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A rural Illinois hospital closed its labor and delivery unit. A month later, a baby was born along I-55.

More than 65% of the nation's small, rural hospitals took out loans from Medicare when the pandemic hit. Many now face repayment at a time when they are under great financial strain.<strong></strong>
Daniel Acker
Bloomberg via Getty Images
What happened at Lincoln Memorial in Lincoln in 2022 was hardly an anomaly and, instead, more of a predictable result of a declining number of births at rural hospitals, aging populations, and insurance reimbursement favoring Medicare patients over Medicaid.

Faced with a litany of operational challenges, many rural hospitals in Illinois have shut down their labor and delivery units, leading to maternity care deserts. A 2022 March of Dimes report counts Woodford, Piatt, DeWitt and Iroquois counties as being among those deserts.

This is the first of a two-part WGLT series about maternity care deserts in central Illinois. You can also read Part 2.

On Nov. 1, 2022, the CEO of the only hospital in Logan County — Lincoln Memorial — announced in a news release that the three maternity suites dedicated to obstetrical care at the 25-bed hospital would close the following month, "ending labor and delivery services at the nonprofit hospital."

After the Dec. 31 closure, the release said, then-current Memorial Health patients could coordinate with the two OB-GYN doctors who delivered babies at Lincoln Memorial to "choose another hospital" for their delivery.

On Jan. 29, a mother delivered a baby on an Interstate 55 off-ramp near Elkhart.

According to 911 call audio obtained by WGLT, the mother and the driver of the vehicle were heading from Lincoln to Springfield, likely toward Memorial Health's flagship hospital in the state capital.

As far as that 8-minute call to emergency dispatchers went that day, things appeared to go as well as one could hope in an emergency, roadside delivery: The baby — a girl — was breathing, then crying, the dispatcher was helpful and calm, and first responders arrived minutes later.

But an interstate delivery is no one's ideal birth scenario, no matter the outcome. Yet as hospitals across rural Illinois are forced to shut down cash-strapped obstetrical units, emergency deliveries are becoming increasingly common.

"We're seeing more and more babies delivered in our rural emergency departments than we ever have over the years," Illinois Critical Access Hospital Network executive director Pat Schou said in an interview. "Over the years, yes, that's happened — you know, somebody's driving on the interstate and they go into labor and they pull over and deliver. But now we're seeing more and more of that."

Illinois Critical Access Hospital Network
Illinois Critical Access Hospital Network executive director Pat Schou.

Schou has been with the network that connects more than 50 rural hospitals for collaboration and resource-sharing for "20-some" years. She estimates when she joined the nonprofit in 1999, nearly 30 rural hospitals offered OB services.

"Now there's four," Schou said. "That's just within 20 years."

Nationally, the American Hospital Association has tallied 89 OB unit closures at rural hospitals between 2015-2019; the AHA also reports just half of all rural hospitals in the U.S. offered OB services.

In that context, what happened at Lincoln Memorial in 2022 was hardly an anomaly and, instead, more of a predictable result of a declining number of births at rural hospitals, aging populations, and insurance reimbursement favoring Medicare patients over those on Medicaid.

"It's not one, simple thing, and the long-term effects of this are serious. You want to have healthy babies, healthy mommies — that's the ultimate goal of anything," Schou said. "When you think long-term effects for the viability of Illinois and our rural communities, we need to have stable, OB care."

Less than six months after Lincoln Memorial closed its obstetrical unit, another medical challenge arose: One of the only two OB-GYN doctors retired — meaning that, since early May, Dr. Kristen Green has been the only such provider in Logan County.

'In my heart, I just want to stay in Lincoln'

"When the OB unit closed, I will admit, I was trying to figure out my options," Green said in an interview. "But ... I'm committed to Lincoln and that's why I'm staying here."

Green has been an OB in Lincoln for 22 years and is affiliated with Springfield Clinic, a provider-owned, community-based health care system with locations across Illinois. Originally from "between Danvers and Mackinaw in the middle of nowhere," she knew she loved "the rural setting, I love farming communities."

Settling in Lincoln came naturally enough.

Dr. Kristen Green
Justin L. Fowler
Springfield Clinic
Dr. Kristen Green

"It's really fabulous seeing your young families have babies and watching them grow up through school," she said. "My son is 18 and a lot of his friends, I've played some role in them being here and that's a really neat thing. And when moms bring their daughters, that's really humbling because to me, my daughter is just one of the most precious things to me. I feel like that's a huge honor and yet very humbling."

