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On edge of access: Infant health in West Virginia — The second in a four-part series

Second in a four-part series


The Register-Herald

BECKLEY, W.Va. — From a mile deep into a Wyoming County hollow, from a street named for her now-deceased father-in-law, Courtney Trent begins her journey. The 26-year-old expectant mother travels the winding, two-lane blacktop 30 minutes before she reaches Pineville, home to the county courthouse, a Dairy Queen, and a store called Pat’s Fashions, offering prom dresses and tax services all under one roof. From there, Trent hangs a right – past the tiny towns of New Richmond, Itmann and Bud – toward the steep incline of Herndon Mountain. At the foot of the mountain, she still has about 20 minutes before she reaches Princeton. In all, Trent travels an hour and 45 minutes to the hospital where she’ll deliver her son. In the latter weeks of her pregnancy, the distance has caused her a great deal of anxiety.

Traci and Steven Browning with their son Lincoln in Wyoming County. Traci had a high-risk pregnancy and had to travel two hours to Charleston to get prenatal care.
(Photo by Jenny Harnish)

In West Virginia, a state with roughly 20,000 births each year, less than half the hospitals in the state – 24 of 64 – offer child delivery services.

In the southern part of the state, five hospitals currently have birth facilities – Greenbrier Valley, Logan General, Raleigh General, Princeton Community and Bluefield Regional – down by two since last year.

One birth facility in the region, Summersville Regional Medical Center, closed its doors in March, citing a $2 million loss the previous year in keeping the obstetrics department open.

WSAZ reported the hospital’s delivery rate was once around 350 babies per year. West Virginia Birth Score’s report shows 272 babies were born at Summersville Regional Medical Center in 2016.

The hospital’s Chief Executive Officer Karen Fiducia said as the coal mining industry declined, so did the number of births at the hospital.

The decrease, or increase, in coal mining jobs almost directly correlates with the number of births in West Virginia.

The West Virginia DHHR Bureau for Public Health’s Vital Statistics report shows births steadily dropped from 12.6 births per 1,000 residents in 1990 to 11.4 in 2003.

During the same time, the West Virginia Coal Association reports coal mining jobs decreased from 28,876 to 14,871. And when mining jobs were on the rise from 2004 to 2009, the number of births were greater than average from 2007 to 2009.

Courtney grew up in Beckley, but she and her husband, Adam Trent, a coal miner, decided to make their home in Clear Fork beside Adam’s father, Dwight Trent.

“The land is beautiful down here. It would have been crazy to buy a piece of property somewhere else,” Courtney shared. “We got it for free. (Dwight) just deeded it to us. He really didn’t want Adam to leave Clear Fork.”

Adam always wanted to build his own home. He started saving in high school, adding money to his account each time he mowed a lawn. And as his and Courtney’s relationship grew more serious, she began helping him design what would one day become their home.

Before the two were even engaged, Dwight told Courtney he knew she was going to have his grandson. He said he was going to call him AJ.

Just two weeks after their wedding in September 2014, Dwight had a heart attack. And a few months later, he was diagnosed with liver cancer.

He passed away in February 2016, just five months before Courtney found out she was pregnant. Six weeks into her pregnancy though, before her first prenatal appointment, she experienced severe bleeding. A Beckley doctor confirmed she had miscarried.

They tried again later that year, and in October 2016, she was pregnant again – a boy they would name Adam Jase.

After hearing bad reviews from friends, she decided not to see an obstetrician in Beckley, an hour and 10-minute drive from Clear Fork. Instead, she chose a doctor at Princeton Community Hospital, just shy of two hours from her home.

The first time she met her OB/GYN, Dr. Brandon Lingenfelter, she immediately felt at ease. He sympathized about her miscarriage. He gave her an ultrasound at six weeks, the same time she lost her first child, to show her the baby’s strong heartbeat.

Because she’s so far away from the hospital, the doctor told her he planned to induce her if she had not gone naturally into labor by Week 39.

Early inductions and C-sections are interventions commonly utilized by obstetricians with patients from rural areas, according to Angelita Nixon, an Advanced Practice Registered Nurse in Teays Valley.

Nixon said such interventions can be cost-effective for doctors. C-section and induction deliveries are scheduled, like clockwork, thus avoiding downtime of waiting through hours of labor for baby to arrive. But such inteventions carry greater risks for mom and baby.

