“Will we make it to the hospital in time?” That’s one of the big questions faced by young families living on Outer Cape Cod and expecting a baby.
As intimidating as Route 6 traffic can be in the summer, it turns out that there are even more daunting issues facing prospective parents here — including a lack of prenatal care and childbirth alternatives and the distance to the nearest neonatal intensive care unit in case of complications.
Cape Cod Hospital (CCH) in Hyannis has the closest birthing center, but it’s 47 miles from Provincetown on Route 6 — an hour and 15 minutes’ drive even without summer traffic. “I joked that I’d be giving birth on Route 6,” said Sadie Hutchings, who delivered her first child, a girl named Juniper, on July 21 at CCH after a 90-minute ride in Saturday morning traffic.
It’s not all about the distance. After all, many Outer Cape residents cherish its remoteness. More important to many young parents here is access to a more holistic approach to prenatal care and childbirth.
For years, many expectant parents bypassed CCH for even more distant hospitals because they offered birthing options that weren’t available in Hyannis, including women obstetricians. The hospital has made changes, however, like adding a midwifery program, that have made its “Family Birthing Place” more attractive, according to Ruby Anastasio, a certified birth doula who has worked with families on the Cape for nearly two decades.
Doulas are not midwives. Hired by families independently, they work alongside medical providers to educate parents on birth options and to provide emotional and physical support during labor. Anastasio is one of several certified doulas now offering their services to families on the Outer Cape.
“We love doulas,” said Corey Signs, a midwife in CCH’s obstetrics and gynecology practice. “The biggest thing in labor is support around you. Doulas are so well-versed in being that support system.”
Doulas make a difference
Given the dwindling number of young adults able to make a life on the Outer Cape, it may seem as if birthing facilities are not among the area’s most pressing medical needs. But ask younger residents here and they’ll tell you that if these outermost
towns are going to survive as year-round communities they must address the issue. In 2018 a total of 59 babies were born to families living here: 15 births were recorded in Provincetown, 8 in Truro, 15 in Wellfleet, and 21 in Eastham.
CCH was the obvious choice for Hutchings, a veterinarian who lives and works in Provincetown. “While I have heard excellent things about other hospitals just off Cape, distance made the closest hospital the best option for me,” she said.
Fortunately, emergency births in an ambulance or car aren’t as frequent as expectant parents fear, nor do families tend to feel the need to call an ambulance to get to the hospital. According to Theresa Townsend of Wellfleet Fire and Rescue, “Most get there on their own. We might see a birth in an ambulance every two to three years on the Outer Cape.”
Anastasio said that, while most families are concerned about the drive to the hospital, extremely fast births are rare and, when they do happen, uncomplicated.
“Only one of my clients had a precipitous labor,” she said. “Her baby was born in the parking lot of the fire department in Eastham. By the time the EMTs came, the baby’s head was out already. The baby was healthy and did great. It’s the babies who have to endure long, slow labors that tend to suffer more complications.”
In spite of the fact that the distance to the hospital is rarely an issue, doulas make a difference by alleviating parents’ anxiety about the long trip.
“I take a lot of time explaining the stages of labor to my clients,” said Anastasio, “and watch carefully for signs of labor progressing, especially in women living on the Outer Cape. I provide support at home and during the drive as soon as a woman feels that she needs me. We try to leave the home not too soon, but before labor progresses too far. A drive during active labor can be very challenging.”
Anastasio lauded recent changes at CCH, including the focus on midwifery care and the introduction of nitrous oxide as a patient-controlled option for relaxation and pain relief in labor. She said she sees fewer families in recent years choosing to go off Cape for births.
The real problem: lack of prenatal care
Lisa Holmes, a Brewster native who has lived in Wellfleet for the past 10 years, gave birth to her first son at CCH in 2016 and is due to deliver a baby girl in September. “I love their midwifery program,” she said. But she sees a significant problem in the lack of a prenatal program at Outer Cape Health Services (OCHS). She has to go to Hyannis for all her appointments — not a happy prospect in August.
The option of home birth on the Outer Cape is offered by just one certified professional midwife: Rebecca Taylor of Wellfleet, who runs a mom-and-baby group in Provincetown. “I think it’s a hardship on a lot of Outer Cape families that prenatal care happens so far up Cape,” she said.
Eastham resident Kimberly Anne Kaplowitz, who gave birth to her first daughter in February 2019, was under the care of midwife Meredith Goff at OCHS for the first half of her pregnancy. “I loved her,” Kaplowitz said, “but she retired last October.” Kaplowitz felt frustrated that her only options for prenatal care were Cape Cod Hospital or traveling even further away.
Patricia Nadle, the CEO at Outer Cape Health, acknowledged the problem but said that in spite of a lengthy search OCHS was not able to find a replacement for Goff. “We were looking for almost a year and had no one who had interest, so we decided that the best thing to do was collaborate with Cape Cod Healthcare,” said Nadle. “Patients at OCHS are now, unless they request otherwise, referred to Cape Cod Hospital for their prenatal care and birth.”