Although she's rooted in her community, Green said on the day of her interview with WGLT that "even as I left the hospital today, someone stopped me and asked if I was interested in going somewhere else."

"And that would be no. (But) again, there's a shortage of OB-GYNs, so if you need that help, sometimes you are a little flagrant because you're in that position," she said.

The American College of Obstetricians and Gynecologists predicted in 2018 that the country would be short by up to 8,000 OB-GYNs by 2020 — and up to 22,000 by 2050.

There are programs attempting to pipeline in new OB-GYNs to rural areas, but Green said the problems that face these providers are systemic — and like Pat Schou of ICAHN said — complicated. Even if, say, there was a sudden influx of OB-GYNs, the same system-wide problems that have contributed to fewers doctors in the first place persist.

"In smaller towns, Medicaid rates are about 43-50%," said Green. "And if you've ever compared the numbers — reimbursement from private insurance and Medicaid, you'll find that Medicaid reimbursement is really suboptimal. One could argue that you rally can't survive just treating Medicaid (patients) alone because of the reimbursement that the government gives."

Green said that could be a deterrent to up-and-coming OB-GYNs who are considering a practice in a rural area.

"Not everybody sees Medicaid because it reimburses so poorly," she said.

Pregnant women on Medicaid in rural areas are statistically more likely to dieof a pregnancy-related complication than their suburban counterparts: According to an Illinois Department of Public Health study from 2018, "pregnancy associated mortality rates" were "highest for women living in rural counties and the city of Chicago" in the years the study covered (2014-16).

"Women on Medicaid during pregnancy were two and a half times as likely to die within one year of pregnancy as women with private insurance," according to the study.

Green recalled one high-risk pregnant woman who struggled to find transportation to her appointments.

"I couldn't get her to her maternal fetal medicine appointment in Springfield because of transportation issues," she said. "My nurses literally spent hours calling different agencies, calling Medicaid, trying to find some way to get her there."

She added that Springfield Clinic recently purchased a non-stress test machine to monitor fetal heartbeats in attempt to eliminate the need for some high-risk women to travel to there for care. It helps, but remains a stop-gap for larger issues facing rural families in Illinois.

"My first thought is always, 'When are we going to take care of our women?' Give them better access to medical care?'" said Green. "But an extension of that is how do we take better care of our future? When we think about pregnant women, we need to remember that we're investing in our future, so that we have healthy babies that become contributing members to society."

Change how we reimburse?

By the time Lincoln Memorial Hospital closed its OB unit, deliveries there were down to 1-2 a week, a trend not unique to that facility: On Tuesday, OSF HealthCare announced it would transfer OB patients to its Bloomington hospital from OSF St. James in Pontiac while the organization evaluates "where it will provide birthing, labor and delivery units."

As was the case with Memorial Health, OSF leadership said births at the Livingston County hospital had fallen from hundreds a year to 10-15 a month.

The downward trend in births at rural hospitals is likely due to a conflation of variables, including rural population loss, an aging population, an increase in home births and more.

At any rate, the low volume of births at these hospitals combined with a low Medicaid reimbursement rate leads to financial challenges.

"If a hospital has a narrower operating margin — let's say they're making $500,000 a year and they're losing $1.5 million for OB services. You can only sustain that for so long," said ICAHN's Schou.

Many people who end up in rural hospitals are on Medicare, Schou said, which reimburses them well — "cost plus 1%."

Medicaid, a state-administered public health insurance program for low-income people and children, does not reimburse at the same rate.

"Medicare provided the funding to set up this new payment program — a new type for rural communities," Schou said. "Medicaid does not reimburse the same way: The state of Illinois with Medicaid recognizes that (these hospitals) are critical access hospitals, but they don't pay more just because there's an OB patient, or if they have a department of OB services."

The federal Centers for Medicare & Medicaid Services estimates that 42% of births in the United States are funded by Medicare. Schou said it's going to take changes at a policy level to correct reimbursement disparities.

"What we are trying to do is raise awareness," she said. "We have to rethink the formula."

Lyndsay Jones is a reporter at WGLT. She joined the station in 2021. You can reach her at lljone3@ilstu.edu.