By Kylie Marsh for the Charlotte Post, with support from the Pulitzer Center on Crisis Reporting.
Broadcast version by Shanteya Hudson for North Carolina News Service reporting for the Charlotte Post-Public News Service Collaboration.

Amirah McCree planned to deliver her second child, Yara, at a hospital in Pineville. She immediately felt rushed by the all-white nursing staff.

Because delivery required an induction, McCree, a Charlotte paralegal, did her research. She knew she did not want to take pain medication, because it would make labor harder and faster. She was able to convince the nurses to go with a different induction method, but "they still felt it wasn't going fast enough."

There is growing awareness of the medical racism Black women like McCree have faced during pregnancy.

"[The nurse] literally said, 'we're here to have a baby,'" McCree said. "It scared me a little...even though I tried to advocate for myself, it still went nowhere. It was really scary because you're in a hospital bed and you can't say, 'I don't like this, I want to leave.'"

The nurses then asked McCree's family to leave the delivery room.

"When they left, it was just me, the nurses and the midwife," McCree said. The nurse then informed McCree that she'd check her cervix, and proceeded to perform an amniotomy, which is manually breaking the amniotic membrane.

"I know what a cervix check feels like. She went further," McCree said. "She swiped my fluid, and when I tried to stop her, the nurses held my hands. It was completely traumatic."

McCree never returned to the hospital, and has trouble recollecting what followed due to blocking out the memory.

In the U.S., Black women are far more likely than white women to report that health care providers scolded, threatened, or shouted at them during childbirth, research shows.

In April, the Charlotte-based nonprofit Care Ring hosted a panel discussion during Black Maternal Health Week, a national initiative geared toward tackling the high rates of death for Black mothers and their babies. There, healthcare professionals Jonisha Brown and Keyona Oni shared their stories about receiving sub-par medical care.

A 2016 survey of medical students and residents found that half held false beliefs about biological differences between Black and white people, including that Black people feel less pain. That belief is just one factor that can cause bias and lead to inaccurate treatment recommendations or clear medical neglect in patients of color.

"We recognize that there is a trust breach that has occurred in healthcare. That trust breach is present, that there is implicit bias, and certain things we took as dogma," said Noellee Clarke MD, a OB-GYN at Novant Health who is Black. "During my residency, they'd talk about the number one risk factor for preterm labor and preterm delivery, and by de facto, it was Black maternal risk.

"It was no more risk factors. The only other would have been prior history of what the condition is, but back then it was, there's a race-based system."

Implicit bias is just one piece of the larger Black maternal and infant mortality puzzle. In addition to lifelong trauma and generational distrust of the medical community, a history of neglect and malpractice are significantly more deadly for women of color.

According to the federal Centers for Disease Control and Prevention, the maternal mortality rate for non-Hispanic Black women in 2021 was 69.9 deaths per 100,000 live births, 2.6 times the rate for white women.

Rates for Black women were significantly higher than rates for their white and Hispanic peers. The increases from 2020 to 2021 for all race and Hispanic-origin groups were significant.

In North Carolina, the maternal death rate is higher than the U.S. average. In 2021, the state's maternal mortality rate was 44 deaths per 100,000 births, according to CDC data compiled and analyzed by the investigative news organization MuckRock.

North Carolina's Maternal Mortality Review Committee's report on North Carolina reported that more than 85% of those deaths were preventable, and discrimination was the leading probable contributing factor in nearly 70% of cases.

Bias and discrimination went beyond race or ethnicity, and included weight, geography, substance use, history of incarceration, and other factors.

Panelists at Care Ring's Black Maternal Health Conference in Charlotte addressed issues relating to maternal and infant mortality in addition to implicit bias, like lack of access, poor policy, and the threat of reduced funding for programs aimed at certain demographics.

Other issues that can contribute to maternal mortality are connected to housing insecurity and intimate partner violence. Clarke explained Novant's three-tiered strategy geared toward increasing ease of access for expecting mothers.

