KENNETT, Mo. — A few hours after the only hospital in town shut its doors forever, Kela Abernathy bolted awake at 4:30 a.m., screaming in pain.
Oh God, she remembered thinking, it’s the twins.
They were not due for another two months. But the contractions seizing Ms. Abernathy’s lower back early that June morning told her that her son and daughter were coming. Now.
Ms. Abernathy, 21, staggered out of bed and yelled for her mother, Lynn, who had been lying awake on the living-room couch. They grabbed a few bags, scooped up Ms. Abernathy’s 2-year-old son and were soon hurtling across this poor patch of southeast Missouri in their Pontiac Bonneville, racing for help. The old hospital used to be around the corner. Now, her new doctor and hospital were nearly 100 miles away.
Medical help is growing dangerously distant for women in rural America. At least 85 rural hospitals — about 5 percent of the country’s total — have closed since 2010, and obstetric care has faced even starker cutbacks as rural hospitals calculate the hard math of survival, weighing the cost of providing 24/7 delivery services against dwindling birthrates, doctor and nursing shortages and falling revenues.
Today, researchers estimate that fewer than half of the country’s rural counties still have a hospital that offers obstetric care, an absence that adds to the obstacles rural women face in getting health care. Specialists are increasingly clustered in bigger cities. Clinics that provide abortions, long-term birth control and other reproductive services have been forced to close in many smaller towns.
“It’s scary,” said Katie Penn, who said she was rejected by eight doctors before finding an obstetrician in Jonesboro, Ark., about an hour from Kennett. “You never know what can happen.”
When obstetric services leave town, a cascade of risks follows, according to experts at the University of Minnesota Rural Health Research Center who have studied the consequences. Women go to fewer doctor’s appointments and more babies are born premature, compared with similar places that do not lose access to care. And when women go into labor, they are more likely to end up at emergency rooms with no obstetric care or to deliver outside a hospital altogether.
Families struggle to afford the gas, child care and time off work to drive hundreds of miles for an ultrasound, shots or hospital tests. Women say they have ended up on waiting lists at overwhelmed clinics, or been turned away because they said doctors did not want to take them as patients late into their pregnancies.
Women like Ms. Abernathy and Ms. Penn are particularly isolated because they live in the Missouri Bootheel in the southeast corner of the state, named for the way the area juts out of the state’s otherwise orderly shape.
The region was already coping with some of the state’s highest rates of maternal and infant mortality, and then in April came the news that Dunklin County’s only hospital, the Twin Rivers Regional Medical Center, would be closing. More than 179 rural counties have lost hospital obstetric care since 2004. Dunklin was now one of them.
The white, 116-bed hospital had been a busy lifeline for this 31,000-person county’s most vulnerable people. The emergency room received about 22,000 visits a year, and unlike many struggling hospitals, the maternity ward was busy. About 400 babies were born at Twin Rivers every year, often to mothers who had themselves been born in the same rooms.
About 95 percent of the hospital’s patients were on Medicare, Medicaid or had no insurance, said Dr. Steve Pu, a former member of the hospital’s advisory board. Rural hospitals like Kennett’s are being financially battered by several factors: Cuts to public health-insurance programs, struggles with debt and sharply worsening finances in states that did not expand Medicaid.
In April, Twin Rivers announced it would be shutting down as part of a corporate consolidation by its owner, Community Health Systems, a publicly traded, for-profit hospital company. In a statement announcing the closing, the hospital’s local chief executive, Christian H. Jones, called it the “most sustainable plan for the future.”
Patients say they were told to seek care at another Community Health Systems hospital in Poplar Bluff, about 50 miles away down narrow two-lane roads. The hospital in Kennett had about 300 employees, the largest employer in a county with a 5.5 percent unemployment rate.
Then last month, with little warning, a sign went up at Twin Rivers: HOSPITAL CLOSED. CALL 911 FOR EMERGENCIES. Its last day of operations was June 11, more than two weeks earlier than the date executives initially told people in Kennett.
The only obstetrician in Kennett had operated his practice out of the hospital, and he began discharging patients and winding down services in the weeks before Twin Rivers closed. Women said his waiting room became a scene of sadness and confusion as they worried about where they would go next and how they would afford gas for weekly visits at distant hospitals when they barely had enough money to pay electric bills and rent.
The only pediatrician in Kennett, Andy Beach, hung a banner outside his clinic that mirrored the town’s defiant spirit, “We are not leaving the area!”
