology to deliver my baby in Calais, and even if we went to Machias they would’ve diverted me to Bangor, which — in an ideal situation — you get ambulanced two hours away.”

Things can go wrong quickly even in a pregnancy that’s otherwise progressing normally, said Kelley Bowden, a retired neonatal intensive care unit nurse and consultant who has helped several Maine hospitals navigate the closure of their maternity units. While ER staff are trained to handle emergencies, “they’re not used to responding to sick pregnant people or sick newborns.”

“A lot of the time it works out,” said Mahar, who gave birth to a healthy baby girl in the fall. “But what if it didn’t? There aren’t a lot of health care providers at this end of the county. It’s the drawback of rural living.”

Calais is one of nine hospitals in Maine that have closed or announced plans to close their birthing units in the past decade. Roughly half of Maine’s 36 hospitals do not offer birthing services. 

The closures span the state but have hit rural areas particularly hard. Last year saw the announcement of birthing unit closures at hospitals in Belfast and Waterville, both of which will cease offering the service this spring. In 2023, hospitals in York, Rumford and Fort Kent announced closures; the year before saw the shuttering of the birthing unit at St. Mary’s Regional Medical Center in Lewiston.

On average, rural Mainers whose closest hospital doesn’t have a birthing unit are now driving 45 minutes one-way to the nearest birthing hospital, according to a recent analysis by the Center for Healthcare Quality and Payment Reform, the longest drive time in New England. 

Rural residents carrying high-risk pregnancies may be forced to go even farther — to Bangor, Portland or in rare cases Boston — for a specialist’s care. 

Impossible to recruit

Town after town, the reasons cited by hospital administrators are the same: difficulty hiring, a declining number of births and reimbursement rates that do not cover the high, fixed costs of providing a service that requires a team of specialists on-call at all times.

Recruiting providers to work in rural Maine has always been tough, said Natalia Hall, associate vice president of Northern Light Women’s Health. The hospital system recently announced that it was shuttering birthing service at Northern Light Inland Hospital in Waterville due to difficulty recruiting providers. 

In the past few years, Hall said, finding physicians willing to work in obstetric care “has been a challenge more than I’ve ever seen in my career here.”

Other hospital executives around the state echoed this sentiment.

MaineHealth Waldo Hospital tried for two years to recruit a pediatrician, said Denise Needham, president of both Waldo Hospital and Pen Bay Hospital, in Rockland. When they finally hired someone, it was short-lived.

“They gave their notice within six months,” said Needham. “When you are on call one out of every two days because there’s no one else to cover you and you have to cover the hospital at all times… it is not a sustainable model.”

Waldo Hospital announced last year that it would close its birthing unit on April 1, shifting births to Pen Bay, a 35-minute drive south. While pregnant patients will still be able to receive prenatal care in Belfast, all deliveries will be shifted to Pen Bay, which is also an affiliate of MaineHealth.

Dr. Jane Carreiro, dean of the University of New England College of Osteopathic Medicine, Maine’s only medical school, said students are searching for a better work-life balance than physicians of earlier generations.

“Young graduates with families — they don’t want to be on call seven days a week,” she said. “They don’t want that kind of lifestyle. And that’s fine, but it means that it’s going to take more people to do the same work.”

A national crisis

Maine is not alone. Between 2010 and 2022, 537 hospitals around the country closed their labor and delivery departments, according to a large study published in the Journal of the American Medical Association in December.

As of 2022, more than half of all rural hospitals nationwide did not offer labor and delivery services, while more than a third of urban hospitals were left without obstetric care.

Maine is one of the most rural states in the nation and birth rates are among the lowest in the country. The number of births in the state in 2023 — 11,205 — is half what it was in 1960. 

Low birth rates mean that staff have a harder time sustaining their skills. 

“It’s difficult to maintain your skills and expertise just based on training,” said Needham, president of Waldo Hospital and Pen Bay. “You really have to be engaging in live deliveries to be able to keep your skill set up.”

While several of the hospitals that have shuttered labor and delivery services in recent years, such as Northern Maine Medical Center in Fort Kent and Rumford Community Hospital, had fewer than 100 births per year when they announced the closures, hospitals with higher birth rates have not been immune. 

York Hospital, which closed its unit last September, averaged more than 300 births per year in the five years before its closure; at St. Mary’s Regional Hospital in Lewiston, that figure was 527 births for the four years prior.

All of this is happening against the backdrop of rising maternal death rates in the United States that far outstrip those in other developed nations. The rate of people dying due to pregnancy-related causes during pregnancy or 42 days postpartum nearly doubled between 2018 and 2021, from 17 to 33 deaths per 100,000 live births. 

Researchers estimate that 80 percent of those deaths are preventable, and that proper and consistent prenatal care can go a long way toward improving outcomes.

Several experts said it is still too early to tell how recent labor and delivery closures are impacting the health of women and babies in Maine. But research from other areas of the country that have lost access to care has shown that women tend to get less prenatal care and have higher rates of preterm birth. 

