Hartford HealthCare’s recent appeal of the state’s denial of its application to close the labor and delivery unit at Windham Hospital is the latest step in a two-year saga that has pitted community organizers in Windham against one of the state’s largest health systems.
The filing also initiates the final stage of the process before the state issues a final decision on the proposed closure.
In the appeal filed Friday, Hartford HealthCare stated, “The proposal at its core is about patient safety and the need to close a labor and delivery service that can no longer operate in a safe and consistent manner.”
On Friday evening, in the hours after Hartford HealthCare submitted its appeal, activists held a vigil outside Windham Hospital. People braved the on-and-off downpours and held signs calling for the restoration of labor and delivery services. Passing cars beeped in support and attendees cheered in response.
“It’s hard when you’re going up against such big powerful interests,” said Lynne Ide, a Willimantic activist and member of Windham United to Save Our Healthcare, the community coalition leading the opposition against the closure. “You’ve got to celebrate being together and celebrate the spirit of people trying to make change as much as you can.”
Hartford HealthCare initially applied for state approval — called a “certificate of need” — to terminate birthing services at Windham in September 2020. Last month, the Connecticut Office of Health Strategy issued a proposed final decision rejecting the closure due to concerns that it could exacerbate existing health inequities, diminish access, increase costs and limit patient choice in the region.
But the certificate of need process gives the applicant an opportunity to respond to a proposed decision before it becomes final. In the 76-page appeal, Hartford HealthCare requested one more round of oral arguments ahead of the final decision. It also submitted new evidence to further illustrate the patient safety concerns and difficulty recruiting health care providers that it has long cited as the reasons for the unit’s closure.
“They’re staying on message and stating their case over and over again about why they think this is OK to do,” said Lynne Ide, who gave birth to all of her three children at Windham. “And we would argue every single one of those points with them.”
A representative from OHS said there is no set date yet for oral arguments, but “once that hearing is complete, a final decision shall be rendered within 90 days following the closing of hearing or due date for filing of briefs, if allowed, whichever is later.”
Low birth volume
Among the new evidence Hartford HealthCare presented was the findings from a survey on the safety and financial viability of operating a rural birthing unit.
The survey found that hospital administrators reported “needing at least 200 annual births for safety and financial viability.” Hartford HealthCare noted that “Windham handled approximately 100 births in each of its last several years of operation.”
The same survey also found that 65% of hospitals prioritized “meeting local community needs” as the No. 1 consideration when making decisions about maintaining obstetric care, ahead of financial considerations (17%) and staffing (13%). The survey’s authors concluded that “many administrators indicated prioritizing local community needs for obstetric care over concerns about viability and staffing.”
The issue of low birth volumes at Windham has been one of the most contentious points of disagreement between Hartford HealthCare and community members opposed to the closure.
“It comes down to both sides saying it’s unsafe,” said John Brady in a November 2021 interview with the CT Mirror. Brady is a registered nurse and serves as the executive vice president of AFT CT, a union representing health care professionals, as well as teachers and public employees.
“We say it’s unsafe for people to have to travel down Route 32 or up Route 6 [if the unit closes]. They say it’s unsafe because there’s a low number of births. We say, there’s a low number of births because you made that happen,” he said.
In the appeal, Hartford HealthCare stated that the number of babies born at Windham decreased from 384 in 2011 to just 99 in 2019.
According to data submitted by Hartford HealthCare to OHS in the certificate of need application, births at Windham remained steady between 2011 to 2014, hovering around 380. But, between 2014 and 2015, the number of births plummeted from 376 to just 205, representing a nearly 50% decrease.
Brady acknowledged that it’s impossible to know exactly what caused the drop in births at Windham. However, he said, one thing is clear: the number of births in the area has not seen a similar decline.
“They have the demand in the area,” said Brady. “The important question is why are people going to other hospitals to give birth?”
In an emailed statement, Hartford HealthCare attributed the drop in births to the departure of Mansfield OB-GYN, a major practice at the hospital. In 2015, the group left Windham and began delivering babies at Manchester Memorial Hospital.
According to Dr. Robert Gildersleeve, the lead physician at Mansfield OB-GYN, the practice stopped delivering at Windham because of patient safety concerns and the intense call schedule, which required physicians to be on call once every three nights.
“Hartford HealthCare didn’t drive us out,” said Gildersleeve.
The practice had operated at Windham for around 20 years before leaving, but patient safety concerns were mounting for around five years before they moved to Manchester Memorial in 2015, he said.
