Inside A Maine Hospital’s L&D Closure

MaineHealth Lincoln Hospital – A Case Study

MaineHealth is planning to close L&D in Damariscotta, following a familiar pattern in its interactions with local communities. Let’s take a close-up look at what’s happening in this picturesque midcoast community.

For perspective, note that Lincoln Hospital is a “critical access hospital,” meaning that it is publicly funded and not a private company. It receives more than $700,000 in property tax breaks alone each year, plus other public services.

On April 9, MaineHealth assured the community that rumors they were considering closing the unit were false.

Just 6 weeks later, MaineHealth instructed providers to tell patients the unit would be closing in December.

June 1-2, MaineHealth conducts two “listening sessions.” By the end of the week, there were marches in opposition and the newly formed Miles Delivers Action Coalition collected more than 2500 signatures opposing the closure.

Since then, MDAC has done extensive research which it delivered to Board members and legislators, and then produced a counterproposal with their vision for the future, which MaineHealth promptly said was “utopian” and “infeasible.”

One of MDAC’s major complaints is the lack of transparency and lack of communication with people who will be affected. It’s telling that when asked about discussions with MaineHealth, Evan Goodkowsky, a Lincoln County Commissioner, said they “would never ever, ever consider meeting with us!” He added, “I just can’t imagine any scenario where they would ever communicate their plans with us.”

Melissa Keyport, a pediatrician who attends deliveries, echoed concerns about the lack of transparency, noting, “The more open MaineHealth would be, the easier it would be to solve the problem and come up with creative solutions. But when we don’t know what’s going on, it’s hard to offer ideas.”

Why The Rush To Close Miles?

MaineHealth is showing a remarkable urgency, from June to a planned Board vote on August 5^th.

MDAC member Lizzy Anderson, MPA, believes the timing is deliberate, being after the Maine legislature had closed and during the summer when some town committees take a break, and everyone is very involved with school vacations and the tourist season. It would also prevent newly elected representatives from taking action.

MaineHealth says the decision is not financially based. In fact, Lincoln Hospital is more profitable than most, with a net operating margin of 5.56%.

Why Close Miles?

MaineHealth argues that the low volumes of births are not sustainable and represent a quality issue.

But the volume of births at Miles is up 43% since 2019. Lincoln County’s total population has increased by ~1200 since 2020 (3.5%). While the county has the oldest population in Maine, the number of birthing age women has increased by ~300 (9.2% increase), far more than the county as a whole.

Also, articles show that Miles and the Family Birth Center have received national recognition for adopting World Health Organization baby-friendly practices. The Chartis Center for Rural Health named LincolnHealth as one of the Top 100 Critical Access Hospitals in 2023 and the Leapfrog Group named it a Top Rural Hospital.

Physicians also disagree with MaineHealth’s conclusion. Stephanie McCollough is a family physician who completed an additional surgical OB fellowship. She’s also the associate medical director for OB/GYN. She told me that Lincoln only allows a low-risk population to deliver there—anyone considered high risk (obesity, vaginal birth after C-section) is automatically sent out of town.

McCollough says the staff are consistently best or near the top on outcome data, in part because they have frequent safety drills covering emergencies like hemorrhage, neonatal resuscitation, and breech births, among others.

What Happens If Labor And Delivery Closes – Impact on Women

The obvious answer is that women will have to travel for care. In rural Maine, this is not easy. There is essentially no public transportation in Midcoast Maine. MaineHealth estimates 37” additional travel time, which would put the total time at ~70” under ideal conditions, for women living far down on the Boothbay or Pemaquid peninsulas. Google Maps tells me it is currently 45” from Miles to MidCoast Hospital in Brunswick, fitting with an analysis of average driving times. This does not include delays from summer tourist traffic or traversing foggy, dangerous roads in the winter. And it assumes a car and driver are immediately available. How much longer will it take to call an ambulance to go down the peninsula?

One oft-cited study estimates that rural women are 9% more likely to endure life-threatening complications or to die in pregnancy, during birth or after. Another shows that pregnancy-related deaths are 64% higher in rural than urban women. The infant mortality, premature birth, and low birth weight rates are also higher in rural communities.

Women whose care is far away receive less prenatal and postnatal care, adding to their risk of complications. There’s also the additional burden on the women. If you have to take a half day off work to get to an appointment (and perhaps find someone to drive you), that is an extra expense. So is additional childcare. In Lincoln County, 60% of the deliveries are covered by Medicaid, which is being cut. Common issues complicating pregnancies are obesity, substance abuse, and depression or mental health problems. Having to travel away from their home communities will be an additional burden for women who are separated needlessly from their families and support systems.

Impact Of L&D Closure On The Hospital

In some cases, closing a major service like maternity care leads to the decline of other services. Will the hospital remain a viable, full-service hospital?

In this case, the answer appears to be “maybe,” as MaineHealth is investing in new operating rooms, reportedly planning to shift some gynecologic surgery to Miles. They have also added an infusion center for chemotherapy. Some people believe they will close other services. Seemingly, the tradeoff is to focus on the elderly retirees rather than young mothers.

What Happens To Communities In A Maternity Desert?

A study from the University of Kentucky found that rural counties that lost obstetric care services also experienced a 17% decrease in business establishments, 5% more than in metropolitan or urban counties. The paper concludes, “access to obstetric care may be thought of as an economic development issue as well as a health care issue. Rural areas seeking a comprehensive economic growth and population retention strategy may need to prioritize maintaining obstetric care services as a tool for keeping and attracting adults and families of reproductive age.”

Alison Davis, Ph.D., Director, Center for Economic Analysis of Rural Health at the University of Kentucky, said via e-mail that loss of obstetrics “is a critical rural issue.” She added, “Many rural places already see an outmigration of the exact population they want to retain and attract: young professionals and productive labor force. This will exacerbate the loss. Future families are quite selective about their location decisions, particularly post-COVID, and this is one of the selection criteria for sure.” Further, hospitals become more financially vulnerable, relying on public payers for an aging population.

Growing maternity deserts are not only causing a crisis for women’s health, which is too often overlooked, but also for the viability of a community. As Dr. Keyport said about losing Obstetrics, “I definitely think it would dissuade people from moving to the area if they know that it’s a place that people are going to die rather than be born.”

There is widespread opposition to the proposed loss of Labor and Delivery from the communities (e.g., MDAC), Damariscotta Select Board, and Lincoln County Commissioners, and staff physicians. This appears to describe the MDAC sentiment: