SOME EMERGENCY RESPONDERS<\/strong> go years, decades, or even their entire careers without ever having to deliver a baby in an ambulance. For John Cuddahy, it took just a few months.\u00a0\u00a0<\/p>\n The Leominster-based firefighter EMT completed his academy training in April, and this summer responded to a call in Leominster of a woman in active labor.\u00a0\u00a0<\/p>\n \u201cShe was in the middle of her contractions, so we loaded her up as quick as we could and started driving out to Worcester,\u201d Cuddahy said.\u00a0\u00a0<\/p>\n But 10 minutes into the 20-mile drive to UMass Memorial Medical Center, the baby was delivered.\u00a0\u00a0<\/p>\n In those critical minutes, they could have gotten the expecting mother to UMass Memorial Health Alliance-Clinton Hospital in Leominster, but its maternity unit closed two years ago, ruling that option out.\u00a0<\/p>\n Luckily there were no serious complications, and both patients were healthy when they finally arrived at the hospital. Cuddahy delivered the baby along with a paramedic of nearly 30 years. It was a first for both responders, but likely not their last.\u00a0\u00a0<\/p>\n \u201cI think it\u2019s something to expect a lot more now that there is no maternity [unit] in Leominster. We almost had another one two shifts ago,\u201d Cuddahy said. \u201cIt would save a lot of in-the-field deliveries if they still had it there.\u201d\u00a0\u00a0<\/p>\n Reports of women giving birth in cars, ambulances, emergency departments, or reaching a maternity unit just in time to deliver are a far cry from what is expected in a state that consistently ranks first in the country for its health care system.\u00a0<\/p>\n But in North-Central Massachusetts, pregnant women and families are living a reality that data, statistics, and health care rankings don\u2019t always show.\u00a0<\/p>\n Two years after the maternity unit at Clinton Hospital closed, the region is struggling. The fallout of the closure paints a complicated picture in a state that technically, according to the nonprofit advocacy and maternal health research group March of Dimes<\/a>, doesn\u2019t have maternity care deserts. But experts and advocates say recent losses and impending cuts to Medicaid will make it harder to access maternal health care in Massachusetts.<\/p>\n Since 2014, 11 hospitals in Massachusetts have closed or filed to close their maternity unit services, according to\u202fHealth Policy Commission data<\/a>. Two birth centers in Beverly and Holyoke have also closed, leaving Massachusetts with just one free-standing birth center.\u00a0\u00a0<\/p>\n The loss of maternity units and obstetric care is a trend seen nationwide. But while most states have at least one, if not multiple maternity care deserts<\/a> \u2013 counties without hospitals or birth centers offering obstetric care, and no obstetric providers \u2013 Massachusetts has none, according to March of Dimes.\u00a0<\/p>\n \u201cThe rate of closure is very similar for us as it is in other states,\u201d said Chloe Schwartz, Massachusetts director of maternal\u202fand\u202finfant health initiatives for March of Dimes. \u201cThe only difference being, we started with more to begin with, so we don’t have any official deserts yet.\u201d\u00a0<\/p>\n Each county in Massachusetts has been deemed \u201cfull access\u201d by March of Dimes, meaning it has two or more hospitals or birth centers offering obstetric care, and 60 or more obstetric clinicians per 10,000 births.\u00a0\u00a0<\/p>\n \u201cWe have a standardized definition, but the folks living and working on the ground will tell you a very different story about the reality of access,\u201d Schwartz said. \u201cChanging access is just as difficult as having little to no access. It’s whiplash.\u201d\u00a0\u00a0<\/p>\n Schwartz warned that the Bay State is in a precarious position when it comes to maternity care, pointing to recent service closures and reports of UMass Memorial Health\u2019s financial stress<\/a>.\u00a0<\/p>\n Community Healthlink, an affiliate of UMass Memorial, recently closed two primary care programs \u2013 one in Leominster in September 2024 and another in Worcester in March \u2013 and will soon close an adult behavioral health program in Fitchburg. The system has halted hiring for all nonclinical and non-patient-facing roles and faced an $86 million operating loss in the first half of fiscal year 2025, the Boston Globe reported<\/a>.\u00a0<\/p>\n As health care providers face an impending decrease in Medicaid payments because of the sweeping tax bill passed by Republicans, more closures could be on the horizon.\u00a0\u00a0<\/p>\n \u201cIt\u2019s an ever-changing landscape, and there\u2019s so many ways in which these hospitals and health systems have to pivot, and unfortunately, maternity care is one of those areas that\u2019s always going to be the hardest to keep open,\u201d Schwartz said.