In the days and weeks before Providence Hospital closed its maternity ward, Caitlin Givens, a midwife, explained to pregnant patients what they needed to do to continue their prenatal care.
She talked to them about scheduling appointments with a different provider, how many visits they would need before their delivery. She reminded them they needed their blood pressure checked regularly.
Many of Providence's patients were Spanish-speaking, some undocumented immigrants, and most on Medicaid. After Givens would finish explaining all the steps they would need to take to maintain a healthy pregnancy, some would ask, "So, you're going to call these people for me?"
"Knowing how to navigate the system is very difficult if you don't know the system and you don't speak English," Givens said. "They came to see us on the very last clinic day because they didn't have care and now I don't know where they've gone."
The closure of Providence's labor and delivery unit, as well as two other recent changes to maternal services in the District, has disproportionately affected low-income women — including in some of the poorest areas of Washington, where access to care already was scarce.
The Northeast hospital closed its obstetrics unit Oct. 16, including all prenatal care, in what was largely seen as a cost-saving measure. In August, the city shut down deliveries at United Medical Center in Southeast Washington over several critical mistakes, including failing to take necessary precautions to prevent an HIV-infected mother from passing the disease to her baby.
Now no labor and delivery services exist on the east side of the city, leaving "a maternity care desert," as the D.C. chapter of the American College of Nurse-Midwives called it.
Meanwhile, MedStar Health, which operates MedStar Washington Hospital Center, lost its contract with the city to operate its own Medicaid managed-care organization. The affected patients were automatically transferred to a new plan — but not one that MedStar accepts, leaving women planning to give birth there confused about their options.
The trio of changes in the city, while unrelated to one another, each hurt women who do not need added barriers to prenatal care, said Kelly Sweeney McShane, chief executive of Community of Hope, a nonprofit organization that offers services to low-income residents, including a family health and birth center.
There already are dramatic disparities in infant health outcomes in the District's minority communities.
Using data from 2013, the city found that the infant mortality rate among white mothers was 1.7 per 1,000 births. For Hispanic and black mothers, it was, respectively, 6.4 and 9.9 per 1,000 births.
"If a woman is pregnant, you know it's going to be nine months, so she should be able to plan where she's going to have birth and set everything up — that's the gold star standard," McShane said. "But there is already not a good continuity of care between prenatal care and delivery [for low-income women]. And now it's come to a head with all this going on at the same time."
Patients at Providence were given a letter less than two months before the unit closed, explaining what was happening and offering a list of five alternative locations where they could go, Givens said.
Providence took patients no matter their legal status or ability to pay, she said, and set affordable rates and offered charity packages to those in dire financial need. It delivered between 1,500 and 2,000 babies a year.
At United Medical Center, the city's only public hospital and the only one east of the Anacostia River, there were fewer deliveries — about 360 a year — and almost all of its patients were from Ward 8, the city's poorest ward.
"It's a huge maternal health crisis," Givens said. "Providence was a place that would take anybody, the whole motto is, we don't leave anyone behind, and here we are closing the door to the most vulnerable in the population. If there's a clear message to get through, it feels like this whole half of this city is being ignored in terms of the services."
While MedStar Washington Hospital Center and George Washington University Hospital still deliver the most babies from patients who live citywide, including women from Ward 8, there is concern that those larger institutions will not be able to absorb the added patients.
Providence and UMC had utilization of their obstetrics beds of about 30 percent. MedStar Washington Hospital Center and George Washington are over 75 percent, according to a D.C. Department of Health report of its health systems.
The report concluded there are no service gaps in hospital services in the District, but it added that "hospital beds are maldistributed, which presents barriers to access for certain segments of DC's population."
Officials at George Washington University Hospital did not respond to an interview request and specific questions sent by email asking about its obstetrics services.
Gregory Argyros, chief medical officer for MedStar Washington Hospital Center, convened a meeting last month with local hospitals and community groups to discuss what they could do to mitigate harm during this period of transition. Washington Hospital Center, for one, is looking to add capacity in its delivery ward.
"October is going to be a crazy month, but we want to make sure this patient population has a safety net to care for them," he said. "We're looking to play our part to ensure moms and the babies are safe."
But there's also worry about where the women will get their prenatal care. Several community clinics around the city provide prenatal services, but coordinating between a clinic and a delivery hospital that may be part of another network is yet another hurdle
"The biggest risk factor for infant and maternal mortality is a lack of prenatal and obstetric care," said Melissa Fries, chair of Women's and Infants' Services at Washington Hospital Center.
Aza Nedhari, founder of Mamatoto Village, another D.C. nonprofit group that works with low-income women during and after their pregnancies, said her organization often sees women well into their second and even third trimester who have not had prenatal care. She said she also has met mothers in postpartum who didn't see a doctor until they delivered.
Nedhari said she worries these vulnerable women "will fall through the cracks."
"What I feel is going to end up happening is when you increase capacity you diminish quality," Nedhari said. "It's not like there is a plethora of OBs anyway, or midwives. It's a mess, it's a monumental mess. How did they allow this to happen or let this happen?"
As Washington Hospital Center works to determine how many new patients it can take on because of the closures of Providence and UMC, it is also contending with current patients who are confused about what services are available to them now that their Medicaid plan has been changed.
Earlier this year, the city had announced it would not be renewing MedStar Health's managed care organization, called MedStar Family Choice. The health system is appealing the city's decision. Meanwhile, members of that coverage group were transferred by the District to a new managed-care organization, Amerigroup.
But that is not the Medicaid carrier that the hospital now uses exclusively.
Wayne Turnage, director of the D.C. Health Care Finance Department, said members were informed in a letter in September of the change to Amerigroup and the option to switch to the other Medicaid plan — called AmeriHealth — if they wanted to continue going to a MedStar facility, including Washington Hospital Center. So far, he said, it has been a smooth transition, with slightly more than 1,000 making the switch.
Arja Nelson, who is pregnant and due in December, gets most of her prenatal care through midwives at Community of Hope, but she receives her sonograms and other testing at MedStar Washington Hospital Center. She said she never received a notice and learned of the change from a midwife at Community of Hope.
A mother of three, she spent close to an hour on the phone recently trying to switch to AmeriHealth to try to stay with Washington Hospital Center.
What Nelson didn't know is that the hospital is not dropping patients who have an existing treatment plan, including pregnant women. A woman who was pregnant as of Sept. 30 under the old Medicaid carrier may continue to get obstetrics services and deliver at MedStar Washington Hospital Center — but she would not be able to get new services there unless she switched to AmeriHealth.
Nelson has worked as a doula — a person who serves as a companion to women giving birth — and is well-versed in the health-care needs of pregnant women. She lost an 11-month-old child who was born with one lung and is diligent about her checkups, she said.
If she is in the dark about her options, she said, imagine what those less educated about the health-care system must be going through.
Nedhari said she believes the consequence of the recent changes in the city will be grave.
"When we look back one year from now," she said, "the rates of mothers dying are going to reflect this situation."