A hospital in Idaho recently announced it will shutter its labor and delivery services due to doctors’ unwillingness to practice medicine in the face of the state’s restrictive and punitive laws surrounding reproductive health care. This comes on the heels of a hospital in rural Washington state closing its labor and delivery services due to concerns over the cost of these services. CNN reported 13 hospitals ceased labor and delivery services in the past year.
The trend of rural hospitals shuttering perinatal services is not new. A February 2023 report from Chartis, a health care consulting firm, found that 217 labor and delivery units have closed across the nation since 2011. When these facilities close, the care of both pregnant people and their newborns must occur elsewhere. Recently, the National Vital Statistics System flagged an appalling and calamitous 38% increase in maternal mortality rates, just two weeks after the organization affirmed stagnant infant mortality rates these last few years. As a neonatologist, I worry about newborns’ access to pediatric and neonatal services at birth — and I fear the infant mortality rate will increase if this access continues to constrict.
More times than I care to count, I’ve had to say the words “Your baby is dying” to mothers as their fingertips graze their children’s scalps through incubator portholes. I’ve said this after nurses and I agonized for hours over precise prescriptions of intravenous fluids, life support settings, blood tests, blood pressure medications, and blood transfusions. These babies, often born at the limits of viability, slipped beyond the grasp of modern neonatal intensive care interventions. After discussing the what — because there is never an answer for the why — each beloved person lay, breastbone against breastbone, atop their mother’s chests, their bodies shrouded in the steady cadence of their mother’s beating hearts. Pronouncing babies dead is the hardest thing I do as a neonatologist.
Infant mortality, defined as death before a baby’s first birthday, and neonatal mortality, defined as death within 28 days of birth, remain increasingly rare. Perri Klass explored at length how science, medicine, and public health interventions such as pasteurization, vaccination, sanitation, and safety legislation contributed to our modern American paradigm: “children are not supposed to die.”
Yet premature babies like my patients do die. Prematurity is a common cause of neonatal mortality even though I and my colleagues working in NICUs across the nation succeed in saving premature babies’ lives so very often; decades of innovation allow the majority of these children to live meaningful, happy lives.
Their likelihood of survival is inversely related to how many weeks they spent growing and developing in the womb before delivery. My lost patients, like 26% of all the babies who die, were born at the limits of viability. Termed periviable, this subset of babies includes those born after 20 weeks of pregnancy and before 25 weeks of pregnancy with the possibility of intensive care beginning, most commonly, at 22 or 23 weeks. Not all babies who receive intensive care survive. But neither do they all die. Outcomes vary in part because the human body born at near the midpoint of gestation is, sometimes profoundly, immature and incapable of adjusting to the world outside the womb even with aggressive, intensive supports.
But outcomes also vary based on where these babies are born because the knowledge, equipment, and expertise to save their lives is complex.
Proximity to labor and delivery services is important not only for the health of pregnant people, but also for the health of their fetuses. People living on ranches and reservations, in villages and valleys, and even parts of our nation’s cities and suburbs have inequitable access to the resources required to save babies’ lives. Access to NICUs, particularly NICUs with the most experience helping periviable babies survive, is a geographic lottery.
Geographic disparities are amplified by the effects of systemic racism. Racial disparities in overall infant survival persist in part because racial disparities in preterm birth persist. The disparate outcomes for Black babies are a primary reason the United States’ infant mortality rate hovers above the rate of other industrialized nations. Every day, I witness how preterm birth affects birthing people inequitably. I work in a hospital that serves primarily Black and immigrant families. Circumstances beyond the control of an individual pregnant person contributed to the increasing rate of preterm birth.
There are ways to mitigate some of the stressors birthing people experience. For instance, increasing access to Medicaid would help people start pregnancy healthy, receive prenatal care, and assure they can give birth safely, all of which might save more babies’ lives. But these interventions cannot universally prevent prematurity. Human physiology assures that some babies will always be born early, and many would die without neonatal intensive care at birth.
I cannot know what tips my patients’ mothers into preterm labor. I do not know if they struggle with the disadvantages that contribute to preterm birth: unemployment, poverty, racism, and inequitable access to education. To save premature babies means assuring access to the services required to care for them. Effectively interpreting blood tests and managing life support machines is just as important to equitable neonatal care as defining, exploring, contextualizing, understanding, and confronting the role of racism.
My patients’ parents continually tell me they want to watch their children grow up. As a mother myself, I imagine that they want to see the sunrise lighten their babies’ faces day after day. Wielding the powers of intensive care is all I can offer. But, for some families, access to this medical knowledge and specialized equipment is changing.
Post-pandemic and post-Roe v. Wade, the demographics of childbirth are shifting. Hospital profit margins and state laws increasingly affect which maternity units and associated newborn care units and NICUs can continue saving lives.
To speak of dying babies is distressing. People ask me how I can do this work, how I can witness the harrowing moment when death imbues my patients’ tiny human bodies with a pale gray hue. My answer is that, as a parent and physician, I dedicated myself to the mission of neonatal intensive care because I aspired to save newborn human lives. But death is as much a part of doctoring as it is part of living. In this world we’ve made, horrible things sometimes happen. I choose to confront those things, even and especially when it means helping other parents dignify their beloved children’s too-short lives.
The initial phase of bereavement devastates me every time. The phase when these perfect, precious bodies are untethered from the tubes and wires that could not save them. The phase when nurses and I scour through drawers to find appropriate books and crafts for siblings. The phase when mothers bathe their dead sons and fathers dress their dead daughters. The phase where nurses stamp tiny hands and feet into clay to memorialize unmet hopes and dreams.
When my patients die, their final breaths are imperceptible. Each mother draws a tiny head beneath her chin, keening. I choose to remember these babies forever clutched and cradled in their mothers’ hands as they rocked and swayed. A lifetime of love wrenching every bent finger.
Rachel Fleishman is an attending neonatologist at Einstein Medical Center Philadelphia.