Mom-to-be Stephanie Zuroski hopes she recognizes the signs of labor quickly, because the hospital where she plans to deliver her first child is more than an hour from her home in rural Elk County, Pennsylvania.
Elk County is about 2½ hours outside Pittsburgh, nestled at the edge of the Allegheny National Forest. Zuroski grew up on a farm and is familiar with the tradeoffs that come with rural living.
“I am accustomed to driving to get the things that I need,” said Zuroski, 32.
What she didn’t expect was the lack of labor and delivery units in the county, which means she’ll have to drive out-of-state to give birth in a hospital.
“When I started looking into pregnancy and [obstetrician] care, I was shocked local hospitals weren’t delivering babies,” Zuroski said.
In February, the Penn Highlands Healthcare hospital system announced that it was “realigning services” and moving labor and delivery services from Penn Highlands Elk — the only hospital in the county — to its sister hospital Penn Highlands DuBois, about 30 miles south in Clearfield County, on May 1. The shift limits maternal health care options in the area, and could raise the risk of people delivering in riskier conditions — even at home or in their cars.
New and expecting mothers would still be able to get scans, tests and exams at Penn Highlands Elk, but they will no longer be able to deliver there.
The hospital in DuBois has the only neonatal intensive care unit within 100 miles, according to Penn Highlands Healthcare, and is staffed to handle high-risk deliveries.
“The transition is designed to offer a higher level of care for mothers and newborns,” the health system said in a news release.
It added that the declining number of births at Penn Highlands Elk was another factor in the decision.
Maternity care deserts
The closure of the labor and delivery unit leaves five counties with limited access to a labor and delivery unit. Two of the counties, Forest and Cameron, are considered by maternal health nonprofit March of Dimes to be maternity care deserts: areas without obstetric providers and without a hospital or a birth center offering obstetric care.
“This is a devastating thing that is happening. Women are struggling to have access before, during and after their pregnancy journey,” said Barbara Roth, March of Dimes executive director of market impact in western Pennsylvania.
“The farther a woman travels to receive maternity care, the greater the risk of maternal morbidity and adverse infant outcomes, such as stillbirth and NICU admission. Furthermore, longer travel distances to care can cause financial strain on families and increased prenatal stress and anxiety,” March of Dimes says in a report. “The distance a woman must travel to access care becomes a critical factor during pregnancy, at the time of birth, and in the case of emergencies. Nationwide closures of birthing hospitals have contributed to increased distance and travel time to care, especially in rural areas.”
Roth said the nonprofit advocates for the expansion of access “to doulas, midwives and telehealth” and held an advocacy day at the Pennsylvania Capitol in March to raise awareness about maternal and infant health care concerns such as these access issues.
“In the state of Pennsylvania, women living in counties with the highest travel time could travel up to 42.7 miles, and that’s about 57 minutes on average … to reach their nearest birthing hospitals,” Roth said.
Statewide, March of Dimes says, about 7.5% of counties in Pennsylvania are maternity care deserts, and about 12% of women don’t have access to a birth hospital within 30 minutes of them.
Certified nurse midwife Lauren Narbey said the situation in Elk County is a familiar one.
When WVU Medicine Uniontown Hospital in Fayette County closed its birthing center in 2019, she saw “a huge increase in the number of patients” who drove 45 minutes or more to deliver their babies at Jefferson Hospital in Allegheny County, Pennsylvania, where she has worked since 2018.
“It’s a very high-risk area, not a lot of health care at all available,” Narbey said of Fayette County, which is on the border with West Virginia. “So patients are now having to drive sometimes two hours to get to Labor and Delivery.”
Uniontown Hospital has since announced that it is re-establishing its obstetric services.
At her hospital, Narbey says, she has seen patients come in to deliver without any prenatal care, simply because of the distance to the hospital and the lack of resources or support at home — especially people with multiple children. Many of her patients ask to schedule inductions so they can avoid making the trek while in labor, she said.
“This patient population really wants scheduled inductions at 39 weeks, which is the earliest we can offer without any kind of really risky complication necessitating delivery before then. And they really do want that, because they want to be able to plan the trip. They want to be able to plan child care. They don’t want to have their baby in the car on the way. So I’ve seen a huge uptick in people wanting an induction,” she said.
Emily McGahey, a midwife and the clinical director at The Midwife Center in Pittsburgh, said birth centers like hers also have clients who do their best to plan.
“Sometimes, our families will arrange a time to come in and have a baby, or sometimes, they will labor and then maybe move to a closer family member or friend’s home or get a hotel room closer by,” she said, adding that clients at the center are typically discharged hours after birth and return for a checkup within the first 72 hours.
And that’s just the patients who are able to plan ahead; many don’t make it in time for their deliveries.
“That happens a lot for us,” Narbey said. “I mean, like a few times a month that patients will have babies at home or in the car and then they’ll just bring them in the ambulance, and then we just cross our fingers that they’re not hemorrhaging when they get here because their placenta is still inside.”
