MENDOCINO Co., 9/25/21 — Around 11 a.m. on April 19, 2020, Susana Macias, a registered dietician at Mendocino Coast Clinics (MCC) in Fort Bragg, was working when she started having contractions more than two weeks earlier than expected. As the contractions became more pronounced, Macias called her husband. Then she alerted the hospital that she was on her way.
A month earlier, Macias could have driven two minutes to the Mendocino Coast District Hospital’s Labor and Delivery Center in Fort Bragg where she had been planning to have her second child. The contentious shuttering of the coast’s only labor and delivery center on April 1 2020 left Macias and other birthing parents with only one choice in Mendocino County. The couple headed to Adventist Health hospital in Ukiah on Highway 20, more than an hour’s drive away on a snaking mountainous road.
“We were on 20, and [the contractions] started getting worse,” Macias remembers. “Halfway through 20, my water broke, and I thought ‘Now it’s really happening.’” By the time the couple hit Highway 101, “I could feel [the baby] coming out,” she recalled. Macias considered stopping in Willits but was determined to get to the hospital where medical staff was waiting. “So we just drive faster. Just speeding down [the highway]. I felt so bad for [my husband] because he was just staring down the window and I was just trying to hold the baby in. Then we got there and realized we weren’t familiar with where labor and delivery was.”
Macias says she had to Google directions while in labor. After going to the emergency room mistakenly, the couple finally found the labor and delivery center. “I couldn’t move from the car because the baby was pretty much there,” Macias remembered. Macias was helped into a wheelchair and moved into the delivery room – within ten minutes of arriving at the hospital and three pushes, Macias gave birth to a healthy baby boy. “I was in shock,” she recalls with how fast everything happened.
Macias was one of the first birth parents to be transferred to Ukiah. Despite it being her second pregnancy, she said she felt lost navigating the system, unfamiliar with providers in another part of the county. “Every time I went [I saw] a different provider,” Macias says. “Delivering on [Highway] 20 was my worst fear,” Macias says. “That really freaked me out. I’m glad I made it to the hospital.”
As a healthcare worker with a strong support system, Macias worries about those in her position without the support of family and some of the at-risk patients she sees at the clinic. “My parents are here in Fort Bragg, so I was able to leave my son with them when we took off to Ukiah when I was in labor,” Macias says. “But I know that there are a lot of people that don’t have that. I know that that could be an issue for some people, because they wouldn’t have anybody to take care of their other kids or didn’t have transportation or enough income for gas or different things like that.”
Covid-19 safety policy at the hospital didn’t make the experience any less stressful. “We were concerned that [my husband] wouldn’t be allowed in the delivery room, but he was because one person was allowed. If this had been my first child it would have been much worse,” Macias says. “Thankfully we went through the process with our first child, so my husband was able to see the ultrasound and everything. But this time he just drove me to my appointments and sat in the car. We understood it was for everyone’s safety.”Macias says she hasn’t made it back to Ukiah for follow-up appointments and receives pediatric care in Fort Bragg because “it’s a hassle.”
For others, the closure of the labor and delivery center paired with the pandemic upended the way they planned to give birth. Daniela Wilkens, of Mendocino, described the closure of the labor and delivery center as “bittersweet,” and her pregnancy during the pandemic “extremely lonely.”
“When you see the baby for the first time, when you hear the heartbeat, when you start seeing how it grows or its weight, gender, everything, you’re doing it all by yourself,” Wilkens says. “That’s something I’ve noticed was very traumatic, even for first-time moms.”
Kei Velazquez, a nurse practitioner and lactation consultant at MCC, says the pandemic exacerbated the impact of the labor and delivery center, noting that women are more at-risk for isolation during and after pregnancy. “Having babies in this time, when your job is to bond, [to] look into their eyes; you can’t do that,” says Velazquez. “Imprinted [on babies] are masks, not smiles.”