The strategy focuses on social determinants of health, personable care and early prenatal care.

"The reality is we don't live in a vacuum," she said. "As patients and as human beings, we each interact with the world, and each patient's world looks different."

Social determinants of health include access to transportation, nutritious food, safe housing, education and community support.

In 2023, Novant reported that each month, an average of 3,000 patients screen positive for food insecurity at Novant Health medical group clinics, with 400 to 600 patients not having food on a given day.

Novant has set up partnerships to address inequities, like referring patients to the nonprofit food bank Nourish Up and providing free transportation with a community health worker to and from the food bank. It includes new and expecting mothers.

Clarke compares trying to change social determinants of health to boiling the ocean.

"It's on us as healthcare workers to help make these outcomes better for our patients," she said. "We have the ability to have influence and we can directly make a difference for our patients."

Earlier access to care is crucial, especially in a country where access to family planning care is becoming increasingly hard to find. Clarke says that's why it's important to get care as early as possible.

"We need to be more aware of our pregnant population," she said.

McCree's experience at Novant Health Ballantyne Medical Center is the opposite of Pineville.

McCree's mother and grandmother faced life-threatening complications with their third birth. Their experiences were on her mind since her son, Noah, would be her third.

"It's really scary as a mother of color to go into institutions where you know there is a prior history of being discriminated against," she said.


"It was like everyone was passing the baton. There was never a lapse," McCree said.

Nurses tried a bulb induction, where a balloon is filled with fluid to stretch the cervix to a safe diameter before the mother can push. However, the baby still wasn't coming. Having been traumatized from her previous experience, McCree refused to let Swiyyah perform an amniotomy.

While the nurses and McCree were weighing a switch to Pitocin, a pain medication that causes faster and harder contractions, Noah was born.

McCree is part of a Facebook group for Black mothers in Charlotte, where people frequently ask for recommendations on Black doctors.

"That comes from a sense of fear that if you don't have someone who looks like you, the likelihood of you being treated normal - not special, just normal - might not be given," she said.

While there are public-private partnerships meant to address historic harms to Black moms, it is still significant. As long as it exists, it will continue to sow distrust.

"I think it's hard to ask how do you remove fear from places that have created the fear," McCree said. "I think that'd be a better question for the people that created the fear in the first place."


Kylie Marsh wrote this article for the Charlotte Post.


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Hundreds of thousands of older Californians will see huge savings on prescription drugs starting in January, according to a new report from AARP.

The Biden administration's Inflation Reduction Act caps prescription drug costs at $2,000 per year for people on Medicare, starting in 2025.

Nina Weiler-Harwell, associate director of advocacy and community engagement for AARP California, said an estimated 271,000 people in the Golden State will hit the out-of-pocket maximum next year.

"Medicare drug plan enrollees nationwide who reach the new out-of-pocket cap will see an average savings of roughly $1,500," said Weiler-Harwell, "or 56% in 2025 for new prescription drugs."

On average, 40% of people on Medicare who reach the cap will save at $1,000 a year. And 12% will see savings of more than $3,000.

Every year from 2025 to 2029, between 3 and 4 million Part D plan enrollees are estimated to benefit from the new out-of-pocket cap.

Weiler-Harwell said the Inflation Reduction Act introduced a number of new policies to cut costs for Americans on Medicare.

"Copays for insulin capped at $35 a month," said Weiler-Harwell. "Vaccines such as shingles and pneumonia are free. The Inflation Reduction Act did allow Medicare to negotiate the price of high-cost prescription drugs. But we won't really start to see that until 2026."

Also thanks to the IRA, drug companies will have to pay a penalty if they raise their prices higher than inflation.

As Congress heads back to work after the August recess, advocates for the nation's safety net Community Health Centers are urging lawmakers to end Big Pharma's roadblock on discounted medicines through a federal program known as 340B.

Donald Moore, CEO of Pueblo Community Health Center, said by denying discounts, drug companies are withholding critical resources to help centers serve a growing number of patients who cannot afford to pay.

