Just past Fredericksburg, Virginia's Northern Neck is increasingly becoming known among Washingtonians for its waterfront real estate, tiny fishing villages and a quiet, isolated rhythm that makes you feel like you're a million miles away.
But if you're a pregnant woman about to go into labor, isolation isn't necessarily a plus -- particularly if you're isolated from an obstetrician.
That has been the case for women on the Northern Neck since early last year, when the only two obstetricians on the 100-mile-long peninsula closed their 300-delivery-a-year practice because of rising malpractice insurance rates after decades in business.
Now, stories are common of women delivering babies in cars, parking lots and emergency rooms, getting their tubes tied and simply being panicky throughout their pregnancies, worried about getting to the nearest obstetrician -- at least an hour away.
"This is like you are on a mountain somewhere, and you're sick. . . . Of course you're going to panic," said Mattelyn Lee, 31, who had her tubes tied after her pregnancy in December, when she had to ride two hours while in labor from her home in Weems to Henrico Doctors' Hospital outside Richmond. "Imagine you're in a car, you have to have your seat belt on, you have to go to the bathroom, you have cramps. . . . I don't want to be in that predicament again."
Over the past year, the situation has created what Del. Albert C. Pollard Jr. (D-Lancaster) calls a furor. It also illustrates how a region that has become increasingly connected to Northern Virginia in some ways seems to exist in another realm where health care is concerned.
More than 17 percent of residents of the Northern Neck's five counties have no health insurance, according to the Virginia Department of Health, which cited data from 2000 and 2001. That is nearly the same rate as Virginians in the western part of the state but higher than Northern Virginia, where it is 11 percent, and the Hampton Roads area, where it is 13 percent. Nationally, 14 percent of people were without health insurance in 2000, according to the census.
Until May, the uninsured poor on the peninsula had one option: Kilmarnock, a town at the southeastern tip, across the Chesapeake Bay from the Eastern Shore. There, they could go to the emergency room of the Northern Neck's only hospital, Rappahannock General, or to the Northern Neck Free Health Clinic. In May, a second free clinic opened in the small Potomac River town of Colonial Beach, in the northern part of the peninsula, but a doctor is there only from 9 a.m. to 2 p.m. Saturdays.
Fredericksburg and its Mary Washington Hospital -- which has one of the busiest emergency rooms in the state -- are about a 30-minute drive from the northernmost towns on the Northern Neck.
Some health care experts and regional officials say the Northern Neck's incomplete health care is part of a nationwide emptying out of rural communities. The main problem on the Northern Neck is the worsening health of the bay, traditionally the economic lifeblood of the region. Growth is coming to the region in the form of wealthy retirees from the Washington area and others buying second homes, but that isn't providing enough jobs, Pollard said.
"Oysters are down, and real estate is up. And the core local folks are struggling," said Pollard, who drives with his pregnant wife nearly two hours to her obstetrician in Richmond.
"So when people are having babies in parking lots, it speeds the decay of the community in terms of people leaving," he said. "How can I ask someone to move back home and raise a family when they can't even have a family, literally?"
Pollard, citing census data, said the number of Northern Neck residents ages 18 to 35 dropped 18 percent between 1990 and 2000.
Patricia Dorsey was born and raised in Northumberland County but has wanted to leave the area since watching her daughter give birth in October on the front seat of Dorsey's Chevrolet Malibu. Melissa Hudnall and her daughter, Deonna Charmaine Mae Hudnall -- whom Dorsey calls "Malibu" -- are fine, but Dorsey said failing to complete the 75-mile trip to the hospital was the last straw for her.
"Something has to be done to wake up the Northern Neck," she said. "People drag their feet -- they don't want to accept change here," she said.
James Hamilton was half of the 27-year, two-man practice that stopped delivering babies last year after several malpractice lawsuits against the practice were settled. The pair couldn't secure affordable insurance, and Rappahannock General Hospital -- where they were based -- said it was losing too much money between rising insurance costs and decreasing reimbursement rates, Pollard said.
Hamilton now practices only gynecology, but he said he has been working with midwives and legislators to find a solution. They have formed an organization that plans to open a birthing center that would avoid some hospital requirements by allowing stays of less than 24 hours only. It would have malpractice insurance under a special federal program for rural areas.
During the last General Assembly session, lawmakers responded to the problem by passing a measure to allow three birthing centers in rural areas but voted against funding the centers until more details are worked out. A Northern Neck center would open next spring at the earliest, and the project is being funded at this point with $10,000 raised from such events as bake sales. Still, the center would be able to perform only vaginal deliveries in which no complications were expected.
"The broader issue is the economic viability of rural practices in general and [obstetrics] especially," said Steve Horan, executive director of the Community Health Resource Center, which provides research and consulting to community-based health organizations in Virginia. "I think the challenge in all rural areas is: Can you develop an economically viable practice, and how?"
Horan works with such places as the Northern Neck to open health centers with federal funding. He said he believes resources are increasing for people who know how to apply for them.
Meanwhile, the needs of the area are changing. The Rev. Jerome Magat, who opened the Northern Neck's second free clinic in May on the grounds of St. Elizabeth Parish in Colonial Beach, said 75 percent of the clinic's patients are Hispanic, primarily Mexican immigrants.
With that in mind, the clinic was named Guadalupe Free Clinic.
"If we weren't here, people would likely go without," he said, noting that the nearest clinics, in Fredericksburg and Kilmarnock, are 40 and 55 miles away, respectively.