Velazquez says it’s been hard on partners and family, too. “[Before] partners were included in every part, now it’s just a woman and Facetime,” says Velazquez. “It’s a huge loss. They have to choose between their mom and their partner. You can’t get that birth back. You take away the experiences of women having babies. Instead women are falling through the cracks. We couldn’t mourn that loss, because everyone was losing everything.”
Wilkens, despite her doctor’s recommendation and healthy pregnancy, scheduled a C-section to reduce the stress of delivering her baby far from home during the pandemic. “I’ve heard of a lot of women that had to do that drive on Highway 20 in the middle of the night with full-on contractions,” she says. “If anything, that made me feel more comfortable about scheduling a C-section as soon as I could because I was so afraid of that. Basically, I chose to not have such a traumatic experience when the water breaks.”
Wilkens says she knows other women who made similar choices because of the long travel and costly logistics, such as renting motel rooms, getting time off work, fuel, or childcare. Wilkens notes it isn’t only the person giving birth who has to take time off work but her partner or support person, too. “It is very stressful,” says Wilkens. “You have to rely on people because it’s hard to be driving yourself, especially such a long drive, over eight months pregnant. You have to think about that drive home [and] make so many decisions. I have also heard of women who have to rent a motel room for a week or something because they just don’t know [what to expect] and they can’t walk. That’s another kind of privilege to even have the resources to do that.”
Not to say that Wilkens isn’t happy with the medical care she received at Adventist and Care for Her, but she wishes she had those services closer. “[My provider] told me if anything happens baby-related, you have to go to Ukiah,” Wilkens says. “Oh man, that makes emergencies really scary.”
The closure of a labor and delivery center
Behind the sign that reads her name in gold glitter, Lucresha Renteria, the executive director for MCC, fields calls and pens reports, under the watchful gaze of a Ruth Ginsberg bobblehead doll. The clinic serves an estimated 10,000 patients annually out of a population of 20,000 extending from Fort Bragg to Elk, Westport to Comptche. In 2020, MCC provided perinatal services to 186 birthing parents and 96 birthing parents up to July, according to MCC data. Renteria estimates a third of MCC’s patients are seeking perinatal care.
The closure of the Mendocino Coast District Hospital’s Labor and Delivery department in April last year couldn’t have come at a worse time, with the pandemic wreaking havoc on travel and healthcare access. “I’ve been executive director for five and a half years and it’s been my number one battle to keep it,” Renteria said. But the community lost. “[It was] a business decision, but sad for our community.”
MCC has provided prenatal care since 2005, but Renteria and her staff scrambled with a three-week notice to prepare and fill in the gaps left by the closure. They also had to prepare birthing parents for the costly reality of planning every time they needed to see a care provider. The pandemic lockdown complicated the tender nine-month period for birthing parents, who couldn’t utilize tele-health services to hear their baby’s heartbeat or other gestations, had to travel at least three hours round-trip per appointment, and couldn’t have their family join them for the baby’s milestones.
For women who need financial support, MCC receives funding from Mendocino Coast District Hospital to help birthing parents who may struggle with transportation, temporary housing, or other care costs or at the time of their baby’s delivery in Ukiah. Renteria describes the fund as inconvenient but necessary with no other plan in place. “They got a black eye from closing,” she says. “The fund was a way to mitigate the bad publicity.”
Mendocino County mirrors a national decline in rural healthcare
The barriers to healthcare access Macias, Wilkens, and other birthing parents on the coast have grappled with reflect a national decline of reproductive health care and labor and birth delivery centers. The COVID-19 pandemic has only exacerbated the problem for geographically isolated communities. Prior to the pandemic, nearly 100 rural hospitals have closed, and 54% of rural counties have no obstetric units, increasing travel and the risk of both emergency room birth and preterm birth. In an op-ed on rural maternal health, Dr. Katy B. Kozhimannil, director of the University of Minnesota Rural Health Research Center wrote, “Access to needed health care in rural communities – including childbirth – is a leading indicator of the health of the nation.”
