“What we had here was amazing”

By Clarissa Donnelly-DeRoven 

Before the sun rises on a Tuesday morning in December, Amelia Cline smooches her partner goodbye and heads out the back door of her house in West Asheville. With a thermos of coffee in one hand and a handful of medical supplies in the other, she climbs into the driver’s side of a white Toyota and settles in for her hour-ish drive to Macon County. 

Cline is an obstetrician/gynecologist (also known as an OB-GYN) for the Mountain Area Health Education Center, and she makes this Tuesday trek every week. She sees patients from 8 a.m. to 5 p.m., spends her lunch calling people with their test results, and, once the office is closed, she makes sure the medical charts of everyone she saw that day are up to date.

The next day, she does surgeries at the community hospital in town, usually hysterectomies and other simple procedures. If complications arise in more challenging cases, she likes to see patients at Mission Hospital in Asheville.

Cline’s role as a traveling OB-GYN is part of the way women’s health care providers are trying to fill the gap in obstetric and gynecologic care in western North Carolina, and especially in Macon County.

In Macon, along with 11 other counties in the western part of the state — an area geographically larger than Delaware and Rhode Island combined — there’s nowhere to deliver a baby. It’s been that way in Macon County for the past five years, since the Mission Health system closed the labor and delivery unit at Angel Medical Center. 

The clinic Cline works at, MAHEC OB/GYN specialists at Franklin, has become the medical home for many of the clinicians and community members who were left without anywhere to go once Angel’s maternity ward closed. It’s filled some of the need for the time being, but those who work there say as long as women’s health care services are inadequately funded, their efforts can only go so far.

The need was there; the money wasn’t

Before Mission Health closed labor and delivery at Angel Medical Center, “it was a busy women’s unit,” Cline said. “There were four full time OB-GYNs and midwives, and they were busy. I mean, they were doing lots of [gynecologic] care, lots of surgery and delivering a lot of babies.” 

In the years before the closure, births at the hospital were rising steadily — up nearly 144 percent between 2011 and 2016, according to data from the NC Department of Health and Human Services. 

Macon County has a similar-size population to that of Dare County in the Outer Banks. When Angel’s labor and delivery unit closed in July 2017, the number of births there each year was comparable to the numbers at the Outer Banks Hospital, which is open and has a labor and delivery unit. In 2015 and 2016, the number of babies born at Angel surpassed the number of babies born at neighboring Haywood Regional Hospital, even though Macon County’s population is just about half the size of Haywood County’s.  

Mission Health acquired Angel Medical Center in 2013, and in 2017 — before health care giant HCA bought Mission in 2019 — hospital executives informed labor and delivery staff at Angel that the unit would close that July. 

At the time, Mission’s President Karen Gorby told Blue Ridge Public Radio that the hospital was losing about $1.4 million a year on labor and delivery services, making it too expensive to keep open. 

At the same time, Mission said it planned to spend $46 million to build a new hospital for Angel Medical Center. That hospital opened in September 2022 and actually cost about $70 million. It does not have a labor and delivery unit.

Even though the old unit was busy, it’s not hard to believe that it was operating at a loss. 

“It is universally known that, specifically, maternity care is a loss,” Cline said. Labor and delivery services are expensive. Units need to be open and fully staffed 24 hours a day. 

Many hospitals decide it’s worth it, despite the financial hardship, she said. “It brings patients to the hospital, and it’s the only department in the hospital where people are happy to be there.” 

Judi Layton was a midwife at Angel from 2014 to 2017. She now works with Cline at the Franklin office. Moms, she said, tend to be “the health care consumers for the family.” 

“That means if you take really good care of them here, they’re going to spend their money in that same system with their kids and their husband and all the other things that need to happen with their families, because they got taken really good care of during pregnancy and labor and birth.”

It’s also widely known, those in the field say, that insurers reimburse hospitals for labor and delivery care at rates far lower than what the service actually costs — Medicaid, especially. An analysis by the nonpartisan Health Care Cost Institute found that when it comes to childbirth, North Carolina has the sixth worst payment disparity between Medicaid and private payers. In 2020, Medicaid paid an average of $4,200 for a birth, while employer-sponsored private insurers paid about $13,300.

Between 2015 and 2019, Medicaid paid for an average of 70 percent of births in Macon County. The reimbursement difference can help explain why, for a small rural hospital operating on tight margins, it can become too costly to keep delivering babies when Medicaid is the payor — even though the community wants and needs the service.

“A small critical access hospital with a labor and delivery unit doing over 300 deliveries a year, with a very high Medicaid insured population, the fact that that unit is not sustainable speaks to a greater issue of how the health care system and the insurance companies value women’s health and women’s health services,” said Katlyn Moss, who works at the Franklin clinic researching rural OB-GYN access. “That that service is not being reimbursed in such a way that it can keep happening, to me, says that the insurance companies don’t think it’s worth that much money.”

‘You’re talking to women who have delivered at this hospital’

Moss was also a labor and delivery nurse at Angel Medical Center from 2015 to 2017. She gave birth to her first baby there, and she remembers the day a higher-up from Mission came to tell her and her colleagues the unit was closing. 

“There were tears. There were a lot of questions, both about the community and what we were supposed to do,” she said. “I remember him starting to talk to us about how they were going to restructure employment, and everybody was going to get to keep their job, they would just have to maybe go to a different office.” 

But going to a different office isn’t what these workers wanted. Being a women’s health provider is a passion — as Cline said, “You catch one baby, and you’re hooked.” 

You can’t just reassign a labor and delivery nurse, Moss said. It’s not the same to work in an operating room or in pediatrics. 

“A nurse is not just a nurse,” Moss said. “We were all working in a women’s health office because that was the area we wanted to be in.”

Job security, though, wasn’t the only thing on Moss and other employees’ minds. As the Mission official spoke, Moss interjected: “You’re not just talking to employees. You’re talking to women who have delivered at this hospital. And you’re telling us we’re not gonna get to do that anymore, and we don’t have anywhere else to go.”

Layton, the midwife, said the work environment at Angel was special. The midwives, nurses and doctors trusted each other deeply and worked well together. 

“We all just felt, I think, betrayed really more than anything,” she said, “because we knew what we had here was amazing, and good for this community.”

Even though they were in a hospital, Layton said the birthing process didn’t feel as medicalized as it did in other places she’d worked: There were large tubs for water births that they used often, and there were strapless monitors, so people’s vitals could be watched while they labored, without needing to be tethered to a bed.

“Women had more independence at Angel,” Layton said, so telling her patients that they would no longer be able to deliver there was devastating.

“A lot of them were very mad, very upset — especially pregnant women,” she said. “What a horrible thing to do to somebody in their second, third trimester — I mean, at any stage. But when I’ve delivered several of their babies, and now [they have to ask] ‘Who’s going to deliver my baby? What’s going to happen?’”