CONCORD, N.H. — Jessie Ingerson was feeding her goats and sheep at her home in Jefferson when her water broke in March 2023.
She knew it was time to head to the hospital, a 42-mile trip that often took 90 minutes over mountain roads that could become impassable in bad weather.
As her husband drove up Gorham Hill, Ingerson could feel the pressure mounting with the elevation, her contractions growing more painful.
“That definitely added more anxiety,’’ Ingerson said.
Since 2002, 11 of the 26 labor and delivery units in the state have closed, creating what the state has deemed “maternity deserts’’ in parts of rural New Hampshire. To help fill the gaps, the state is training emergency first responders who say they are increasingly coming to the aid of women in labor.
“This is a service that people desperately need, that people will literally die if they don’t have,’’ said Daisy J. Goodman, a nurse-midwife at Dartmouth Health who works with the North Country Maternity Network, a group that seeks to create and support maternal health infrastructure in northern New Hampshire.
Many of the hospitals that have closed their labor and delivery units faced financial pressure to do so, according to the latest report from the New Hampshire Department of Health and Human Services. The units can be expensive to maintain, requiring costly malpractice insurance, 24-hour staffing, and specialists, such as someone who can provide a C-section.
The units that closed had fewer births and more mothers who were insured by Medicaid, which traditionally doesn’t reimburse as well as private insurance, Goodman said.
New London Hospital had been operating at a loss for three years when it closed its birthing unit as a way to control costs, a hospital spokesperson told the Concord Monitor in 2002. In 2008, when Weeks Memorial Hospital in Lancaster closed its birthing unit, it pointed to escalating costs and fewer births, something the state’s report also said was driving the closures of labor and delivery units.
Statewide, the birth rate has declined 33 percent, dropping from 12.67 births per 1,000 people in 1995 to 8.51 per 1,000 people in 2023, the latest data available. In the state’s most-populous county, Hillsborough, the rate is still at 10 births per 1,000, while it’s the lowest in more-rural parts of the state like Carroll County, where the rate has dipped to 6.6 births per 1,000.
Before the closures, about 7 percent of the state’s population lived more than half an hour away from a hospital with labor and delivery services; now, about 19 percent do, according to Sanam Roder-DeWan, a primary care physician at Dartmouth Health who works with the North Country Maternity Network.
Nationally, a typical drive to the nearest hospital takes about 16 minutes, according to the March of Dimes. After eight New Hampshire maternity wards closed, the median driving time in New Hampshire doubled, rising from 18 minutes to 39, a 2021 report from the Urban Institute found.
Roder-DeWan said that for about 14,000 people, the drive to the nearest hospital with such services is over an hour. For people who live in Pittsburg, N.H., it can take nearly two hours to drive to Littleton, N.H., where there is a hospital with a labor and delivery unit.
“If you’re in labor, that’s a huge distance,’’ said Goodman. “In the winter, it’s an almost insurmountable distance. It’s life-threatening to drive in a car in certain kinds of snowstorms up there.’’
Roder-DeWan said the distance can add anxiety to an already intense process.
“There’s a ton of fear,’’ she said. Women wonder: “Am I going to give birth in an ambulance? Am I going to give birth on the side of the road?’’ she said.
That was the concern for Brianna Lareau, who lives in Piermont, a 45-minute drive from Dartmouth Hitchcock Medical Center in Lebanon, where she gave birth to her two youngest children, now 4 months and 2 years old.
She had experienced placental abruptions in her first three pregnancies, a complication when the placenta separates from the wall of the uterus before delivery. It can decrease the baby’s oxygen supply and cause heavy bleeding for the mother.
“There was always an anxiety that if something did happen while I was at home or on the road, the fear of bleeding out or the baby not getting the care she would need right away,’’ Lareau said.
Neighboring states are seeing access to maternal care diminish, too. In Maine, 42 percent of community hospitals have closed their birthing units because of financial challenges, according to Roder-DeWan. Essex County in Vermont has been designated a maternal health desert by the March of Dimes, a nonprofit that works on maternal health. The county has no birthing hospitals, birth centers, or obstetric providers. “We’re looking at a trend that is going in the wrong direction,’’ said Roder-DeWan.
The farther people have to travel for care, the less likely they are to receive the recommended number of prenatal care visits, and the more likely they are to give birth enroute to the hospital or to have an unplanned home birth, the most recent report from the New Hampshire Department of Health and Human Services found. Since 2005, the rate and number of unplanned location births have been rising, according to the report, from 2.2 per 1,000 live births in 2005 to 3.8 per 1,000 in 2022.
That’s what happened to Keelin Shea, 32, last January. Shea, who lives in Tuftonboro, was planning to give birth at Memorial Hospital in North Conway, about 40 miles away. Huggins Hospital in Wolfeboro is just 15 minutes away, but it closed its labor and delivery unit in 2008.
“Anywhere we were going to go would be an hour or more because there’s no local birthing centers,’’ said Shea.
When she was 38 weeks pregnant, Shea felt contractions but didn’t leave for the hospital. Her thinking was: “I don’t want to drive the whole hour to the hospital if I’m going to get sent home,’’ she said.
Shea was still at home when her water broke. With a 911 dispatcher on the phone, she ended up having an unplanned home birth, delivering a healthy baby girl.
Giving birth in an unintended location can come with increased risk, particularly if there are unforeseen complications. Maria Varanka, an EMS training coordinator at the New Hampshire Department of Safety, said some first responders have told her they weren’t comfortable addressing possible problems in an emergency delivery.
Varanka, who is leading efforts to train first responders, said there’s an acute need for labor and delivery training.
“There were some knowledge gaps,’’ Varanka said, especially around the initial postpartum stage, which is also called the third stage of labor, after the newborn is out and before the placenta is delivered.
North Country Maternity Network, the group Goodman and Roder-DeWan work with, is addressing the lack of maternal care in the North Country by hiring and deploying doulas, training nurses on high-risk pregnancy management, and helping hospitals implement better billing practices to improve their bottom lines.
Still, the closures are a devastating loss for the communities that are left behind, according to Julie Bosak, a nurse-midwife at Dartmouth Health. And the longer a hospital has been closed, the harder it is to bring care back to the community after the workforce has moved away.
“We can’t risk allowing more to close,’’ she said.
Ingerson, who faced the 42-mile journey through the mountains to Memorial Hospital, gave birth to a healthy baby boy about six hours after her water broke at home. She had made the trip to the hospital at least 10 times during her pregnancy, taking paid time off and staggering her work schedule to see her doctor. She said if she had the option to get care closer to home, she would have taken it.
But, she said, in the North Country, “We don’t have a lot of options.’’