Bonner General Health, in Sandpoint, Idaho, halted its childbirth services earlier this year as laws that criminalize maternal healthcare in the state made hiring obstetricians a challenge.Nathan VanderKlippe/The Globe and Mail
Mahayla Silbernagel was still months from having her first baby when she heard that Bonner General, her hospital in Sandpoint, Idaho, would no longer offer labour and delivery services – despite being the main provider of birth and pregnancy care in the northern part of the state. Ms. Silbernagel herself was born there.
And so ensued a scramble to find another obstetrician in Coeur d’Alene, where the hospital is a 70-kilometre drive from Bonner General.
“I have never been so mad and let down by my community,” Ms. Silbernagel said.
What happened in northern Idaho has left hundreds of women seeking alternatives for care. But it is a symptom of much larger stresses in a country where pregnancy and childbirth have become increasingly fraught. Long-standing financial pressures on hospitals providing labour and delivery services have been compounded by the Supreme Court decision that overturned Roe v. Wade, which has enabled states to restrict abortions and imprison doctors who violate new laws. And those laws have been enacted in the wake of a two-decade period in which the rate of mothers who die during childbirth in the U.S. has risen sharply.
“Most people think of it as a small-town problem,” Ms. Silbernagel said. “But it’s not. This is affecting women across our country.”
Bonner General once delivered an average of 40 to 50 babies a month. That number had fallen to less than 30. Even so, the hospital maintained its services.
Then the law began to shift. In 2020, Idaho passed a “trigger law” to criminalize abortion providers (with only a few exceptions) that would take effect if the Supreme Court overturned Roe v. Wade. It did so with the Dobbs decision last year, and the ramifications of the Idaho law, which punishes offenders with up to five years in prison, quickly became tangible when Bonner General tried to hire doctors.
The new law may have delivered the final blow, but the closure of obstetrics at Bonner General was, in some ways, years in the making. The medical compensation structure in the United States means that birthing services are “money losers, even in good years,” said Ford Elsaesser, a bankruptcy lawyer who chairs the hospital’s board. Just about any other service – including colonoscopies, mammograms, knee replacements and gall bladder surgery – is more profitable.
“We had obstetrics positions open for months that we didn’t even get an interview with anyone,” Mr. Elsaesser said. Hiring in northern Idaho has never been easy. But “certainly the possibility of criminalizing medical advice is pretty daunting – and that’s not something you can buy insurance for.”
“We don’t prioritize the treatment of moms like we should,” he said.
Since 2020, the number of U.S. counties that experienced a reduction in maternity health services increased by 5 per cent, according to a 2022 report by March of Dimes, a non-profit that seeks better care for mothers and children; nearly seven million women now live in counties with no or little access to care. In 2021, the U.S. Department of Health and Human Services projected that the number of U.S. obstetrician-gynecologists will decrease 7 per cent by 2030, even as demand for their services goes up 4 per cent.
Mahayla Silbernagel and her son Xander are photographed on Dec. 7. Silbernagel had to find maternity care 70 kilometres away when her Idaho hospital stopped offering it.Nathan VanderKlippe/The Globe and Mail
The strict state abortion laws that have arisen since the Dobbs decision have only added to the problems. The American College of Obstetricians and Gynecologists said in a statement it is aware of members who have left Idaho, Florida, Kentucky, North Carolina, Oklahoma, Tennessee and Texas.
“Labour and delivery units have been closing across the country for decades. That’s what’s leading to the worsening maternal morbidity and mortality,” said Leilah Zahedi-Spung, a maternal-fetal medicine physician and family planning provider who moved to Colorado this year from Tennessee, where lawmakers made abortion a felony crime.
Changes related to abortion laws are “only going to accelerate” childbirth deaths, she said. They may also widen gaps in the quality of care between states where doctors are free to provide service and those where they are constrained.
She recalled a conversation about the stakes of providing care under Tennessee’s abortion law with a hospital attorney before leaving the state. He told her, “I know you’re worried about going to jail. But if we don’t do something, someone could sue us for malpractice if something happens.”
“It’s impossible,” Dr. Zahedi-Spung said.
Women, meanwhile, are having to travel greater distances to find proper care. At Dr. Zahedi-Spung’s clinic in Colorado, women have arrived from Nebraska, Wyoming and Texas. One drove from Tennessee.
She’s also seen patients from Idaho, where the closure of Bonner General’s labour and delivery services has forced difficult decisions about what to do when contractions start.
One option is to make for Newport, a Washington state city that hugs the Idaho boundary and is 45 kilometres from Sandpoint. The community hospital there reopened its family birth centre months after Bonner General shut down its services.
“We have seen around a 10-per-cent increase of normal Idaho volume compared to volume prior to our temporary closing in 2022,” said Jenny Smith, a spokesperson for Newport Hospital and Health Services, which hired six nurses from Bonner.
Many Idaho women, however, have chosen the longer drive to Coeur d’Alene, where Kootenai Health operates a state of the art maternity ward.
“I really don’t know what it’s going to look like if it happens fast – it’s about 55 minutes to Kootenai,” said Kelcey Utt-Boss, who is pregnant with her second. She is due next May, but has gestational diabetes and has already wearied of the twice-weekly drive to Coeur d’Alene for checkups. With the time on the road, each appointment takes four hours. “That’s a lot of time out of work,” she said.
The distance is great enough to drive considerations of where is best to give birth.
“Some people don’t have a prayer of making it all the way to Coeur d’Alene, and they would rather have a trained person be with them in their home than be on the side of the highway,” said Charity Catlin, a licensed midwife.
The risks that come with a high-pressure drive only increase in winter. But so, too, do the risks of a home birth now that hospital care is considerably more distant. “We’re going to be thinking about a transfer being possibly an hour instead of five minutes. So that’s definitely something that will play into decision-making,” Ms. Catlin said.
For Ms. Silbernagel, it took weeks to sort out what to do after the closure of birth services at Bonner General. She had to find a new doctor. She had to ensure her ultrasounds were transferred to Kootenai Health, all while in the throes of severe morning sickness. A medical condition that made it difficult for her to discern the onset of contractions brought additional anxiety.
“I had to be induced because I lived so far away,” she said. “My doctor and I were very worried about me having the baby on the side of the highway.”
She gave birth to Xander, her son, in July. But the joy of new life – Xander is healthy and Ms. Silbernagel wants four more children – has done little to dim her anger. She blames financial mismanagement at Bonner General for the end of labour and delivery services, although she is also furious at the ways abortion laws have stripped women of medical autonomy.
Several Idaho women and doctors are now suing the state over its abortion ban, saying it has “sown confusion, fear and chaos among the medical community, resulting in grave harms to pregnant patients whose health and safety hang in the balance.”
Ms. Silbernagel has begun working with other women to raise protest and demand the hospital reopen birth services.
But Mr. Ford, the Bonner General chair, said it is difficult to contemplate reopening in the current legal environment.
“If the Idaho law is upheld, it would probably be an impossibility,” he said.