The physicians felt, for example, that the hospital didn’t have adequate Neonatal Intensive Care Unit capacity, so they worked with Hartford HealthCare to bring in staff from Connecticut Children’s Medical Center to do shifts at Windham.
“We still ended up transporting a fair portion of our babies because we couldn't monitor them effectively,” said Gildersleeve.
The hospital’s anesthesia group also stopped performing VBAC procedures, or vaginal birth after cesarean, because of concerns that patient volume was too low to perform them safely. Gildersleeve said their concerns were valid but that his practice did not want to continue operating at a facility that didn’t perform the procedure.
“It wasn't the administration that said, ‘We're stopping the services here,’” explained Gildersleeve. “It was the professionals that we worked with caring for these patients that felt like it was not an appropriate place to do some of the things that we felt were crucial for good obstetric care.”
In response to the cuts facing rural labor and delivery in Connecticut, Gildersleeve, who grew up in the state, attended medical school at the University of Connecticut, and has practiced at Windham, Manchester Memorial, and Hartford Hospitals, said that the situation here is still far better than what other parts of the country face.
“I trained in Colorado, and I had people driving out of the mountains to come to Denver to do their deliveries. In the northeast, the commute time to get to a medical center is considerably different than what's normal in other places in the country.”
Hartford HealthCare also provided evidence to disprove the state’s claim that “it did not pursue all avenues available to it” to staff the labor and delivery unit.
“Even after it was brought to the Applicant’s attention that the UConn Family Practice Residency Program and [Day Kimball Hospital] might be able to provide coverage assistance, [Windham Hospital] did not bother to contact either one,” reads the state’s proposed final decision.
In its appeal, Hartford HealthCare stated that UConn Family Medicine physicians deliver babies at Saint Francis Hospital and Medical Center, which is part of Trinity Health of New England. Trinity Health recently announced its intent to close the labor and delivery unit at another one of its hospitals, Johnson Memorial in Stafford. In its certificate of need application, it indicated that patients can go to Saint Francis, among other hospitals, to give birth.
As a result, Hartford HealthCare stated that “with women displaced from Johnson Memorial to St. Francis, these residents and attendings will arguably have even less capacity to assist an unaffiliated hospital located 30 miles away.”
In emailed comments, Hartford HealthCare added that UConn Family Medicine physicians are "residents who cannot deliver babies without in-house attending physician presence and supervision" and that there is only one attending OB at Windham — who can't be on call to supervise 24/7.
In response to the claim that Day Kimball OB-GYNs could provide support at Windham, Hartford HealthCare submitted affidavits from two Norwich-based obstetricians testifying that they currently provide “occasional OB call coverage at DKH because the practice that staffs DKH’s OB services, DKMG OB/GYN, cannot fully cover the service,” suggesting that that the DKMG OB-GYN practice is not “a feasible option” for coverage at Windham.
The additional evidence presented does not address whether Hartford HealthCare contacted these practices in an effort to staff the unit, but it calls into question the likelihood that either practice could have provided the necessary coverage to keep the unit operational.
In emailed comments, Hartford HealthCare reiterated that clinical experts had attested that neither UConn Family Medicine nor DKMG OB-GYN served as a viable option for providing coverage. But it did not address a question about whether the company had directly contacted either UConn Family Medicine or DKMG OB-GYN to explore staffing solutions.
'A little sisterhood'
The state’s final decision regarding Hartford HealthCare’s application is the first in a series of proposed changes that could significantly impact the future of reproductive health in rural Connecticut.
Since Hartford HealthCare filed its application, two more hospitals in rural areas of the state — Sharon Hospital and Johnson Memorial in Stafford — have either filed or announced intent to file for state permission to close labor and delivery units.
Additionally, Day Kimball has filed an application to join Covenant Health, a Massachusetts-based Catholic health system. A coalition called Save Day Kimball has formed to petition the state to deny the proposal, citing potential restrictions the new owner could place on reproductive health and emergency contraception, as well as gender-affirming, end-of-life and other care.
Members of Windham United said they have been in touch in one way or another with activists in all three of the other rural communities facing threats to reproductive health offerings at their local hospitals.
“It’s sort of like we’re this little sisterhood,” said Ide.
At Friday’s vigil outside Windham Hospital, the group was joined by a handful of activists from Save Day Kimball who, despite the weather, made the trip to support guaranteed reproductive health services in rural communities across the state.
Rev. Jane Newall, a steering committee member of Save Day Kimball who attended the vigil, said that Windham activists have been a crucial resource to their organizing efforts, serving as “a model” for navigating the certificate of need process.
“The [Windham United] group is just tremendous,” she said, “I just wanted to show up and support their efforts.”