An ambulance service has been shuttling patients to other hospitals in the region, and a medical helicopter is on call for the worst emergencies. Doctors around Kennett and a hospital in Jonesboro are working to open urgent-care clinics, and officials have put a tax increase onto August ballots to raise money to build a hospital. Someday.
State officials and doctors are also trying to work out a plan and find $1.5 million to reopen the obstetric unit at the Pemiscot County hospital in Hayti, the closest hospital to Kennett.
In the meantime, the absence of local care is being felt already.
Mary Louisa, who was 26 weeks pregnant, recently started experiencing contractions that are a hallmark of preterm labor but had not had a full prenatal checkup in a month.
Susanna Hernandez’s first pregnancy ended in miscarriage. Now she was worried about her second and had not seen a doctor since the hospital in Kennett closed. Every few minutes, she touches her abdomen to feel for a kick, a movement, any sign that the girl inside is still healthy and growing. Ms. Hernandez, who emigrated from Mexico a year ago, speaks almost no English and spends her days trying to relax and pray.
“Our community is just in panic,” Deloris Johnson, who sits on the county’s ambulance board, said in an interview in June. “They don’t know what to do.”
Then, this month came the news that she and many in Kennett had been dreading. Two infant boys, each about a month old, died on opposite ends of the county, one on July 4 and the other the following morning.
In both instances, officials said that family members discovered the children unconscious and rushed them to local ambulance stations. One was driven 20 miles to a hospital in Paragould, Ark., and the other was taken to a hospital in Piggott, Ark., where they were each pronounced dead, investigators said. Investigators would not release the children’s names or any additional details. They said autopsy reports had not been completed and said they did not yet know how the children had died, or whether any intervention could have saved them.
Their deaths sent a shudder through Kennett.
“This is just the beginning,” Ms. Johnson said. “To think we don’t even have a damn hospital for these people to go to.”
As Ms. Abernathy and her mother raced down dark country roads at 90 miles an hour, all they could think about were the twins. Would she have to deliver them on the side of the road, before she got to a hospital? Would the babies be O.K.?
They pulled into the town of Hayti 17 miles east and rushed into the Pemiscot County hospital. It was an act of desperation. The hospital’s obstetrics unit had closed four years ago, and the emergency-room staff looked shocked to see her. The labor and delivery rooms now sat unused.
The staff told Ms. Abernathy she needed to reach the hospital now caring for her after Kennett’s closed: St. Francis Medical Center in Cape Girardeau, Mo., nearly 80 miles away. It had a neonatal intensive care unit, neonatal operating rooms and a full battery of obstetric doctors and nurses. But there was no ambulance ready to take her.
Ms. Abernathy said she waited for about 25 minutes as an ambulance rushed over from Kennett to pick her up. An obstetric nurse rode along, rubbing her back and helping her breathe as the contractions continued.
When they passed through the small town of Sikeston, Ms. Abernathy said the ambulance driver asked whether they needed to stop at the hospital there. Keep going, Ms. Abernathy and the nurse told him. Nearly four hours after she woke up screaming in bed, they arrived at a hospital with an obstetrics ward.
Her doctor rushed to get her into surgery. Forty-five minutes later, the twins were born by cesarean section, first Kaleb at 3 pounds 6 ounces and then Kylynn at 2 pounds 12 ounces.
They were healthy, but because they arrived early, they would need weeks of close care at the hospital: nurses who could check their breathing and vital signs and also show Ms. Abernathy how the babies needed to be touched and held.
This meant that Ms. Abernathy had to make regular 200-mile round trips to the hospital to see the twins and then back to Kennett to be with her 2-year-old. One day, her C-section incision was so inflamed by the drive that she could barely stand. Another afternoon, she and her mother had to pull over when a summer storm swamped the highway.
Ms. Abernathy said she was eager to bring the twins home and to get back to her $8.50-an-hour job as a home health aide. There is rent to make, baby clothes to purchase, $80 of gas to buy for the coming week.
“My mom raised me to be independent,” she said. “I’ve always worked.”
One morning, she lay underneath a blanket on her couch, exhausted and upset about the inconveniences and indignities of the past month and the stress of not seeing a doctor for weeks when she knew she was a high-risk patient.
“I was an emotional wreck. I can’t tell you how many times I cried,” Ms. Abernathy said, as her mother hovered beside her. “We can’t keep a hospital. What is our community coming to?”
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