\u00a0\u00a0<\/p>\n More of the region\u2019s births are now taking place at UMass Memorial\u2019s main campus in Worcester. The facility has increased the number of labor and delivery staff “to meet the modest increase in patient volume,” said Shelly Hazlett, the hospital\u2019s director of media and public relations, in a statement.\u00a0<\/p>\n But maternity deserts are only designated at the county level, which doesn\u2019t do enough to illustrate accessibility in cities and smaller areas, according to Hao Yu, associate professor of health care policy in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute.\u00a0\u00a0<\/p>\n \u201cWhen we talk about health care access, that’s really a local issue,\u201d Yu said.\u00a0\u00a0<\/p>\n In Massachusetts, the ratio of OB-GYNs\u202fper 10,000 births decreased in rural counties from nearly 162 in 2010 to 87 in 2021, while the ratio increased in urban counties in that same timeframe, according to a 2024 March of Dimes report<\/a>.\u00a0<\/p>\n Obstetric services are often not financially advantageous for hospitals due to low reimbursement rates from Medicaid, which pays for about a third of all births in Massachusetts.\u00a0\u00a0<\/p>\n As federal cuts to Medicaid roll out after the midterm elections, Massachusetts could see even more maternity unit closures, according to Yu. Community hospitals serving low-income areas will be most at risk. \u201cIf federal support for Medicaid is going to be decreased substantially, then state governments will have difficulty maintaining their current reimbursement rate,\u201d he said.\u00a0\u00a0<\/p>\n OB-GYNs have one of the highest malpractice insurance premiums across all medical specialties due to a high risk of lawsuits. And, maintaining operations amid a workforce shortage is costly due to round-the-clock staffing requirements in maternity units, including OB-GYNs, nurse midwives, anesthesiologists, and other supporting staff.\u00a0\u00a0<\/p>\n \u201cThe cost of maintaining OB units is high. On the other hand, the reimbursement from the payers for this type of service is low,\u201d Yu said. \u201cPutting these two together, you can imagine it\u2019s really making OB units the easy target if hospitals want to downsize.\u201d\u00a0\u00a0<\/p>\n While 11 closures may not seem like a significant amount, Yu noted it represents about five percent of all obstetric unit closures that have occurred in the US in the last decade. Meanwhile, Massachusetts accounts for just two percent of the US population.\u00a0\u00a0<\/p>\n Maternity patients in 29 municipalities increased their distance traveled by at least five miles between 2011 and 2021, and 14 of those communities increased their distance traveled by at least 10 miles, according to the Department of Public Health\u2019s 2023 review of maternal health services<\/a>. Only two towns \u2013 Newburyport and West Newbury \u2013 out of 351 municipalities \u2013 have residents whose average travel distance to birthing facilities decreased in the past decade.\u00a0<\/p>\n While they may not live in a \u201cdesert,\u201d expecting mothers and families are driving further and further to receive care, and each closure brings more ambulance, roadside, and emergency room deliveries, meaning a delay in treatment for some of the most common complications like premature delivery, postpartum hemorrhage, and neonatal hyperthermia. \u201cThose types of births will surely be associated with adverse outcomes, both for babies and for mothers,\u201d Yu said.<\/p>\n The decision to close the Leominster maternity unit in September 2023 took local leaders like Mayor Dean Mazzarella\u202fby surprise. Mazzarella, who fought alongside other leaders, residents, and health care workers to keep the unit open, said the city was notified of these problems years too late.\u00a0\u00a0<\/p>\n \u201cThis stuff doesn’t happen overnight, so the Department of Public Health needs to do better monitoring,\u201d Mazzarella said in an interview. \u201cWhen [the UMass] Health Alliance started seeing a problem with this, they should have reported it to the Department of Public Health. We should have had these meetings then.\u201d\u00a0\u00a0<\/p>\n UMass Memorial officials noted that workforce shortages and declining births at Clinton contributed to the decision to shut down the maternity unit. These issues \u201chad a significant impact on our unit\u2019s ability to provide the best possible labor and delivery care to our patients,\u201d Hazlett said.\u00a0<\/p>\n The maternity unit closure came five years after the hospital closed its 11-bed pediatric unit in 2018.