Los Angeles County: the epicenter of urban maternity ward closings

LOS ANGELES — Simone DeRoche, expecting her fourth child in December, had her birth plan set: delivering at USC Verdugo Hills Hospital, where her three other kids were born. 

But when she received the text from her OB-GYN last week that the hospital will be closing its maternity ward and NICU in November, DeRoche felt a wave of disappointment and sadness. She’d enjoyed the experience of giving birth at the Glendale, Calif., hospital, calling it “a special place.”  DeRoche said she has options, including giving birth at Huntington Hospital in Pasadena, a mere 10- to 15-minute drive from her home in La Crescenta. But she’s uncertain where she’ll end up, or what the experience will be like — she’s recently heard stories about overcrowded area hospitals where deliveries are happening in the ER. The news about Verdugo Hills hit home: She knew about rural hospitals closing maternity wards, but not urban area hospitals.  

California has been a longtime national beacon in setting the agenda for comprehensive maternal and child health care. Maternal death rates in the state are about half the national rate — although pre-term birth rates are only slightly below the national average and sharp disparities persist for Black maternal and child health outcomes. Now, providers and patients alike are facing a rash of maternity ward closings like those that have occurred around the country, creating what have been called “maternity deserts.” 

Those deserts often are found in rural areas, but they also are popping up in urban areas. An investigation done by CalMatters, a nonprofit newsroom based in Sacramento, found that since 2021, 29 hospitals in the state stopped delivering babies. Nearly 50 obstetrics departments have closed over the past decade, and 17 were in Los Angeles County.

For pregnant people in the county, especially Black and Hispanic people whose communities are most affected by closures, the uncertainty and challenges are often greater than those facing DeRoche. Not only is their continuity of care affected, but the impact is amplified by being forced to travel great distances, potentially without transportation or child care, or the financial resources to obtain them. Some hospitals won’t accept patients’ insurance, and insurance companies are slow to make decisions about prior authorization for patients to give birth out-of-network. Providers and community-based advocates work hard to find services and fill in all the gaps for pregnant people who have had their birth plans upended. 

“The situation is a little chaotic” for patients and providers right now, said Yohanna Barth-Rogers, chief medical officer of UMMA Community Clinic in Los Angeles. Patients may find that a new hospital, uncertain of who may come with a potential high-risk pregnancy, is reluctant to take them on. Some patients are in the dark about who their consistent provider will be after they deliver. That’s a paramount concern if they or their babies experience complications, and in the critical six weeks postpartum, extending out to the first year after giving birth.

“A lot of women are scared, particularly women of color, to deliver their babies because the outcomes are just worsening in this country,” Barth-Rogers said. “It’s scary right now to deliver, it’s scary to not have your voice be heard.” 

Providers, public health experts, and legislators told STAT they have been flummoxed by the alarming number of maternity ward closures. The culprits cited in California, as elsewhere, include a declining birth rate, staffing challenges (especially since Covid-19 arrived in 2020), and the constant loss of revenue to keep labor and delivery services open. Another oft-cited reason is poor Medicaid reimbursement levels for maternity care. Medi-Cal, California’s health insurance program for low-income residents, has the country’s fifth-lowest reimbursement rate for obstetrics, according to CalMatters.

“The decision to close maternity service is an agonizing one that our hospitals don’t come to easily,” said Peggy Broussard Wheeler, vice president of policy for the California Hospital Association, the industry advocate for the 400-plus hospitals statewide. 

There are several factors that can make maintaining a labor and delivery department that’s ready for births year-round unsustainable, Broussard Wheeler said. The pandemic put financial stresses on hospitals generally. And maternity service expenses in particular are high, often only second to that of emergency rooms. 

In addition, the declining birth rate, both in California and nationwide, means that “the staff capability, staff competency for those high-risk deliveries is not there and staff begin to be concerned that they’re not prepared for a high-risk delivery because they’re not seeing enough deliveries,” Broussard Wheeler said. “When staff start coming to hospital leadership to say that they’re worried about their capabilities, it’s another reason those decisions are on the table.”

The fear that ‘something bad is going to happen’

UMMA Community Clinic, in south Los Angeles, has four locations serving mostly Black and Hispanic patients. Barth-Rogers said many of the patients receive care under Medi-Cal or they’re uninsured, complicating their search for new hospitals if they had been planning on delivering at one that closed.

Patients’ choices may be further constrained if they want to give birth vaginally but previously delivered by cesarean section or if they want to also have a bilateral tubal ligation — referred to as “getting their tubes tied” — to prevent future pregnancies. Barth-Rogers pointed out that if a patient has a high-risk pregnancy, it’s difficult to send them to someplace like Martin Luther King Jr. Community Hospital, just outside the L.A. city limits, because the hospital doesn’t have a neonatal intensive care unit and often prefers taking on lower-risk pregnancies.

Some patients are choosing to deliver at birthing centers because they’re not happy with the hospital options available to them in Los Angeles County, said Barth-Rogers. She also said her patients have expressed fear that “something bad is going to happen” while they give birth, because they’re worried they will not be listened to in new, unfamiliar settings. 