According to a study of mothers in Louisiana published in 2021, women in maternal care deserts — areas with no hospitals providing obstetric care, no birth centers, no ob-gyn services and no certified nurse midwives — were three times more likely to die during pregnancy or the year after.

Maine, which had the lowest rate of infant deaths in the country in the mid-1990s, now has one of the highest rates in New England, said Bowden.

And those rates are much higher for certain groups, such as Black and Indigenous Mainers, or those living in poverty, figures that are mirrored nationally. Babies born to people in Maine who have only a high school education are also at higher risk, and are twice as likely to die before reaching their first birthday compared to those born to a parent who has attended at least some college. 

The reasons are complicated, but inadequate prenatal care is a factor in both maternal and infant health, said Bowden, who worked on a 2020 report that explored the drivers of infant mortality in the state. 

“In the ideal world, everybody’s as healthy as they can be going into a pregnancy, but that’s not what’s happening,” said Bowden. Consistent prenatal care can improve outcomes for babies by managing chronic conditions of people who are pregnant, like obesity and depression.

“That’s where the bottleneck is”

In many ways, obstetric care is unlike any other medical specialty. 

“It really is the only area of medicine where you’re dealing with two or more patients,” said Bowden.

Because of the unpredictability inherent in a pregnancy — babies who may be born at any time, the possibility that even the healthiest-seeming pregnancy might require an emergency C-section — a labor and delivery unit must be staffed at all times with a surgeon who can perform a C-section, an anesthesiologist, skilled nurses and other support staff. 

“Any instability in one of those four legs really calls into question whether or not you can continue to sustain the program,” said Needham.

It also means that any hospital that wants to offer labor and delivery needs to have an ob-gyn on staff who can perform C-sections, as well as someone to fill in when they’re away.

The federal Bureau of Labor Statistics estimates that there were 19,820 ob-gyns working nationwide as of 2023. Roughly 100 were employed in Maine, down 17 percent from a decade earlier. 

Across the country, most ob-gyns were employed in just a handful of cities centered around large medical centers in Boston, New York and San Francisco.

There’s a reason for that, said Dr. Carreiro.

Research shows that new physicians are most likely to practice within 100 miles of where they complete their residency program, where they’ve grown familiar with colleagues and perhaps even started their own family. 

Maine has just one obstetric residency program, at Maine Medical Center in Portland. Nationwide there are more medical students who apply for obstetric residency programs than there are spots available, according to data from the National Resident Matching Program.

“That’s where the bottleneck is,” said Dr. Carreiro. “You can make as many medical students as you want, but if you don’t create the residency programs, you don’t have the obstetricians.”

Reimbursement rates do not cover increasingly expensive care

Hospital administrators also said that reimbursement rates from MaineCare, which covers 37 percent of all births in the state, do not approach the high fixed costs of running a labor and delivery unit.

According to comparemaine.org, which tracks health care costs at hospitals around the state, the average total payment to a health care provider for a vaginal delivery is $18,947, including both payment from the patient and from an insurance provider. That includes all medical services – ultrasounds, medications, anesthesia — in the month before and the month after delivery. The average payment for a C-section is $23,347.

On average, private insurance reimburses providers in Maine $23,595 for a C-section and $14,630 for a vaginal delivery, according to research by the Health Care Cost Institute. MaineCare, however, reimburses providers just a fraction of the cost of providing care — $4,607 for a vaginal birth and $6,847 for a C-section.

The discrepancy can hit providers in rural areas, which often serve a higher proportion of patients on MaineCare, particularly hard.

“It’s not like you’re making money off obstetrics,” said Mount Desert Island Hospital President Chrissi Maguire. Particularly in a rural hospital like MDI with low birth volumes, “that price per baby is expensive.” 

The United States has long been the most expensive country in which to give birth. A comprehensive 2013 study found that for those with commercial insurance the average total charges ranged from $32,093 for a vaginal delivery to $51,125 for a C-section. For Medicaid patients, the figures were $29,800 and $50,373, respectively. Insurance — private or otherwise — covered just a fraction of the total charges, between 26 and 57 percent.

Maine’s high price per delivery and declining birth rates are compounded by an increasing share of pregnancies among patients who are less healthy to begin with and who are often older and at higher risk for complications than in previous decades, said Katherine Simmonds, a researcher with the Roux Institute at Northeastern University who recently authored a report on the maternal health care workforce in Maine.

“The administrative leadership commitment to keeping the obstetrics unit open is critical,” said Simmonds, noting that this may not be enough. “We really need system-wide changes.”

“The heart and soul of a hospital”

Maine’s birthing unit closures have left towns reeling from the loss of a service many say is not only vital to the health of families but also central to the identity of a community.

Waldo’s birthing unit is “the heart and soul of the hospital,” said Rachel Keidan, whose daughter was born there in September.

The fact that Waldo Hospital had a labor and delivery unit was one of the deciding factors for Keidan when she and her husband moved to Belfast. “It makes us a better, more proud community.”

On June 14, 2024, Keidan was six months pregnant with her first child when she and other Waldo Hospital patients described being confused and blindsided by an email with the subject line “Providing The Best Possible Care.” 