\u00a0\u00a0<\/p>\n Mazzarella, who has served as mayor since 1994 when Leominster Hospital and Burbank Hospital merged to form Health Alliance, said the Leominster campus was meant to be a strong regional hospital offering a comprehensive set of services. (UMass Memorial purchased Health Alliance in 1998 and merged the hospital with Clinton in 2017.) Now, he sees that slipping away.\u00a0<\/p>\n \u201cIt’s like this big network that had been established for so long is now being pulled apart in fragments,\u201d he said. \u201cWhether it’s a desert or not, it was certainly filling a gap at the time.\u201d\u00a0\u00a0<\/p>\n Maternity patients have been absorbed by surrounding centers, including Henry Heywood Hospital, Emerson Hospital, or UMass Memorial Medical Center in Worcester, which are approximately 15, 23, and 25 miles away from Clinton Hospital by car. Distance is a barrier to many pregnant patients, Mazzarella said, who used to be just a bus ride away from their obstetric care unit.\u00a0\u00a0<\/p>\n Leominster Fire Chief Robert Sideleau called it a \u201ctremendous loss.\u201d His team of firefighter EMTs and paramedics have delivered an increasing number of babies in ambulances. At Clinton Hospital, emergency room secretary Shelly Roy says women have given birth in the ER because they couldn\u2019t make it to UMass Memorial in Worchester.\u00a0<\/p>\n Their roadside and ambulance deliveries have been free from serious complications so far, according to Sideleau, but it\u2019s not a matter of \u201cif\u201d but \u201cwhen.\u201d He worries about emergency staff having to decide between transporting high-risk patients to Leominster\u2019s emergency room to deliver without an OB-GYN or taking a chance to transport them to UMass Memorial in Worcester.\u00a0\u00a0<\/p>\n \u201cThat’s what makes us nervous,\u201d Sideleau said. \u201cIf there’s a prolapsed cord or breach birth, and we were able to bring them to Leominster and right up to an OB-GYN doctor, it could make the difference between life and death.\u201d\u00a0<\/p>\n The loss of the labor and delivery unit has been complicated by the closure of another community hospital \u2013 Nashoba Valley Medical Center in Ayer \u2013 in 2024. The region\u2019s emergency medical services have since been stretched thin.\u00a0\u00a0<\/p>\n Traveling longer distances to surrounding hospitals means staff and ambulances are away from their stations for longer periods of time. Waiting to unload patients at crowded emergency departments only adds to the delay. Leominster\u2019s fire department often responds to mutual aid requests from Ayer, which also means less time spent in their area.\u00a0<\/p>\n \u201cIf there’s another ambulance call, and we don’t have an ambulance available, then we have to call mutual aid, and it just starts the whole round robin,\u201d Sideleau said. \u201cThe less resources up here, the busier we get.\u201d\u00a0\u00a0<\/p>\n Amy Gagnon, a former labor and delivery nurse at Clinton Hospital who now works at Henry Heywood Hospital, said she couldn\u2019t sleep for weeks after the closure. She worries for the future of maternal health access in the region. \u201cIf anything happens to Heywood, this whole area will be a desert,\u201d she said.\u00a0\u00a0<\/p>\n For months after the closure, Gagnon said Leominster patients came to deliver at Heywood but hadn\u2019t received prenatal care there. Medical staff knew very little about their pregnancy history and due dates. Without access to their prenatal records, providers can\u2019t anticipate complications or be ready for necessary inductions based on preexisting conditions.\u00a0\u00a0<\/p>\n \u201cIt was hard in the beginning, because we weren’t prepared staff wise,\u201d she said. \u201cWe only have three nurses.\u201d\u00a0\u00a0<\/p>\n At the time of the closure, DPH determined that the unit was an essential service<\/a> \u201cnecessary for preserving access and health status within the hospital\u2019s service area.\u201d Beyond that recognition, the state has little authority over hospitals and service closures.\u00a0\u00a0<\/p>\n \u201cThis feels inherently broken … When I was born in 1988, my mom had four choices between the city of Leominster and the city of Fitchburg to give birth in, and now we have zero.\u201d <\/p>\n State Rep. Natalie Higgins<\/p>\n<\/blockquote>\n \u201cIf the Department of Health determines that a service is essential to the health and safety of a community, why in the world do we agree to exist in a system that lets it close down?\u201d Rep. Natalie Higgins, who represents Leominster, said in an interview.\u00a0\u00a0<\/p>\n After the closure, Higgins authored legislation that would prevent hospitals from closing a service for three years after DPH deems it \u201cessential.