The CDC reported West Virginia had the sixth highest C-section rate in the country in 2015, with nearly 35 percent of women having C-section deliveries. The national rate is 32 percent.

Courtney saw her doctor at every prenatal appointment – not another physician or team member – which she said she values as a private person.

Her prenatal appointments were scheduled once every four weeks through the first 28 weeks, then once every two weeks through week 36, then, in the final month, once a week.

“About 95 percent (of the visits) I have had to go by myself due to Adam’s work schedule,” she said. “He’s using all his vacation and personal days when the baby gets here.”

Around 30 weeks into her pregnancy, as her baby bump grew indisputable, the distance between her and the hospital – more than 60 miles – became worrisome.

“This late in the pregnancy (37 weeks), I’m freaking out about it. His dad lived right beside us. That was the plan. He was going to drive me.”

Adam works at a mine near Welch. If she were to call him, it would take him 45 minutes to travel from underground to the surface of the mine, then 30 minutes to their home, then an hour and 45 minutes to the hospital.

They’ve never considered moving closer to care. They love where they live.

“It’s this big, open field. We grow it for hay. You can’t even see the main road. You can’t even see our street we’re so far back. It’s so peaceful and quiet. Deer come into the yard and we feed them apples. It’s perfect. I don’t think I could live anywhere else now.”

She said many other Wyoming County mothers have experienced the same issues: they want access to care, but they don’t want to relocate.

“It’s at least an hour drive to a hospital, no matter which one you go to – Logan, Beckley or Princeton. It’s a matter of picking which hour you want to drive.”

Another hospital, Welch Community, a state-owned acute care hospital in McDowell County, ceased delivery services May 31 when the facility’s only OB/GYN retired.

The West Virginia Department of Health and Human Resources announced July 6 the hospital is contracting with Appalachian Mountains Medical, a physician group based in Beckley, to provide non-emergent OB/GYN services three days a week. Non-emergent services, however, do not include delivery.

To give birth, women being seen in Welch will have to travel more than an hour to Raleigh General Hospital in Beckley.

The West Virginia Birth Score’s annual report said 41 babies were born at the Welch hospital in 2016.

“There is a shortage of physicians and medical professionals nationally and in West Virginia, particularly in the southern part of our state,” said Nancy Sullivan, acting commissioner for DHHR’s Bureau for Behavioral Health and Health Facilities.

“The budgetary issues that the state continues to face do not help us in our recruitment and retention efforts and the contract we’ve entered will actually cost the state more than if we were able to hire a permanent physician.”

The DHHR said the contract for OB/GYN services will cost $234,000 a year, whereas the previous physician made $160,000.

Molly McMillion, a Special Projects Consultant with the West Virginia Perinatal Partnership, shared her concerns about mothers having to travel for delivery services, especially expectant mothers who would have utilized the Summersville Regional Medical Center’s birthing center.

“Nothing is close for them,” McMillion said. “They will have to go an hour easily or more.”

Raleigh General is 55 minutes from Summersville. The next closest hospital, CAMC in Charleston, is nearly an hour and a half away.

The closure of Summersville’s services left residents of Webster Springs, a rural town with winding, two-lane highways intersected by the Elk River, with an hour and half drive to each of the three nearest delivery centers – St. Joseph’s, Davis Memorial or Stonewall Jackson Memorial.

Any complications experienced during pregnancy would necessitate extensive travel for mothers in rural areas.

The majority of birthing centers throughout the state, while able to provide Level I (basic care) and Level II (specialty care), do not offer Level III (subspecialty care) services for more serious maternal medical conditions, obstetric complications and fetal conditions.

Three Level III centers, or tertiary care centers, are in the state – CAMC in Charleston, Cabell-Huntington Hospital in Huntington, and Ruby Memorial Hospital in Morgantown.

Early in her four-year pregnancy journey, Traci Browning knew she would have to travel for access to higher levels of care.

Since she was 16 years old, Browning struggled with endometriosis – a disorder causing tissue that normally lines the inside of the uterus to grow outside the uterus. Several years later, an OB/GYN also found she had a bicornuate uterus, a common congenital uterine anomaly in which the uterus is “heart-shaped.” The condition can affect a woman’s reproductive capabilities.

When she was 22, she and her husband, Steven, started trying to have a family. After four months without conceiving, she decided to see a doctor.

They were living in Beckley at the time, but she said her local gynecologist hadn’t been helpful in addressing her endometriosis symptoms – extreme pelvic pain, painful sex and infertility. She began traveling to South Charleston for care.

