Photograph by Kevin C. Cox/Getty Images
The morning after news breaks that Atlanta Medical Center would be abruptly closing its doors, the hospital’s hallways are practically vibrating with anxious energy. Walking from the parking deck across the pedestrian bridge and into the main hospital campus, I pass dozens of hospital employees in scrubs and white coats, nearly all of whom are either huddling in corners with colleagues or fervently talking on their phones.
At my prenatal visit, the medical assistant taking my blood pressure tells me that she and her colleagues found out the same way the rest of us did: by reading it in the news.
“We were blown away,” says Margaret Strickhouser, who founded Intown Midwifery, one of the only midwife-led groups in the city, in 2009. The story ran on August 31, and the following day, Wellstar sent out a letter confirming that the hospital would shut down on two months later on November 1. The news sent Intown Midwifery (and other AMC-based practices) scrambling to figure out a plan: the group would need to establish privileges at another hospital (a process that typically takes about 90 days), find a new office space, and potentially plan an office move, all while fielding anxious phone calls from patients and maintaining continuity of care, particularly for those with due dates in the month or two ahead.
A month later, I’m back at AMC for another appointment. This time, the atmosphere in the hospital hallways is noticeably more withdrawn, but stepping inside Intown Midwifery’s waiting room, the mood is much more somber: I’m there the morning after the practice has announced that after 13 years, they would be closing their doors permanently. “We’ve been faced with an impossible timeline to navigate and have explored every option we have to move forward with no attainable solution,” the announcement sent out to patients read. “Therefore, it is with heavy hearts and great sadness that we have to announce the closure of the practice.”
The same medical assistant from last time is drawing my blood today, and I ask her how she’s holding up in light of the news. As she talks about how her work and her patients have become a huge part of her life over the years, she starts crying.
• • •
Midwives have been helping women give birth for centuries. In more recent years, a growing body of research has established what many midwives have known for years: the midwifery model of care, characterized by a holistic and low-intervention approach, is statistically shown to result in better outcomes for both mothers and infants in low-risk births. About two-thirds of the way through my first pregnancy, I transferred from a typical obstetrical group to Intown Midwifery—not because I was specifically set on an unmedicated birth, but because I was drawn to the midwifery model’s emphasis on allowing women to have more options for their labor, as well as AMC’s progressive policies around labor and delivery. I benefited from some of those policies even when I had to pivot to a C-section after all: instead of being whisked away after he was delivered, my newborn son was immediately placed on my chest for skin-to-skin contact while I was still on the operating table—a practice with numerous proven benefits for both mom and baby, yet one that many hospitals still don’t offer in their O.R.
But the midwifery model is a challenging one to keep afloat in a for-profit healthcare system, where surgeries (like C-sections) are more profitable than vaginal births. Strickhouser tells me that Intown Midwifery had about an 11-12 percent C-section rate, compared to the national average of about 30 percent. (Georgia’s rate, at 33.9 percent, is higher than most of the country.)
“We always felt like we were a part of a system that was not designed for us,” says Kristie Picklesimer, who has worked as Intown’s patient coordinator for 11 years. “People would always ask me, ‘Why aren’t there more models like this? It just makes sense. It’s smart. It’s safe. It’s effective. It’s evidence based.’ And the only answer we all could come up with was, because it’s not a great business model.” She adds that this year alone, two other Atlanta-area midwifery practices, Lifecycle OB-GYN and Marsha Ford’s practice based at the now-shuttered Wellstar East Point, have closed their doors, too.
The abrupt timeline of AMC’s closure made those pre-existing challenges insurmountable. “Nothing in the corporate world moves quickly,” says Picklesimer. “When you’re talking about getting hospital privileges, moving your office, getting the word out to patients, that’s a lot of legwork and a lot of expense that no one’s rushing in to help fund.”
Strickhouser, who has worked as a nurse midwife for 48 years and has delivered roughly 6,000 babies over the course of her career, founded Intown Midwifery after having spent nearly two decades making the 60-mile round trip from her home in Grant Park to North Fulton Hospital in Roswell. (“When they opened GA-400, I was the first person to get a cruise card,” she jokes.)
In her time at North Fulton, Strickhouser introduced the practice of water birth, and attended the first hospital water birth on record in the state of Georgia. When her employer announced a move further north to Northside Forsyth, she decided to set up shop closer to home at Atlanta Medical Center. Strickhouser met with the administrator of the hospital (which at the time was owned by Tenet Healthcare), and asked for leeway in bringing some different policies to the hospital’s labor and delivery unit. “I told him I felt like I could change the face of this hospital,” she tells me.