Seeking solutions
In Elk County, Nick Burdick, manager of the St. Marys Area Ambulance service, is preparing for the possibility that his team will be called upon to deliver babies more frequently and is working with Penn Highlands Elk to get up to speed on the latest labor and delivery technology.
“We are certainly all trained in labor and delivery, although it’s not something that we experience often. But with the news of this unit and service closing in our local hospital, we’re absolutely taking the opportunity to increase our training and get more experience in labor and delivery and neonatal care,” Burdick said. “So we will be working with Penn Highlands Elk in taking labor and delivery training as well as advanced neonatal life support, so they are willing and definitely helping accommodate us in their transition and giving us the resources and the education to be able to care for the community.”
Zack Pontious’ pregnant sister-in-law was due May 1, the day the unit at Penn Highlands Elk is set to close. But the baby came early, saving her the 45-minute drive to Penn Highlands DuBois, said Pontious, a member of the Ridgway Borough Council in Elk County.
The new uncle says the council is limited as to what it can do to replace labor and delivery services in the area.
“Boroughs provide services like trash pickup and snowplow. We’re not really in the business of providing health care,” he said.
After Penn Highlands’ announcement, he and other local officials and business owners formed a group to with state representatives and come up with ways to support and incentivize the health care system to maintain its services in Elk County.
Despite their efforts, the system is still moving forward with its plan, frustrating Pontious, who moved to Elk County to be closer to family as he and his wife plan to start their own.
“My wife and I moved here, and she never thought that this was a concern that we would have to have: that we’d have to be fighting for women’s services to be left in – not even our town – in our county,” he said.
In neighboring Cameron County, Commissioner Joshua Zucal said officials are also exploring options to offset the closure of Penn Highlands Elk’s labor and delivery unit, such as midwives to help with home births.
“Cameron County was never notified or brought into the loop that this was occurring. It was just something that we had to hear through the news of it happening,” he said.
Zucal said it’s not just maternal health care that is taking a hit in rural Pennsylvania; some local doctors’ and dental offices have also closed or relocated, and it’s hard for Cameron County to attract enough people to work for emergency response teams in the area.
“There are the basic needs communities must have, and we need to have access. It’s not that we have lost all access, but you can see pieces of the puzzle falling apart,” he said.
The county commissioner said he is focusing on the solutions to try to remain optimistic.
“What are the things that we can implement to still have a thriving community, though there are challenges? How can we still focus on the quality of life that a rural community can offer? And then also the health and wellness aspects, that if you’re a healthy person, the amount of care that you’re going to need is much less than somebody who’s unhealthy. So if we can create healthy communities, we won’t need such a crutch and be so reliant on these organizations that choose to do things such as closing maternity,” he said. “So we just need to figure out solutions to take care of our own.”
Many people think a birth, or birthing, center is the perfect solution for an area like Elk County. These centers – where people with low-risk pregnancies can deliver in a home-like facility, with more autonomy over the experience – are designed to “provide routine care and initiate emergency procedures” and must be positioned close enough to a hospital where women can get c-sections if they need, according to the American Association of Birth Centers.
“I think that’s a really valuable resource that our community should look into,” Zuroski said. “It’s definitely a resource that I would consider using in the future.”
Narbey, acknowledging her perspective as a midwife, also agrees.
“This is my biased opinion. I think midwives are part of the solution. Most women are low-risk, and we could staff a birthing center starting with three midwives, which is cheaper than an obstetrician, and midwives tend to be really good at connecting with their communities and meeting people in a culturally sensitive, appropriate trauma-informed perspective,” she said, adding that communities in Alaska, Montana and South Dakota are turning to this model as a solution.
Health care by ZIP code
Health care wasn’t at the front of Zuroski’s mind when she moved to Elk County in her mid-20s. Now, the the environmental engineer said she feels a deep connection to the community.
It’s vibrant and green in the spring and summer and awash with fall color in the cooler months, and Zuroski says she was drawn to the area by the sky-scraping trees and the “beautiful little mountain streams that hold wild trout populations.”
“I’m willing to compromise and give up some things in order to stay here and live where I’m happy,” she said.
For now, Zuroski makes a 45-minute commute every four weeks to her appointments with a certified nurse midwife in Bradford, Pennsylvania, close to the New York state line.
And when it’s time for the baby to come in August, she plans to pack up and head to Olean, New York, now one of the closest hospitals to her with a maternity ward.
“Traveling far while in labor will be uncomfortable,” she said.
McGahey says it is time for communities to step up to ensure that maternal health care remains accessible to families.
“I think on a larger community level, we need to be advocating for us as a society to figure out how we value maternity care in our country because it’s not valued,” she said. “As we can see, all of these maternity care deserts in our counties, across our state and the country, and this is leaving hundreds of thousands of families without care.
“Where you live and where you choose to raise your family shouldn’t affect the quality of health care that you receive,” McGahey said. “And I think that’s the biggest issue right now is how we continue to show families support and take good care of them.”
Narbey agrees. “In some cases, it can be a life-and-death situation, and that should never be the case. But unfortunately, your ZIP code determines more about your health outcomes than any other factor.”