"That $1.5 million now is staying in their pockets," Moore pointed out. "It's not going into my organization's charitable mission to provide access to care."

The roadblock comes as more Coloradans, who have been dropped from Medicaid coverage, turn to centers serving all patients regardless of their ability to pay. Drugmakers have claimed discounted medicines are being diverted to patients not eligible under 340B, or savings are not being used to expand access to health care.

Justin Hanel, director of pharmacy for Valley Wide Health Systems, which serves southern Colorado, said even with discounts, drug prices have gone up by 200% over the past five years. He emphasized all patients filling Valley Wide prescriptions are eligible under 340B, even if they get them at their contracted pharmacies making it easier for people living in remote areas to access medicines.

"The intent was so that it would enable entities like ourselves to stretch scarce federal resources as far as possible," Hanel explained. "Reach more eligible patients and provide more services."

Moore pointed to a third-party audit, which showed his center is in full compliance with 340B but he said no one has asked to see his books. He said denying discounts nationwide will ultimately end up hurting patients, and taxpayers, if people with chronic conditions such as diabetes, hypertension or depression cannot access medicines.

"Someone who doesn't have access to the medicines they need to control chronic conditions is at greater risk of going to the ER, being admitted to the hospital, and having complications associated with that," Moore emphasized.



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By Tony Leys for KFF Health News.
Broadcast version by Mark Moran for Iowa News Service reporting for the KFF Health News-Public News Service Collaboration

Rural regions like the one surrounding this southern Iowa town used to have a lot more babies, and many more places to give birth to them.

At least 41 Iowa hospitals have shuttered their labor and delivery units since 2000. Those facilities, representing about a third of all Iowa hospitals, are located mostly in rural areas where birth numbers have plummeted. In some Iowa counties, annual numbers of births have fallen by three-quarters since the height of the baby boom in the 1950s and ’60s, when many rural hospitals were built or expanded, state and federal records show.

Similar trends are playing out nationwide, as hospitals struggle to maintain staff and facilities to safely handle dwindling numbers of births. More than half of rural U.S. hospitals now lack the service.

“People just aren’t having as many kids,” said Addie Comegys, who lives in southern Iowa and has regularly traveled 45 minutes each way for prenatal checkups at Oskaloosa’s hospital this summer. Her mother had six children, starting in the 1980s, when big families didn’t seem so rare.

“Now, if you have three kids, people are like, ‘Oh my gosh, are you ever going to stop?’” said Comegys, 29, who is expecting her second child in late August.

These days, many Americans choose to have small families or no children at all. Modern birth control methods help make such decisions stick. The trend is amplified in small towns when young adults move away, taking any childbearing potential with them.

Hospital leaders who close obstetrics units often cite declining birth numbers, along with staffing challenges and financial losses. The closures can be a particular challenge for pregnant women who lack the reliable transportation and flexible schedules needed to travel long distances for prenatal care and birthing services.

The baby boom peaked in 1957, when about 4.3 million children were born in the United States. The annual number of births dropped below 3.7 million by 2022, even though the overall U.S. population nearly doubled over that same period.

West Virginia has seen the steepest decline in births, a 62% drop in those 65 years, according to federal data. Iowa’s births dropped 43% over that period. Of the state’s 99 counties, just four — all urban or suburban — recorded more births.

Births have increased in only 13 states since 1957. Most of them, such as Arizona, California, Florida, and Nevada, are places that have attracted waves of newcomers from other states and countries. But even those states have had obstetrics units close in rural areas.

In Iowa, Oskaloosa’s hospital has bucked the trend and kept its labor and delivery unit open, partly by pulling in patients from 14 other counties. Last year, the hospital even managed the rare feat of recruiting two obstetrician-gynecologists to expand its services.

The publicly owned hospital, called Mahaska Health, expects to deliver 250 babies this year, up from about 160 in previous years, CEO Kevin DeRonde said.