Nadle admitted that there is no active effort to re-establish a prenatal program on the Outer Cape. “The root is the demographic changes occurring in the Outer Cape towns,” she explained. “With younger people leaving our towns, and the mean age rising, aging is driving the need in health care.” Statistics confirm this trend: 2010 saw 78 births recorded on the Outer Cape, 19 more than in 2018.
Nadle named two other hospitals regularly chosen by some OCHS patients for birthing: Beth Israel Deaconess in Plymouth and Tobey Hospital in Wareham. Anna Wyoma Jordan, who lives in Eastham, gave birth to her daughters in 2014 and 2017 with Louise Bastarache, a certified midwife and nurse practitioner at Tobey. Bastarache established her practice in 1998 and offers what she calls a holistic, personalized approach to birth.
“I ended up driving all the way off Cape for my births because that was the only way I felt I could have the birth I wanted,” Jordan said. “Giving birth with Louise was the best choice I could have made. I saw her at every checkup, and she stayed with me and my husband throughout my entire labor.”
Jordan almost gave birth to her second daughter, Eleanor, in the car on the way to Wareham. “By the time we got to the rotary in Orleans,” she said, “still an hour away from Tobey, I was on my knees in the passenger seat of the car moaning and my husband kept saying, ‘I’ll pull over — if we need to give birth at a rest stop, that’s fine.’ ” They made it safely to the hospital, where Jordan gave birth a mere 50 minutes later.
The NICU dilemma
The most serious concern of local birthing experts is the absence of a neonatal intensive care unit (NICU) on Cape Cod. Complications in childbirth can be harrowing and their aftermath highly stressful.
“Few people expect to have a NICU stay,” said Liz Libby of Brewster, a certified doula and lactation consultant. “Nearly any NICU experience is traumatic, involving being separated from your baby and having way more scary medical interventions done to your baby than you ever wanted.”
The distance from the Outer Cape to a NICU in Boston can precipitate a crisis. “Families either have to put their entire lives on pause to be near the hospital or have to make the long commute to the city just to visit their baby,” said Libby. “In the case of an extended NICU stay, this can be devastating, both financially and emotionally.”
Libby said the Outer Cape families she has worked with tend to be resourceful. “I hear families lament having to go to Boston for more complex prenatal care,” she said, “but they make it work as best they can, planning carefully for the long ride to the hospital in a million creative ways.”
Dr. Tara Chute, an obstetrician-gynecologist at CCH, described how the hospital handles an unexpected premature birth or the birth of a full-term baby needing specialized care. “There is always a midwife on the labor floor, 24 hours a day and 365 days a year, so that when a patient comes in in a very urgent scenario, there is no delay in care,” Chute said. The hospital also has pediatric hospitalists from the Floating Hospital for Children at Tufts Medical Center on staff around the clock. But there is no high-risk obstetrics specialist on staff.
In an emergency, either the laboring mother or the newborn must be transported to Boston. “We make a fairly quick medical assessment as to whether the patient needs to be delivered here or off Cape,” said Chute. “We try not to deliver patients before 35 weeks because there is a high risk of the baby needing neonatal care. If the patient is stable, we transport them to another facility that has a NICU, usually by ambulance and rarely by medflight.”
If a newborn needs special care, the Tufts hospitalists provide it until a NICU team arrives with the equipment and skills needed for transport to the city.
Wellfleet resident Katy Escher-Jacob was due to give birth to her second son in February 2018. She unexpectedly went into labor at 28 weeks, 12 weeks early, in late November 2017 and had an emergency delivery at CCH.
“The midwife and doctors were amazing and made me feel reassured because I was so scared,” Escher-Jacob said. “I heard him make a sound, which was a great sign, and saw him for a split second, then he was off to Boston. I was transported to Tufts the next day by ambulance and could recover with him there.”
Escher-Jacob said her son’s long NICU stay in Boston was very hard on the family. “I commuted from Wellfleet almost every day, spending six or seven hours in the car for about two months,” she said. “Gas and parking became very expensive. At the same time my husband and I were trying to keep life as normal as possible for our older son. I was feeling guilty if I wasn’t at the NICU for long enough one day, or if I was not at home with Drew enough. It was pretty awful.”
Dr. Chute said she would love to see CCH one day provide a NICU and a nursery that can support care for higher-risk deliveries. She feels it is possible. But the chances look remote.
“We do not have plans to build a NICU because there simply are not the numbers of premature infants born on Cape Cod each year to warrant the types of resources needed for this specialized unit,” said CCH Communications Director Robin Lord by email.
Efforts to reach Michael Lauf, the chief operating officer of Cape Cod Hospital, for comment on the NICU dilemma were unsuccessful.
Editor’s note: Due to a fact-checking error, an earlier version of this article incorrectly reported that midwife Rebecca Taylor lives in Provincetown. She lives in Wellfleet. The original version also misreported the number of births recorded on the Outer Cape in 2010; it was 78, not 75.