\u201d The bill<\/a> \u2013 which failed but was reintroduced<\/a> in January and has yet to make its\u00a0way through the legislature \u2013 did not specify if the state would help keep a service open if the hospital cites financial reasons for the proposed closure. Higgins called it a \u201cbig ask.\u201d \u00a0<\/p>\n Lawmakers have also introduced a bill<\/a> that instructs the attorney general to seek an injunction to keep essential services open during a required one-year notice period. It would require hospitals seeking a service closure to notify any affected cities or towns and prohibit them from applying for a new license or expanding for three years after a service or facility is closed. The current legislation has yet to pass but is scheduled for a hearing at the end of the month.\u00a0<\/p>\n The maternity unit was one of four essential service closures in and around Leominster in the last eight years. Higgins is worried her community will stop showing up to the closure hearings. \u201cIt’s feeling pretty futile.\u201d\u00a0\u00a0<\/p>\n \u201cThis feels inherently broken,\u201d she said. \u201cWhen I was born in 1988, my mom had four choices between the city of Leominster and the city of Fitchburg to give birth in, and now we have zero.\u201d <\/p>\n Emerging research<\/a> has shown that birth centers and midwifery care are safe, lower-cost, and desired options for labor and delivery. They also have the potential to absorb patients that have otherwise lost access to a maternity unit or prefer not to give birth in a hospital.\u00a0\u00a0\u00a0<\/p>\n Seven Sisters Midwifery in Northampton is currently the only free-standing birth center in Massachusetts. Ginny Miller, the center\u2019s owner, said patients drive from all over the state, as well as from bordering states, for care. They currently have a waiting list for pregnancy care and delivery until May 2026.\u00a0\u00a0<\/p>\n New Hampshire, a state with one fifth the population of Massachusetts, is home to three independent birthing centers.\u00a0\u00a0<\/p>\n By share of total deliveries occurring in birth centers, Massachusetts ranks 35th out of the 44 states where birth centers are available. The Health Policy Commission<\/a> asserts that about 25 percent of births in Massachusetts hospitals are low-risk deliveries that could qualify for birth center care.\u00a0<\/p>\n But one challenge that comes with the establishment of community birth centers is that they must be within reasonable distance of a hospital with a labor and delivery unit in the event of major complications. That could rule out cities like Leominster and Fitchburg if potential centers determine that the nearest maternity hospital is too far away.\u00a0<\/p>\n Emily Anesta, co-founder of the Bay State Birth Coalition, called birth centers \u201ca necessity.\u201d Massachusetts has one of the highest rates of severe maternal morbidity \u2013 unexpected outcomes of labor and delivery that can result in short- or long-term health consequences \u2013 ranking 45th\u202fin the country according to the Commonwealth Fund<\/a>. A 2023 DPH report<\/a> showed that the prevalence of severe maternal morbidity nearly doubled in Massachusetts from 2011 to 2020.\u00a0\u00a0<\/p>\n \u201cHospital care is not what everyone needs. Midwifery care is not just something people like. \u2026 It really is lifesaving,\u201d Anesta said. \u201cTo have that access denied for most people currently in Massachusetts is not actually giving people access to the care that they need.\u201d\u00a0<\/p>\n Low insurance reimbursement rates and a lack of licensing have prevented birth centers from operating in Massachusetts, making it an uncommon, expensive option for pregnant patients. Nurse midwives are not reimbursed at the same rate as physicians and OB-GYNs, meaning hospitals and other health care centers aren’t incentivized to build or expand their midwife programs.\u00a0<\/p>\n In August 2024, Gov. Maura Healey signed a maternal health bill mainly providing a pathway to licensure for certified professional midwives that advocates had long called for. The legislation also requires MassHealth to cover midwifery and doula services for up to 12 months postpartum. The licensing changes have yet to be fully implemented.\u00a0<\/p>\n \u201cUntil that’s in place, and until private insurers also cover that care, most families wouldn’t be able to afford to pay somewhere in the neighborhood of $5,000 out of pocket for their maternity care,\u201d Anesta said. \u201cIf they went to a hospital, they would be paying less out of pocket or nothing out of pocket, depending on what type of insurance plan they have. It becomes more of a luxury option that’s inaccessible to most.\u201d\u00a0<\/p>\n\n