The email appeared so generic at first glance that she almost didn’t read it. 

After scanning the first three paragraphs, which discussed the hospital’s growth and accomplishments, Keidan was alarmed when she noticed the rest of the email was dedicated to obstetric care. Or, more specifically, what was soon to be a lack of obstetric care in Waldo.

The email, which was signed off by Needham, outlined declining birth rates and staffing shortages at the hospital, stating that that would be a “review” and “redesign” of the obstetrics program, in part due to not enough babies being born there.

According to the email, there were 60 births at the hospital between October 1, 2023, and April 30, 2024, a 19.4 percent decrease from fiscal year 2019. “Volumes below 200 annually are considered very low by national standards,” the email stated. 

Waldo Hospital had 109 births in 2023, according to data compiled for The Maine Monitor by the Maine Department of Health and Human Services, up from 98 the year before but down 19 percent compared to 2018. 

Low birthing volumes are not uncommon in Maine’s rural hospitals. Ten of Maine’s 21 birthing hospitals had fewer than 200 births per year in 2023; three — including Pen Bay, where Waldo executives plan to move birthing services — had between 201 and 205 births that year.

The email offered little information about the potential closure — no timeline or details on whether patients like her would be allowed to continue their care there. “It was a very jarring email to get, not just as a member of the community, but of course, selfishly, as a pregnant woman,” said Keidan. 

After a vote by the local hospital board, Waldo officially announced the closure in November, citing declining birth rates and staffing shortages as the primary reasons. The hospital has said the decision was not related to costs. 

“These are difficult decisions that we have to make for the safety of our patients, and again, [they’re] not always understanding of those decisions because they don’t see what’s happening behind the scenes,” said Needham. “The reality of it is, we have to tailor our services to the needs of the community, and although the community of expectant moms is extremely vocal, it’s still very small.”

Locals decried the decision in town meetings and social media posts as out of touch with community needs and driven by the state’s largest health care system, MaineHealth, which owns both Waldo and Pen Bay. 

“The control of what happens at Waldo is so far away,” said a pediatrician who worked in Belfast for more than two decades and spoke on the condition of anonymity for fear of reprisal. “Decisions are made by people who don’t live or work in Waldo Hospital. They don’t have a personal stake in the decisions.“

Before MaineHealth took over Waldo Hospital, the pediatrician continued, “it used to be like neighbors helping neighbors… This move is us turning our backs on our needy patients, who we have a multi-decade proven track record of helping, and now we’re just deciding not to because it’s hard. Is that as good as we can do? I don’t think so.”

Mike Towey, a speech pathologist who recently retired from Waldo Hospital, said the decision to close the birthing unit signals to residents that “it’s all about making money… decisions are made based on what’s best for the corporation and Waldo may be secondary.” 

Needham insisted the decision was “not a financial one” and not done under pressure from the larger MaineHealth system.

“When we start to question whether or not we can safely continue to offer a service because of low volume [and] because of staffing challenges, that’s when you have to make decisions that look like they’re out of alignment with the public opinion,” she said.

“It’s the drawback of rural living”

Thirteen of Maine’s 16 counties now have just a single birthing unit; come this spring, Waldo will become the first to have no birthing hospitals at all. 

In interviews, women around the state recounted spending hours on the road to get to prenatal appointments — as often as once a week in the later months of pregnancy.

While Maine does not have any official maternal care deserts, there are still long stretches — 100 miles between Calais and Bangor, 117 miles between Bangor and Houlton — where there is no access to a hospital with a delivery unit. 

“I was basically doing weekly appointments almost my whole pregnancy,” said Molly Fletcher, who lives in Calais. Fletcher has Type-1 diabetes, a condition that requires careful management during pregnancy. 

Fletcher lives in Calais and works at Calais Community Hospital, which stopped offering birthing services in 2017. When she became pregnant, she commuted the 45 minutes each way to Down East Community Hospital in Machias, sometimes twice a week toward the end of her pregnancy.

“Fortunately for me, I can work over there too. But a lot of people wouldn’t be able to do that,” she said. “They would have to miss work and the day of pay.”

Bowden, the retired neonatal intensive care unit nurse, said hospital executives might assume that patients will simply seek the next-closest option. “But that isn’t always accurate. People have strong feelings about local hospitals.”

Several experts said the ripple effects of closing a labor and delivery unit extend far beyond the unit itself.

“The greater good of your community is dependent on a service like OB,” said Maguire, of MDI Hospital. Maguire said she weighed the future of labor and delivery at MDI Hospital when she came on as chief financial officer more than a decade ago. The unit was losing money and difficult to staff. 

“But the value to the community, the value to our primary care network far outweigh the challenges we need to overcome to subsidize the program,” said Maguire. “You cannot attract new families, young families, young couples, into a community that is not healthy and vibrant and growing.”

This story was originally published by The Maine Monitor, a nonprofit civic news organization. To get regular coverage from the Monitor, sign up for a free Monitor newsletter here.