At 6:58 a.m. last Thursday, Dr. Angela Adams Powell spoke to the nurses at the hospital in south Alabama where she had been delivering babies into the world for 25 years.
“I was afraid I wouldn’t be able to speak,” he said, his voice breaking.
Two minutes later the Monroe County Hospital Delivery Department would close, leaving that rural community of about 20,000 without a delivery hospital. Two minutes later, pregnant women in a county where 22% of residents live below the poverty line would be forced to travel 35 to 103 miles to find a solution.
The last-minute solution Powell hoped for did not arrive.
Adams Powell tried to keep his voice steady as those gathered around him wiped their eyes. “That decision was not ours,” he said, “but for the women and children we have cared for, we have done the best we could.”
Their hospital is the latest in a growing list in Alabama where delivery teams have had to say goodbye. Maternity units in Birmingham and Shelby County closed in October.
In rural areas like Monroe County, a shutdown can leave an entire community without childbirth services. More than a third of Alabama counties are maternity care deserts, lacking hospitals with obstetric care or birthing centers, according to a report by the nonprofit March of Dimes.
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Liz Kirby, director of Monroe County Hospital, said the cause of the closure was a shortage of doctors. After the Supreme Court decision that ended federal abortion protection, some hospitals in states with strict bans on termination of pregnancy warned that it could be more difficult to recruit obstetricians and gynecologists, although Kirby said he was not aware that this was a factor in this case. Residency applications for the specialty have also declined more in states with abortion bans than nationally.
Powell believes administrators could have done more to address issues that he felt were harming recruitment and retention.
Kirby said the hospital has worked with three recruiters to try to staff the labor and delivery department.
“No one wanted this,” he said, “it was certainly not an easy decision.”
Alabama is mired in a maternal and child health crisis, with one of the highest mortality rates in the country. Doctors say that should be offset by more health access, not less.
State Rep. Thomas Jackson, a Democrat whose district includes Monroe County, said withdrawing obstetric care leaves the community “hurt.”
“How are we going to manage?” he asked himself.
Powell understands how risks can increase with every mile a pregnant woman must travel to receive medical care. He still remembers the patient who about 16 years ago walked through the hospital doors with blood dripping down the side of her wheelchair. She had suffered a placental abruption and she had to undergo an emergency cesarean section. Powell thought the baby would not survive, but the mother and newborn lived.
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“That situation, although rare, is not uncommon,” Powell said, “driving a distance of 40 or 90 miles to try to receive that care puts the lives of both the mother and the baby at risk.”
Powell grew up in Gilbertown, Alabama, in a county considered a maternity care desert. Her father was a businessman and her mother ran an automobile shop where Powell sold spare parts, but from a very young age she knew that she wanted to be a doctor.
After medical school, in 1997, she moved with her husband and young son to Monroeville. She began practicing as a family doctor at Monroe County Hospital and opened a private clinic. She and her husband soon also had a daughter.
Some of his patients were in cribs, while others were eligible for Social Security. Her training in obstetrics meant that, in addition to providing primary care, she was able to care for patients throughout their pregnancy and deliver their babies.
Monroeville, a city of about 6,000 people, is known in literary tradition for one of its most famous natives, Harper Lee, author of Kill a Mockingbird.
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Vestiges of the unequal Alabama society that Lee wrote about in 1960 still resonate in national racial and socioeconomic disparities. Black children are 2.4 times more likely to die in childhood than white children. In adulthood, blacks have one of the lowest life expectancies.
This fall, the recent wave of maternity unit closures across the United States reached Monroe County Hospital.
Powell was in the operating room one afternoon in late September when he saw a missed call from the hospital director. The head of surgery and an anesthetist also had missed calls. Powell knew something was wrong. As he walked to his car, he called back. He listened as Kirby told him the board had decided to end labor and delivery services.
Memories of emergencies his team had worked on flashed through Powell’s mind. He couldn’t speak. When he finally did, he asked what the unit’s last day would be.
He turned around, walked back to his office, and started checking his patients’ records so he could call them. She would start with those who had a due date after November 15th. There were 83.
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Over the past few weeks, Powell held out hope that the hospital would reconsider its decision, or perhaps someone from the outside, like the state, could come in with a last-minute bailout.
He also began having serious conversations with his patients. If they go into preterm labor and can still feel the baby moving, she told them, they should probably head to the nearest birthing hospital in another county. But if they do bleed, they should get to a local emergency room quickly; Monroe County Hospital will continue to deliver babies under urgent circumstances.
There wasn’t a day when I didn’t have an “ugly cry,” she explained.
In the hospital’s final days, before the start of a cesarean section, a nurse reminded her colleagues that it could be their last time together.
“Stop,” Powell told him, “you’re going to make my glasses fog up.”
The birth team was very close-knit and had developed rituals. After delivery, they put the Lullaby of the composer Johannes Brahms over the hospital loudspeaker.
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On Monday, Powell discharged the unit’s last newborn. As he had done before, he went over the ins and outs of having a baby at home, such as what sounds parents should worry about.
As he had done before, he also assured the new mother: “The road that takes you home brings you back.”
But it won’t appeal to many more pregnant women. And Powell wonders if she should look for work elsewhere so she can continue delivering babies.
On Wednesday, Powell tried to encourage one of her patients, Stacey Fountain, 38, to decide where she would go to have her baby. Although the doctor still provides prenatal care at her clinic, patients will have to give birth elsewhere.
Fountain, who is 25 weeks pregnant, hadn’t dared to start thinking about it. “I still don’t realize it,” she explained.
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Her due date in February means she has some time, but she’s still overwhelmed. “You’re putting your life in the hands of other people you don’t know,” she said.
The next day, Powell entered the hospital to say goodbye.
After addressing the team through tears, a co-worker put the Lullaby of Brahms on your phone. A nurse dressed in a navy blue scrubs grabbed the receiver of the hospital intercom: “Attention, Monroe County Hospital, at 7 this morning we officially close the doors to the obstetrics department,” she said, before thanking the mothers who They had been entrusted with their care.
“The delivery department cuts and closes for the last time,” he finished.
Powell put her hands to her face as the familiar chimes of the lullaby rang.