“It’s an essential service, and we needed to keep it going and grow it,” DeRonde said.

Many of the U.S. hospitals that are now dropping obstetrics units were built or expanded in the mid-1900s, when America went on a rural-hospital building spree, thanks to federal funding from the Hill-Burton Act.

“It was an amazing program,” said Brock Slabach, chief operations officer for the National Rural Health Association. “Basically, if you were a county that wanted a hospital, they gave you the money.”

Slabach said that in addition to declining birth numbers, obstetrics units are experiencing a drop in occupancy because most patients go home after a night or two. In the past, patients typically spent several days in the hospital after giving birth.

Dwindling caseloads can raise safety concerns for obstetrics units.

A study published in JAMA in 2023 found that women were more likely to suffer serious complications if they gave birth in rural hospitals that handled 110 or fewer births a year. The authors said they didn’t support closing low-volume units, because that could lead more women to have complications related to traveling for care. Instead, they recommended improving training and coordination among rural health providers.

Stephanie Radke, a University of Iowa obstetrics and gynecology professor who studies access to birthing services, said it is almost inevitable that when rural birth numbers plunge, some obstetrics units will close. “We talk about that as a bad event, but we don’t really talk about why it happens,” she said.

Radke said maintaining a set number of obstetrics units is less important than ensuring good care for pregnant women and their babies. It’s difficult to maintain quality of care when the staff doesn’t consistently practice deliveries, she said, but it is hard to define that line. “What is realistic?” she said. “I don’t think a unit should be open that only delivers 50 babies a year.”

In some cases, she said, hospitals near each other have consolidated obstetrics units, pooling their resources into one program that has enough staffers and handles sufficient cases. “You’re not always really creating a care desert when that happens,” she said.

The decline in births has accelerated in many areas in recent years. Kenneth Johnson, a sociology professor and demographer at the University of New Hampshire, said it is understandable that many rural hospitals have closed obstetrics units. “I’m actually surprised some of them have lasted as long as they have,” he said.

Johnson said rural areas that have seen the steepest population declines tend to be far from cities and lack recreational attractions, such as mountains or large bodies of water. Some have avoided population losses by attracting immigrant workers, who tend to have larger families in the first generation or two after they move to the U.S., he said.

Katy Kozhimannil, a University of Minnesota health policy professor who studies rural issues, said declining birth numbers and obstetric unit closures can create a vicious cycle. Fewer babies being born in a region can lead a birthing unit to shutter. Then the loss of such a unit can discourage young people from moving to the area, driving birth numbers even lower.

In many regions, people with private insurance, flexible schedules, and reliable transportation choose to travel to larger hospitals for their prenatal care and to give birth, Kozhimannil said. That leaves rural hospitals with a larger proportion of patients on Medicaid, a public program that pays about half what private insurance pays for the same services, she said.

Iowa ranks near the bottom of all states for obstetrician-gynecologists per capita. But Oskaloosa’s hospital hit the jackpot last year, when it recruited Taylar Swartz and Garth Summers, a married couple who both recently finished their obstetrics training. Swartz grew up in the area, and she wanted to return to serve women there.

She hopes the number of obstetrics units will level off after the wave of closures. “It's not even just for delivery, but we need access just to women's health care in general,” she said. “I would love to see women's health care be at the forefront of our government's mind.”

Swartz noted that the state has only one obstetrics training program, which is at the University of Iowa. She said she and her husband plan to help spark interest in rural obstetrics by hosting University of Iowa residency rotations at the Oskaloosa hospital.

Comegys, a patient of Swartz’s, could have chosen a hospital birthing center closer to her home, but she wasn’t confident in its quality. Other hospitals in her region had shuttered their obstetrics units. She is grateful to have a flexible job, a reliable car, and a supportive family, so she can travel to Oskaloosa for checkups and to give birth there. She knows many other women are not so lucky, and she worries other obstetrics units are at risk.

“It’s sad, but I could see more closing,” she said.


Tony Leys wrote this story for KFF Health News.


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