Over the next decade, Strickhouser and her colleagues worked to change the way women could give birth at AMC, which became one of the only hospitals in the metro to offer options like water birth and the only hospital in the metro to offer water birth to women having a vaginal birth after a previous C-section, or VBAC. Meanwhile, women looking for those options came to Intown from across the metro and even from across state lines. “It was the hardest 13 years of my career,” Strickhouser says. “I pressed on, because it’s the way I’ve always practiced and what I always believed in, which is empowering women to have a choice.”
• • •
Intown Midwifery is one of the first independent businesses forced to close its doors because of the hospital closure, but experts worry it won’t be the last. And that potential trickle-down loss of providers will ultimately make it harder for people to access the necessary healthcare that can prevent later crises—the kind of crises that might land someone in a Level One trauma center, of which the City of Atlanta now only has one, or the kind of crises that contribute to Georgia’s maternal mortality rate, which is among the worst in the country.
“When these hospitals close, it’s not just emergency rooms closing,” says Elizabeth Mosley, a public health researcher and affiliated faculty at Emory’s Center for Reproductive Health Research in the Southeast (RISE). “It’s midwifery access, it’s cardiovascular care access, it’s primary care. Think about all of the primary care clinics whose providers were associated with AMC . . . who will no longer be able to offer the cardiovascular care, or diabetes management, that could make pregnancy healthier and safer for people.”
Researchers don’t yet know what immediate or long-term impact AMC’s closure might have on the community it served. But the loss of both preventative and emergency services to an underserved population, not to mention a labor and delivery unit, is concerning in the context of maternal mortality. “For every one maternal death we see, there’s at least 100 near-misses,” explains Mosley. “Those are the moments when ten minutes, 20 minutes is life or death. And if people can’t get to an ER that can take them, then you could see that near-miss turn into a maternal death.”
Kyesha Lindberg, the executive director of Healthy Mothers Healthy Babies Coalition of Georgia, worries that the loss of AMC could make it harder for women with chronic postpartum morbidities to access ongoing specialty care. “If there are transportation concerns, or other social determinants that inhibit someone’s ability to get to a different facility, a chronic condition that they could [previously] manage now may result in far more tragic implications,” she says. Asking patients to rebuild trust in an unfamiliar setting, Lindberg adds, presents yet another barrier. “What I think this particular case reaffirms, which a lot of us who have been in the space already know, is that access to care is not just aligned with geography.”
“It unsettles me just thinking about it,” says Mosley, who also works as a doula. “One of the major things about an urban healthcare center like AMC closing is that it does predominantly serve lower income people of color living in the city center,” she says. “And so, to lose a medical system of this size from the city itself is a major issue because we know the majority of maternal deaths are happening among women of color, who are more likely to live in urban centers.”
Structural challenges could make it difficult for these patients to get care at other hospital systems in the metro area, she adds: more suburban hospitals are less accessible via public transportation, and also have lower inclusivity ratings than AMC. “This hospital was serving folks who felt more comfortable there,” Mosley explains. “And now all of those people are having to be diverted away.”
• • •
Without a clear timeline from Wellstar outlining which hospital services would shut down when, Intown Midwifery designated their own plan to wind down care for patients: for expectant mothers who wished to stay with the practice, they could support births through October 10. “We came up with our own timeline to keep our patients safe,” explains Picklesimer: the practice did not want to attend births without the assurance that other hospital services would be available, or risk an understaffed labor and delivery unit. “It would’ve been nice too to have more money coming in at the end to help pay all the expenses of abruptly closing the practice,” she adds, “but safety was more important for us.” She tells me that the practice’s last three births all coincided on the same weekend, and everyone was healthy.
When we spoke, Picklesimer shared that only one Intown employee—the medical assistant—has lined up a new position elsewhere. “There’s a lot involved for a provider to be able to switch jobs,” she explains. “The interview process is quite extensive. They have to provide a lot of information and go through multiple interviews. And then they have to get privileges.”
As for the group’s patients, many have decided to move to Providence Women’s Healthcare, which offers perhaps the most similar model of care to Intown, but further away: the group’s offices are in Roswell, Norcross, and Sandy Springs. I too transferred to Providence after researching how limited the options are for truly VBAC-supportive practices inside the city limits. If all goes well, I’ll deliver with Providence at North Fulton Hospital—another hospital owned by Wellstar—which is a 30-mile drive from my house in East Lake. Fortunately, I have the transportation and flexibility to make the treks outside the perimeter for my appointments (which will eventually become weekly). Other Atlantans who are seeking that kind of care, but who rely on MARTA or whose jobs won’t accommodate lengthy trips to faraway doctor’s offices, are now left without many other options.
“I hate the fact that a real option for midwifery care is now gone,” Strickhouser says. “I was so grateful that there was a hospital that would allow me to be able to offer true midwifery care, and offer women choices. Most places, that’s not available. There’s a real dearth of choices here.”
