Dr. Ethan Gable regularly travels about 40 miles, making the nearly hour-long drive between two hospitals in Northcentral Pennsylvania, where he works as an obstetrician and gynecologist, or OB/GYN.
Gable serves as one of three OB/GYNs at both UPMC Wellsboro in Tioga County and UPMC Cole in Potter County.
“Absolutely, it's a priority,” said UPMC North Central PA market president Patti Jackson of providing these services to rural patient populations. “Out of the challenges that face us comes innovation.”
Gable and his colleagues provide care that’s become harder to find in Pa.’s rural counties.
According to the Center for Rural Pennsylvania, 23 of Pennsylvania’s 67 counties do not have a hospital offering labor and delivery services. And all 23 of those counties are classified by the Center as rural.
The decrease of obstetric care
The Chartis Center for Rural Health, part of the Chartis Group, releases an annual “state of the state” report on the nation’s rural health.
This year’s report found that between 2011 and 2024, Pennsylvania lost 42% of its rural obstetrics units, the third highest in the country.
“When we ask CEOs why, it's very expensive, it's very risky and increasingly difficult to provide the high level of service and technology and everything else that's needed to go along with that care,” said Michael Topchik, the executive director of the Chartis Center for Rural Health.
Topchik said the loss of specialized services like obstetrics is generally an indicator of the rural hospitals’ financial situation.
“We haven't seen a statistical correlation, but we do see alignment directionally. I use the term bellwether, it's a canary in a coal mine, so to speak. Because what's happening is, hospitals are struggling to maintain a positive margin, and they shed services in order to protect their financial position,” Topchik said.
The motivation for closure is not always financial, though.
“Part of the [operational] challenge has been that the birth rates have been declining,” Gable said. “We need a certain volume, even just from the clinical space to keep competencies.”
UPMC Cole stopped its labor and delivery services in April last year
and now directs patients to UPMC Wellsboro. Gable accommodates both patient populations, with the ultimate goal being the health of mothers and babies.
“Say it's a Cole patient, she can physically go into our office, she sees the nurse, she gets her vital signs, she gets everything that she would normally do, and then she actually remotes in to see me at another hospital,” Gable said. “That's leveraging technology, that's kind of bringing care where patients are, and so we try to make sure that if there's any level of coordination, it's only towards the coordination of delivery and having that conversation with patients.”
Pennsylvania’s expanding maternity care desert
With the closure of Warren General Hospital’s labor and delivery unit in Warren County, the Center for Rural Pennsylvania said the state’s maternity care desert is growing.
“There's a total of eight contiguous counties, which are home to around 35,000 women in the childbearing age who now lack local labor and delivery services. To put that into perspective, that eight-county region is larger than the size of Connecticut,” said Zachary Adams, the executive director of the Center for Rural Pennsylvania.
Those eight counties are: Cameron, Clarion, Clinton, Elk, Forest, McKean, Potter and Warren.
In WVIA’s coverage area, the following counties do not have labor and delivery units, according to the Center for Rural Pennsylvania: Susquehanna, Sullivan, Wyoming, Carbon, Pike, Northumberland, Carbon and Snyder.
The Center found that residents of counties without labor and delivery services travel an average of 27 miles to the nearest hospital with that service. For someone in Susquehanna County, it would be about 42 miles to Regional Hospital of Scranton. For someone in Wyoming County, the distance to Regional would be about 23 miles. This does not account for pre- or post-natal care. Many health systems, like UPMC, have outpatient locations.
“We're meeting the patients where they are, and then as we get closer to the inpatient stay, that's where some of the coordination comes in. That's where the regionalized approach comes in, to where we're now kind of managing that level of care, that inpatient coordination and a larger geographic spread,” Gable said.
The widening access gap for rural Pennsylvanians can stress urban health, too.
“You could imagine a scenario where those doctors in the remaining labor and delivery units are seeing an increase in their patient load, and not every birth goes to plan. And so we might expect to see an increase in emergency department cases where those ER physicians are the ones that are having to handle sort of emergent issues that can arise with pregnancy,” said Zachary Adams, the executive director of the Center for Rural Pennsylvania.
Disproportionate impact on rural areas
There are significantly fewer OB/GYNS in rural Pennsylvania than in the state’s urban areas.
Kaitlyn Goode, a data visualization specialist at the Center for Rural Pennsylvania, said that according to 2023 data from the Health Resources and Services Administration, there were 6 OB/GYNs per 100,000 population in rural Pa. compared to 16 per 100,000 in urban Pa.
In UPMC’s Northcentral Pa. region, there are 38 OB-GYN providers, including physicians, certified midwives, nurse practitioners and physician assistants.
Thirty-two of those providers work in Lycoming County, and six are spread across Potter and Tioga Counties.
Topchik fears that the disproportionate impact on rural areas could get worse with coming changes to healthcare.
“We're very, very concerned about cuts to Medicaid, which our analysis shows for the median rural hospital, 10% of their patients are covered under Medicaid. The majority of births in this country are paid for by Medicaid. So cuts there are going to disproportionately impact rural health care, because we have a higher percentage of Medicaid enrollees in rural areas,” Topchik said.
The Medicaid changes implement work requirements, with exemptions for certain groups, including pregnant people, individuals with disabilities and caregivers. There will also be more frequent eligibility checks. Most changes will go into effect on Jan. 1, 2027.
KFF Health News found that over 10 years, federal Medicaid spending is expected to be reduced by $911 billion. The changes are estimated to increase the number of uninsured Americans by 7.5 million by 2034. In rural areas, KFF estimates that federal Medicaid spending will decline by $137 billion. In Pennsylvania, that number is estimated to be around $5.5 billion.
KFF Health News found that over 10 years, federal Medicaid spending is expected to be reduced by $911 billion. The changes are estimated to increase the number of uninsured Americans by 7.5 million by 2034. In rural areas, KFF estimates that federal Medicaid spending will decline by $137 billion. In Pennsylvania, that number is estimated to be around $5.5 billion.
Combatting shortages and gaps in women’s health
UPMC utilizes telemedicine to alleviate patients’ travel stress.
“We have telemedicine set up so that a patient can, if they don't want to drive to Wellsboro, they can set up an appointment with me. I do bounce back and forth, and they're really just given the option. So if they prefer to see me in person, and they want to drive to the location I'm at, they're free to do that, or they're also saying, oh, you know what? I live this distance away, why don't we do a telemedicine visit,” Gable said.
UPMC also started a new residency model to help meet the need for rural obstetric care.
“In our current family medicine residency program, we have our residents train alongside with our women's health teams, and they do get experience in obstetrics and women's care and labor and delivery… So family medicine providers can also provide some OB coverage,” Jackson said.
Topchik sees the Rural Health Transformation Program as an area of opportunity for rural maternal health. The program will give $50 billion to the states over five years. Pennsylvania received $193 million this year from the program.
“With the Rural Health Transformation funding, there will be a great deal of energy and money spent around maternal care, and that is from hiring. It's from training various obstetrics-related care workers and also looking at new models of investing in telehealth. We've even seen areas of interest with mobile units providing obstetrics care,” Topchik said.
