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miscarriage

At least you’re (probably) not giving birth in West Texas

This is a long story about the lack of prenatal and obstetric care in West Texas. It’s mostly set in Alpine, Presidio, and Big Bend, which are the “big cities” in the area that actually have doctors and medical facilities in them. The one hospital in the area is in Big Bend, and its labor and delivery unit is now closed much of the time, for a variety of reasons. This is a small taste of what it’s like to be pregnant in this part of the state.

Big Bend is the only hospital in a 12,000-square-mile area that delivers babies. If Billings’s patient goes into labor when the maternity ward is closed, she’ll have to make a difficult choice. She can drive to the next nearest hospital, in Fort Stockton, yet another hour away. Or, if her labor is too far along and she’s unlikely to make it, she can deliver in Big Bend’s emergency room. But the ER doesn’t have a fetal heart monitor or nurses who know how to use one. It also doesn’t keep patients overnight. When a woman gives birth there, she’s either transferred to Fort Stockton—enduring the long drive after having just had a baby—or discharged and sent home.

This situation is stressful and dangerous for pregnant women. Uterine hemorrhages, postpartum preeclampsia (a potentially deadly spike in blood pressure), and other life-threatening complications are most likely to occur in the first few days after childbirth. This is why hospitals usually keep new mothers under observation for 24 hours to 48 hours. “This is not the ‘standard of care’ that women should receive,” Billings says. “You’re not supposed to discharge patients and leave it up to chance.”

Big Bend doesn’t really have a choice. In the past two years, almost all its labor and delivery nurses quit. The hospital has tried to replace them, but the national nursing shortage caused by the pandemic has made that impossible. When Big Bend is too short-staffed to deliver a baby safely, its labor and delivery unit has to close.

[…]

Medicaid pays for 42 percent of all hospital births, but it doesn’t reimburse hospitals for the full cost of care. (In most states it pays between 50 cents and 70 cents on the dollar, which means a hospital loses money when it cares for someone on the program.) To offset its losses, a hospital often charges its privately insured patients significantly higher fees. But if it’s in a poor neighborhood and doesn’t have enough privately insured patients, it can’t recoup the money. So most pre-pandemic maternity ward closures were in low-income areas and disproportionately affected pregnant women of color. Pandemic-related nursing shortages have only made the situation worse. Nowhere is this problem more evident than in Texas.

The state is the national leader in maternity ward closures. In the past decade, more than twenty rural hospitals have stopped delivering babies. More than half the state’s rural counties don’t even have a gynecologist. Texas has some of the lowest income eligibility limits for Medicaid and has declined to expand them, as allowed by the Affordable Care Act. (Childless adults don’t qualify for the program unless they’re disabled.) As a result, more than 18 percent of Texans don’t have health insurance, the highest percentage of uninsured residents in the U.S. Income eligibility limits jump for pregnant women—$36,200 for single mothers, $45,600 for married ones—but the application process takes at least a month. According to the March of Dimes, a fifth of all pregnant women in Texas don’t get prenatal care until they’re five months along. In other words, when a poor woman gets pregnant in Texas, it’s hard for her to find a doctor or even a hospital.

“What we’re seeing in terms of health outcomes, it’s not good,” says John Henderson, chief executive officer and president of the Texas Organization of Rural & Community Hospitals. “We have lower birth weights, more preterm births. When it comes to caring for pregnant women and their babies, Texas does not compare favorably to other states.”

Like I said, this is a long story and it’s worth your time to read. I’m old enough to remember when tort “reform”, in particular putting a cap on damage awards that can be given in medical malpractice lawsuits, was supposed to usher in a new era of doctor abundance in Texas. I don’t think that has worked out in the way we were promised. Towards the end, one of the doctors the author spoke to for the story notes that since abortion was already impossible to get in their region, the new state ban on abortion likely won’t result in more babies being born there. These docs will still deal with miscarriages and ectopic pregnancies and other life-threatening situations – they tell some amazing stories – despite the threat to their own safety. Click over and read on for more.

The costs of the “fetal remains” rule

This is going to cost a lot of people a lot of money.

State health officials have contended that the “minimum costs in complying with the rules” would total $450 a year per health care facility, arguing that those costs would be offset by the elimination of the cost of landfill disposition.

But Michael Land, a funeral home director and spokesman for the [Texas Funeral Directors Association], said that’s unrealistic and that the costs associated with compliance are likely a “higher dollar amount than what they’re projecting.”

Cremations through a third-party crematorium range from $75 to $100 per specimen. If individuals choose burials, the minimum cost of a small space in a cemetery is $500 and caskets of the appropriate size would likely cost $100, Land said.

If you add labor on the part of the funeral home, the fees could go into the thousands of dollars, he added.

Responding to those concerns, a spokeswoman for the Texas Health and Human Services Commission said the rules don’t require that “these processes” go through funeral homes. Health care providers can work directly with crematoriums or medical waste companies to comply with the rules, said spokeswoman Carrie Williams.

“[Funeral homes] don’t have a mandatory role, and funerals are not required by these rules,” Williams said. “Incineration is still available as an option.”

But the rules indicate that incineration of fetal remains must be followed by interment. State health officials define interment as the “disposition of pathological waste using the process of cremation, entombment, burial, or placement in a niche or by using the process of cremation followed by placement of the ashes in a niche, grave, or scattering of ashes as authorized by law.”

Among the few exceptions to the rule are miscarriages or abortions that occur at home. But fetal remains from miscarriages that occur at health care facilities will still require interment — even if the patient does not desire it.

For those in the funeral business, the increased demand for cremations could mean ending their practice of charitably cremating the tissue from a miscarriage for parents who wished to have a funeral.

“What had always been pretty much a charitable process is now going to become costing quite a bit of money,” Land said. It’s estimated that 10 to 20 percent of pregnancies end in miscarriage.

See here for the background. Someone is going to pay for this little unfunded mandate, and there are a lot more women who have miscarriages than abortions. Remember, this only became a thing after HB2 was thrown out by SCOTUS last year. With any luck, this will meet a similar fate after it takes effect on the 19th.