But providers are doing the best they can under the circumstances, Barth-Rogers said: Without the proper information passed on to them about a patient who’s been transferred from another health system, they may not always know how to provide the best or safest care possible, especially if a patient is high-risk. Patients are caught in the middle between hospitals, doctors, and insurance companies — all while experiencing the stress of pregnancy.

“Not knowing what type of care they’re going to be given when we send them off to the hospital to deliver, depending on who might be the provider that day or what the situation might be or how full the labor and delivery department is, is really challenging,” Barth-Rogers said. 

When Centinela Hospital Medical Center announced a year ago that its labor and delivery unit would close by Oct. 25, 2023, the hospital cited a declining demand for services. But the hospital was being investigated by the state for neglect in the treatment of a Black woman, April Valentine, who died during childbirth there in January 2023, and her family filed a wrongful death suit against the hospital in August of 2023. Centinela, located in Inglewood close to Los Angeles International Airport, was fined $75,000 by the state of California for “deficient practices” in connection with Valentine’s death. 

The Centinela delivery ward’s closure resulted in the suspension of 17 perinatal beds, nine NICU beds, and the newborn nursery, and 72 employees were reassigned. The for-profit hospital, owned by Prime Healthcare, delivered about 800 babies annually. Centinela transferred maternity services to St. Francis Medical Center in Lynwood, one of its affiliates, and in its public notice also cited two other hospitals less than 10 miles away with labor and delivery services, Martin Luther King Jr. Community Hospital and Providence Little Company of Mary Medical Center Torrance.

Hospital executives “understand the critical need for maternal healthcare,” Brian O’Dea, a spokesperson for Centinela Hospital Medical Center, said in an email statement, and observed that the state’s declining birth rate created challenges for health care providers. He said the partnership with St. Francis Medical Center would ensure “continued access to quality maternity services for our communities to help expecting mothers welcome their children into the world with the best possible care.” 

Pulling out a map

But it’s not so simple, said Raena Granberry, director of maternal and reproductive health for the California Black Women’s Health Project, for a pregnant person to “just go somewhere else to receive care.”

Whenever Granberry gets a call that someone needs to quickly find a new hospital to give birth at, she takes out a map that shows all the hospitals in the state of California. She peppers the patient with questions: What health insurance do you have? Where were you initially going to give birth? What kind of provider — an OB-GYN, a midwife, if any — did you have? 

“These [are] individual people who get affected, and then everything is just happening on this large sort of business level where people can make business decisions that have nothing to do with people’s health,” Granberry said. “We can help them navigate [this] but… for a systems change type of help, the things they really need and want to see and want to have access to, [it’s] going to take years.” Granberry talks about the “personal pain” she can’t disconnect from when the incoming phone calls, text messages, emails, and even grocery store encounters remind her of how community members are being left behind.

It’s a “crisis,” she said, that has patients suddenly not knowing what to do or where to turn. The California Black Women’s Health Project tries to alleviate their burden by directing funds toward “filling in all these little gaps” that start to add up for pregnant people grappling with maternity care deserts. Granberry said the organization has paid for pregnant people to get Ubers to get to their appointments so they won’t have to travel on the bus by themselves or with their kids; to buy families meals so that if they get home late they have something to eat; and to pay for hotel rooms because families’ children cannot spend the night in the nearby hospital. Other times, the group has given families a lump sum of cash. 

Since Centinela Hospital Medical Center ended labor and delivery services, Granberry said, pregnant people are going to other places in Los Angeles like Martin Luther King Jr. Community Hospital and Cedars-Sinai Medical Center. The former offers a midwife-led birthing model, while Cedars-Sinai, despite being known for high-end maternity suites that draw celebrities, was also the subject of a federal probe in the death of Black woman, Kira Dixon Johnson, from internal bleeding hours after she gave birth via C-section at Cedars in 2016. The medical center today says it’s working hard to reduce the Black maternal health gap. 

‘De facto segregation’

There’s a clear health equity impact from the closure of maternity wards in urban settings, patient advocates and experts say. “This isn’t Cedars that’s closing down, it isn’t a place for folks with money, or [where] a lot of white people are going to have their baby, so we always have to start with racism,” Granberry said. “Racism is the reason why we have problems in the medical field at the hospitals and it plays out here too.… We could not be as dismissive [of maternity ward closures] if it wasn’t [happening in] an overwhelmingly Black and brown neighborhood.”

The reality is “if we really care about equity, and we care about the extent to which Black women and birthing people are disproportionately and alarmingly impacted by this maternal health crisis, then we have to look at what’s happening in urban areas,” said Alecia McGregor, an assistant professor of health policy and politics with Harvard University’s T.H. Chan School of Public Health, who has studied urban hospital closures nationwide. 

