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?’”
Challenges beyond a long drive
What’s happened is that pregnant people in Macon County have to drive at least 30 minutes when they’re in labor. Unless they want to cross into Georgia or Tennessee, there is literally nowhere farther west they can go to give birth in North Carolina. They must go east: 30 minutes to Harris Regional in Sylva, 45 minutes to Haywood Regional in Clyde, or an hour and 10 minutes to Mission Hospital in Asheville.
Labor is unpredictable, as is the weather in the mountains. Moss’s due date for her second baby, for example, was Dec. 20. That weekend, the whole region was expected to get a huge snowstorm. Angel’s labor and delivery unit wasn’t open anymore, and she wanted to deliver in Asheville so she’d be with providers she knew.
Though she hadn’t gone into labor yet, Moss considered going to stay with her brother in Asheville to avoid being snowed in. Ultimately she decided against it, staying home with her husband in far-western Clay County. But she took other precautions.
“I remember having a conversation with him, like, ‘Here’s just the really basic nitty gritty of what you’re going to have to do if we deliver on the side of the road,’” she said. “This is who you will call, this is the hospital I want to go to, this is what you should anticipate as far as the mess and the baby and the cord and all the stuff.”
Being clear about what hospital she wanted to deliver at was important, especially in this part of the state since the hospitals are owned and managed by different systems.
“The electronic records do not talk to each other,” Cline said. “We are literally relying on fax machines.”
Many patients see Cline throughout their pregnancy at the clinic in Franklin, and they plan to drive to Asheville to deliver at Mission with her. But something can always go awry. They may end up only being able to make it to Harris, and that means they’re going to be seen by doctors they’ve likely never met and who will not have immediate access to their medical records.
“Most of the time, it’s just annoying and not dangerous. But sometimes it is dangerous,” she said. “It ends up being a lot of coordination, and I think this is particularly hard for patients who are underserved, because the same thing that makes it hard for them to access health care at all makes it hard for them to stay within one system.”
‘It’s a difficult community that we have here’
Allie Custer also works at the Franklin clinic. She’s 28 years old, a medical assistant, a mom, and she’s lived in town since 2010. Like Moss, she had her first baby at Angel. But when it came time for the second, Angel no longer delivered babies.
When she went into labor, Custer’s boyfriend drove the couple an hour and a half from their house to Mission Hospital. By the time they got there, her contractions were every 30 to 15 seconds, her cervix was 10 centimeters dilated and 100 percent effaced. In nonmedical terms, that means it’s time for the baby to come out — like, immediately.
“The only thing holding her in there was my water,” Custer said. Her baby was also in breech position, meaning feet first instead of head first, and she had to have an emergency cesarean section.
“I was not prepared for that,” she said. “It was very traumatizing to me because then once she was born, they ended up taking her from me and she ended up going to the NICU.”
Her birth was difficult, but Custer was thankful that it was with providers she knew and who made her feel comfortable and supported.
“It’s giving me chills just thinking about it,” she said.
Almost delivering on the way to the hospital is obviously scary, but Moss says there’s another part of the process that is equally difficult and doesn’t get enough attention: the drive home.
“When we got discharged, it was afternoon, and it was December,” she said. Their drive from Buncombe County to Clay County took two hours, and by the time they got there, it was dark.
“I’m wearing a diaper and bleeding and still cramping and trying to establish nursing — and my driveway is very inclined and gravel,” Moss said. “I’ll never forget how sore and painful it was to drive up my driveway after two hours in the car, four days postpartum.”
Even though Custer and Moss and many other women from the community are able to get their OB-GYN care at the MAHEC clinic, and even though many end up having successful births at Mission or Harris or Haywood Regional, they say it shouldn’t have to be this difficult.
“I know people make do, and they do what they’ve gotta do,” Custer said. “But it would make it a lot, a lot easier on a lot of women here if there was labor and delivery. We have low income families here. I mean, it’s a difficult community that we have here.”
On the desk next to Custer was a pile of baby clothes her daughter had outgrown. After every growth spurt, she said, she brings in clothes to give to their patients.
“I mean, they’ve had to deliver babies in the ER over here at Angel,” she said. “Not having that labor and delivery is really hard on a lot of women in this area. That was a really bad, bad decision.
“You shouldn’t take that away.”
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