A Difficult Decision

as published in the Valley News

Susan Mooney, MD, MS, FACOG, President & CEO, Alice Peck Day Memorial Hospital
Joanne M. Conroy, MD, CEO & President, Dartmouth-Hitchcock

Today the Alice Peck Day Board of Trustees announced a process to integrate the obstetrical service with the obstetrical service at Dartmouth-Hitchcock Medical Center (DHMC). As the leaders of health care institutions that serve the Upper Valley, we made this decision with deep consideration and care for what is ultimately best for our community, and how it will feel to close the beloved APD birthing center.  APD has specialized in obstetrics  for more than 85 years and there have been thousands of families in the Upper Valley who have entrusted APD with the birth of a child. We know that many of you will grieve the loss of this community treasure.

Our decision is better understood in the context of what is happening nationally in obstetrics. Rural hospitals across the country are closing or integrating their obstetrical units. One recent study found that 179 hospitals closed their obstetrical units between 2004 and 2014, and today more than half of all rural counties in the United States lack any obstetrical services. As a predominantly rural state, New Hampshire is not immune to the forces that are driving these closures. Many smaller hospitals in the Granite State, such as Valley Regional Hospital and New London Hospital, have closed their birthing units in recent years. Just last month, Lakes Region Hospital in Laconia announced it too was considering eliminating its obstetrical service line. This national trend is driven by the pressures that all rural hospitals face, which include rising costs, low Medicaid reimbursements, workforce challenges, demanding legal requirements, and expensive malpractice insurance.

Demographic trends in New Hampshire are also not favorable for obstetrics: collectively, we are getting older, not younger, and this trend is negatively impacting the local birth rate. According to the Census Bureau, in 2017, Maine, New Hampshire and Vermont were the top three oldest states in the country, with a median age between 42.7 and 44.6 years of age. Projections published by the state of New Hampshire reveal that the proportion of the state’s population older than age 65 will more than double in size by 2040. By that year, every New Hampshire county will experience more deaths than births. In addition, by 2020, the number of births in Grafton and Sullivan counties is projected to drop by a combined 300 births per year. Patients from those two counties accounted for 58% of the births at APD in 2017 and the projected decline in the number of births is greater than the 217 babies delivered at APD that same year.

Although APD is financially stable, Obstetrics is a resource-intensive service that is poorly reimbursed. In addition to running a clinic with obstetric doctors, midwives, pediatricians, nursing, clinical, and administrative staff, we must also staff, equip and pay for an operating room 24 hours a day/365 days a year. APD has had difficulty replacing obstetricians, and nurse midwives who have retired.  In spite of this, the APD providers and nurses have done heroic work to keep the service running, and we are incredibly grateful to them, but as the weeks of being under-staffed stretch into months and then longer, we must acknowledge this very practical limitation.

Many rural hospitals, when faced with these same pressures, close their obstetric services completely and ask their patients to travel hours to the next closest hospital. We have decided to leverage our partnership, where patients can safely and confidently deliver babies in a state-of-the-art birthing pavilion at DHMC with its own proud history of community service and dedicated professionals. Working together, we are ensuring that we are using our limited resources in the safest, most responsible way possible. It also means that APD does not have to completely close its obstetrical service. Instead we are integrating our two services, and together we will continue to deliver prenatal and postnatal obstetrical services on the APD campus.

Change is inevitable, but we do have a vision for our combined future that builds on our current strengths, deepens our commitment to the community and maintains each institution’s unique culture of health care.


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