A comparison of urban area hospitals where white people and where Black people go to give birth often demonstrates “de facto segregation,” said McGregor. Her studies based on hospital discharge data have shown that at some hospitals in New Jersey there are no deliveries among Black people, while at other hospitals in the state more than 90% of deliveries are accounted for by Black patients. McGregor said this is not a phenomenon unique to New Jersey, but it shows how separate — and unequal — birthing experiences can be. 

Ways to address the problem, McGregor said, might include making sure hospitals with majority Black patients have the equipment and funding they need, and reforming the payment systems so that deliveries are not a financial loss for hospitals. With Medicaid reimbursements so low, one route might be for the Centers for Medicare and Medicaid Services to adopt a reimbursement designation that is based on the cost that obstetric units serving vulnerable communities actually incur. CMS has such Critical Access Hospital designations for some rural hospitals. While McGregor said “even critical access hospitals continue to close,” there have been some cases of hospitals reopening after qualifying for such a designation.

McGregor said it’s worrisome there aren’t more solutions on the table to help hospitals and patients navigate this.

“Obstetric units are sort of seen as money losers for hospitals and this is especially the case when these units are located in low-income and low-wealth communities, which, in urban contexts in the United States, tend to be communities of color —people who are racially and ethnically marginalized,” McGregor said. “There tends to be a lot of overlap with concentrated poverty that’s been the pattern of racial residential segregation in this country so that’s the reason why we see maternity wards in Black and brown communities closing at a faster rate.” 

A bill giving six months’ notice of closure

In California, the many closures have drawn the attention of legislators, who find that their hands are virtually tied because the state cannot force private hospitals to continue services, said state assembly member Akilah Weber, an OB-GYN who represents California District 79, east of San Diego, and is chair of the assembly’s health budget subcommittee.

She said she and other legislators often hear from constituents who are traveling long distances to get to the nearest labor and delivery unit. And when Scripps Mercy Hospital Chula Vista announced earlier this year that it would be closing its maternity unit in June, people outside her district called Weber, urging the state to do something to stop it.

“When people think about a delivery, they think of this amazing, wonderful life-changing experience, which it is and that’s the way it happens most times,” Weber said. “When I think of a delivery from an OB-GYN perspective, I understand all of the things that could potentially go wrong and those things can go wrong in a matter of a few seconds.” If families can’t access a properly staffed and equipped hospital, the results “can become disastrous not only for the mother but also for the child.”

In California, hospitals are legally required to give three months’ notice about a closure. But Weber said it’s not enough time for the state to spring into action to do what’s possible to stop it from happening.

That’s why Weber filed a bill that would require hospitals to notify the state if their maternity units are at risk of closure in the next six months. The bill would also require the state to prepare a report about the closure’s impact on the community. The goal of the legislation, she said, is to ensure access to timely information and data about how many babies are born at the hospital, its financial situation, and the workforce that might be affected. She said the bill might even allow the state to offer funds to prevent the closure from happening.

Weber said she initially wrote the bill to require hospitals to give one year’s notice, but reduced it to six months after getting feedback from the hospitals. For hospitals, there’s always a risk in preparing not only patients but also the health care workforce for potential closure too far in advance — ultimately reinforcing and possibly accelerating the process if, for example, workers resign in search of new jobs. 

Changing the model of care

Some clinicians and public health experts believe that the hospital obstetrics ward closures are highlighting an inherent problem with reliance on the hospital system.

It’s important to consider “what a good perinatal network of care could look like in the state and in the country,” said Priya Batra, an OB-GYN and deputy director for the health promotion bureau with the Los Angeles County Department of Public Health. That, she said, would mean moving beyond a hospital model of care to build a diverse and robust network of birth centers, employing midwives and doulas, that could bring about positive outcomes for babies and birthing parents. 

Changing birthing plans for families due to medical considerations or a maternity ward closure can often cause anxiety and panic, said Batra, and making midwives and doulas part of the process can potentially mitigate some stressors so that families are not alone. But advocates note that the state of California hasn’t made it easy for birthing centers to operate, and there have been some recent closures of such centers as well.

Batra also works on the executive committee with the California Maternal Quality Care Collaborative, which brings state agencies, hospitals, and health provider associations together to look for ways to prevent pregnancy complications and deaths. She said the organization has studied the impact of maternity ward closures, and that the travel burden has been greatest in rural areas of California, but exists for many across the state.  

The next steps for the organization, Batra said, include studying what happens to families in urban areas where there may be other birth facility options available but that “still may be far enough away from their usual source of care or their family networks, that it impacts the birth experience and birth outcomes.” 

The struggle for providers dealing directly with patients whose lives are upended by the closures is that those patients need solutions — and right away. UMMA’s Barth-Rogers said she strives to help her patients however she can. But she worries about the future.

“When there was that continuity, and we were able to really partner with one or two hospitals, one for high-risk and one for other patients, it was streamlined,” Barth-Rogers said. “Now we’re dealing with all these different hospitals, all these different systems, different insurances…the landscape has just become much more complicated.” 

This story is part of ongoing coverage of reproductive health care supported by a grant from the Commonwealth Fund. Our financial supporters are not involved in any decisions about our journalism.