Dr. Jodi Parungao began practicing family medicine at Adventist Health Ukiah Valley just before the pandemic began. Dr. Parungao’s passion for her work appears inexhaustible during one of the most challenging times for frontline healthcare workers. Dr. Parungao jumps from outpatient clinics to providing prenatal care and delivering babies while also being the program director of Adventist’s family medicine residency program. Working with some of the most at-risk birthing parents in Mendocino County, Dr. Parungao wants to improve access to maternal healthcare countywide. She has seen firsthand the barriers to reproductive healthcare, and she has some ideas.
“Mendocino County is rural and underserved.” says Dr. Parungao. “Even before this COVID-19 pandemic, we were seeing a lot of women struggling with social determinants of health like money and access to safe housing, food security and substance use disorder. And then not only with the closing of the coast [labor and delivery center], there is the lack of OB-GYN services in their area. So then they’re even more removed from the care. That deepens the barriers for them. And add on to that a pandemic.”
Dr. Parungao says this has resulted in appointment no-shows and mitigating barriers to accessing mental health resources and social resources for housing and food. “For a lot of women, [driving that] distance makes them nervous,” she says. “They want a doctor that really knows their case. And so we have seen a few more women, just starting their care with us from the beginning. I think that’s the biggest change we’ve seen.”
In her practice, Dr. Parungao has been vigilant about screening for depression and anxiety in all her patients. Dr. Parungao says she’s seeing “a lot of pregnant women with increased rates of anxiety and depression, which is already a really common complication in pregnancy. And I think it’s just worse with the COVID-19 pandemic.”
“Offering those screenings and the counseling early on, every single visit, is just that much more important with the pandemic,” she says. “As soon as March last year, I just knew that this was a huge source of anxiety and depression for my patients, being scared to come in because it COVID-19.”
The hospital also has seen an uptick in pregnant women with symptomatic COVID-19. Dr. Parungao underscores the CDC evidence on the safety of COVID-19 vaccinations for pregnant people, which she recommends her patients receive. Understaffing and overwhelmed facilities at the hospital, intensified by the recent wave of Delta variant, have not improved healthcare access, or given anyone much time for reflection. For all the challenges COVID-19 has brought to Dr. Parungao’s practice, she and her colleagues see the opportunities, too.
“The pandemic has enabled us to be more creative,” says Dr. Parungao. “We’ve offered curbside or car side visits to pregnant women and tele-health video and phone visits intermittently throughout the pregnancy. There’s a lot of creative ways that we should be able to offer more care during the pandemic. These are things that are great for any rural underserved patient, and I would think that we would continue this even after COVID-19.”
The pandemic has also thwarted efforts to build relationships between clinics after the closing of the labor and delivery center. Renteria is concerned about not knowing where MCC patients are going after they are transferred and wonders if transferred patients know they can receive postpartum care closer to home.
Efforts to build relationships with local clinics after the labor and delivery center closed remain elusive. “I want to break down these silos and build bridges, and it takes time,” says Taff Cheneweth, a registered nurse and Adventist’s Family Birth Center manager. “What I call care pathways where we have a clear pathway for patients to come to us eventually here, but also get back to [their local clinic].”
Cheneweth is considering the idea of mobile midwives and an app (such as this one) to educate birthing parents who may be limited by geography or other barriers. Dr. Parungao says she would love to see housing for birthing parents instead of motel rooms, such as Ronald McDonald houses for families traveling long distances for medical needs.
For now, Renteria and her staff at MCC use the labor and delivery center’s closure funds to assist birthing parents’ needs for travel and overnight stays in motels. When that fund dries up, Renteria will have to negotiate for more.
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Research on COVID’s impact on pregnancy is underway in California. Researchers at UCSF are currently studying the safety of pregnancy for birthing parents with COVID-19 through a project called ASPIRE. Another UCSF study called HOPE is assessing environmental and biological factors during the pandemic on pregnancy and infants. Yet another project, SACRED, is measuring the experience of Black pregnant women in hospitals.
Dana Ullman reports on health-related stories for The Mendocino Voice with the support of the USC Annenberg Center for Health Journalism This article was produced as a series for the 2021 California Center for Health Journalism Fellowship.