A doctor there immediately scheduled her for surgery to remove a buildup of endometrial tissue. During the surgery, the doctor found her fallopian tubes, where eggs travel from the ovaries to the uterus, were also blocked by endometrial tissue. She was sent to an infertility specialist at CAMC Women’s and Children’s.

The specialist performed a procedure which unblocked her tubes. She was prescribed medications for ovulation and painful endometriosis symptoms. The drugs were not compatible with her body. One medication caused ovarian cysts to form. The other caused her to stop producing hormones.

Around this time, in 2014, with coal mining jobs growing scarce, she and Steven moved to Brenton in Wyoming County so he would be closer to the coal mine where he works.

Traci’s drive to Charleston for doctor’s visits doubled – two hours each way.

A few months after they relocated, in July, she was scheduled for another corrective surgery in Charleston for her uterus – a surgery that nearly ended her life.

Her blood wouldn’t clot. Doctors couldn’t figure out why. They asked her, at age 24, to consider an emergency hysterectomy to remove her uterus, a surgery that would end her hopes of conceiving.

She refused.

She was scheduled the following day for another procedure to block her uterine artery. She was told if the procedure didn’t work, doctors would have to remove her uterus. She woke up from the surgery and immediately asked – “Do I still have my uterus?”

She did, but her doctor told her she may never be able to carry a child. The artery block used to save her life may impede blood to flow to a fetus.

After allowing her body a few months to heal, doctors told her in November she had two options: Intrauterine Insemination (IUI), the placement of sperm into a woman’s uterus when she is ovulating, or In Vitro Fertilization (IVF), a procedure where an egg is fertilized by sperm in a test tube or elsewhere outside the body. One round of IUI failed.

In her first round of IVF, she produced 26 eggs, two of which were successfully fertilized. Both embryos were implanted.

During the treatment process, she was traveling to Charleston every other day, an expensive endeavor with gas and tolls. She considers herself lucky the process wasn’t even more expensive – Steven’s insurance covered three rounds of IVF or IUIs.

“We did one IUI and one IVF, only having to pay co-pays. My fertility clinic joked that I had the ‘golden ticket’ of insurance in the fertility world.”

The travel, the expense and the pain was all worth it on March 5, 2015.

“We finally got the news we had been waiting years to hear. We were pregnant.”

A week later, however, she woke up bleeding. She knew her baby, or even babies, were gone. She grew depressed. She gave up hope – momentarily, it turned out – of ever conceiving. In the fall, she and Steven tried again.“We wanted a family of our own so badly,” Traci shared. “Something kept telling me that wasn’t how my story was going to end.”

Two days before Christmas 2015, she found out she was pregnant.

From conception, Traci’s pregnancy was considered extremely high risk. Doctors were concerned about the baby’s blood flow and the potential for Traci’s uterus to rupture from previous surgeries. Her high-risk status necessitated more doctor visits than a normal pregnancy. To this day, she said she can’t count the number of times she and Steven traveled to Charleston.

“It was pretty terrifying to be so far away with such a high-risk pregnancy,” she said.

“Luckily, I had a direct number to my doctor to advise me, but anything could have happened in the two hours it would take to get to the doctors familiar with my rare case.”

Traci’s pregnancy advanced without issue, and she photographed her baby bump each week. Doctors were not going to allow her to reach full term because of her previous uterine surgeries. She was scheduled for a C-section at 36 weeks.

She welcomed a healthy baby, Lincoln Paul Browning, weighing 6 pounds and 9.6 ounces, measuring 18 inches long, into the world at 1:12 p.m. Aug. 5, 2016.

“We need more delivering hospitals, period,” McMillion said. “But in this day and age, they are not profitable in a state with so much poverty and such a large amount of Medicaid funded births.”

According to West Virginia Center on Budget and Policy, nearly 20 percent of West Virginia women and girls live in poverty, and more than half of the state’s births are financed by Medicaid.

West Virginia mothers are not alone – data from the University of Minnesota’s Rural Health Research Center, as reported by Reuters, shows more than 200 maternity wards closed between 2004 and 2014.

Higher costs, fewer births and staffing shortages have left 54 percent of rural counties across the U.S. without hospital-based obstetrics.

Editor’s note: Courtney Trent gave birth to a boy, Adam Jase, born at Princeton Community Hospital on July 16 at 12:10 a.m., weighing 6 pounds, 12.5 ounces.

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