Plus, Iowa leaders' opinions on child care
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Good morning and happy Monday! This month, we’re focusing on the issue of child care in the state and what’s being done to address it.

Today, we’re publishing the first part of a series on the closures of birthing units in the state. My colleague Sarah Bogaards has intermittently worked on this story for nine months – which is fitting, really – so we’re excited to share it with you now. We’ll be publishing parts two and three as they come out, so stay tuned for those.

We’re also running responses from the Business Record’s annual Leaders Survey that deal with child care and whether or not businesses have a responsibility to pay for it.

Other than that, there’s been plenty of gender-related news in recent days, so we’ve got a lot of headlines and good reads near the end of the newsletter.

Have a great week!

Emily Kestel, Fearless editor

P.S. Thanks to everyone for taking our survey! We are looking forward to digging into the responses and learning about how we can serve you better. If you haven’t yet taken it – you’ve got one more week! You have the option to be anonymous, but if you leave your name, you’ll be entered in a drawing for a chance to win a free lunch with Emily Barske, Suzanna de Baca, Connie Wimer and me.

20 years of decline: Iowa’s dwindling birthing units
Communities, hospitals and doctors seek solutions amid Iowa’s changing maternal health and economic landscapes that drove the loss of 40 birthing units since 2000.
The red areas on the map represent the 53 Iowa counties that do not have a hospital with a birthing unit as of April 2021 due to a closure or because the county has never had a birthing unit. A result partially due to the state’s stagnant population changes in rural and midsized areas, communities are seeking solutions amid Iowa’s changing maternal health and economic landscapes. Data source: Iowa Department of Public Health. Graphic by Patrick Herteen.
Editor’s note: This is the first story in a three-part series focusing on the closure of birthing units in Iowa, the factors driving the trend and how it is changing maternal health care in Iowa. Part one looks at the overall problem, part two explores a couple of communities that have lost a birthing unit in the past two decades, and part three looks at potential solutions.

Angie Pietig had positive experiences delivering her two daughters at the UnityPoint Health-Marshalltown birthing unit in 2009 and 2014. Both were born in the hospital with no complications, and she would have delivered her son there as well if not for a high-risk condition she developed.

Learning the unit would close in 2019 made Pietig sad, less for herself as she was not having more children, but more for the community.

A teacher at Franklin Elementary, which is located just down the street from the hospital, she said the closure takes away the convenience of having services available locally. When she was pregnant with all three of her children, she would always schedule her prenatal appointments right after school or over the lunch hours.

The community connection created by the unit would be missed as well, Pietig said. She recalls attending first-time parenting classes offered by the hospital every Monday night with her husband and newborn daughter, and receiving a gift from a nurse the night her second daughter was born.

With the unit gone, Pietig said she was unsure how her friends would adapt.

"I felt concerned for some of my friends … who are still adding to their families and where they’re going to have to go for care," she said.

One of those friends is Dani Minkel. She also works at Franklin, but as a school counselor, and is expecting her third child in December.

Minkel’s experiences mirror Pietig’s — the deliveries of her two daughters in 2014 and 2018 at the hospital both went smoothly. But her next delivery will be in the Des Moines metro area.

She was frustrated by the closure in Marshalltown as she contemplated driving two hours round-trip for a 10-minute prenatal checkup and the potential need for emergent care with only the hospital’s ER available to help locally.

She said the news made her think: "How can a town of 30,000 people go without this medical service?"

Fortunately, Minkel has been able to see midwives who travel from Des Moines at a clinic in Marshalltown for her prenatal care, but she knows other expecting parents who are traveling to Ames or Des Moines, and some who did so even before the unit closed.

Marshalltown is not the only community navigating this experience and transition. Its hospital is just one of 40 in Iowa to close a birthing unit over the last 20 years. Without other options, parents are adapting while maternal health care in Iowa is undergoing a significant transformation.

In 2000, 77 of 99 Iowa counties had at least one birthing center available. By 2010 closures had reduced that number to 62, and as of April 2021, only 46 counties in the state had at least one open birthing center.

That’s 20 years of loss across communities that are primarily rural.

The anatomy of a birthing unit closure

The reasons behind each closure are different, but from working with hospitals across Iowa as co-director of the Statewide Perinatal Care Program, Dr. Stephen Hunter said he finds common themes.

No. 1 is low volume. Often, hospitals are not delivering enough babies to support the existence of a birthing unit.

"I like to joke in some of the presentations that I give that when I was a kid growing up in Utah, I used to ride horses and motorcycles," Hunter said. "[The motorcycle] I had to feed only when I was riding it, [the horse] I had to feed whether I was riding it or not," Hunter said.

"A labor and delivery unit is like a horse."

Paying doctors, anesthesiologists, nurses and support staff to be on call 24/7 for births that aren’t happening becomes financially infeasible for hospitals, particularly ones that serve less populated areas.

Even if a hospital has the funding to support hiring, the question remains if they can find doctors to work in obstetrics. Hunter, who is also vice chair of obstetrics at the University of Iowa Hospitals and Clinics, said Iowa ranks last in the U.S. in OB-GYNs per capita. There were 280 OB-GYNs in Iowa in 2018 to serve the state’s roughly 600,000 women of reproductive age, who are defined as women ages 15 to 44.

The natural question, then, is: Why aren’t there enough births or OB-GYNs?

But the answers are multifaceted and lie beyond the hospitals, rooted in evolving trends like the state’s population and workforce changes.

Liesl Eathington, coordinator of the Iowa Community Indicators Program at Iowa State University, said the 2020 census data stood out to her because it showed that the overall pattern of Iowa’s population changes in the last 10 years looked almost identical to those from 2000 to 2010.

Iowa’s population has grown about 4% in each of the last two decades, and according to the USDA’s Economic Research Service, each decade saw rural Iowa lose about 2% and urban areas gain 9.9%.

Eathington said these patterns and similar population trends in other Midwest states are confirmations of the ongoing urbanization in Iowa, especially since 2000.

Urbanization happens in many industries, and in health care she said it is taking the form of more regional hospitals as fewer independent ones can deliver obstetric services at a "small scale" and meet new demands for technology.

"In some sense the things that are driving these trends are resulting in outcomes that are better on average for consumers to have more choice, maybe higher quality services, more technology, but it does create the burden on the people out in those more remote areas that they have to travel farther to get these things," she said. "On average, maybe consumers are better off, but we definitely have inequity in terms of who's more able to take advantage of that."

Eathington said these changes are the result of the urbanization of population and services that has been happening in Iowa for the last 20 years. Other Midwestern states with similar demographics are seeing the same changes, she said.

Adding to the problem is that Iowa relies on family medicine physicians to fill the gaps created by the lack of OB-GYNs in Iowa.

Those practicing family medicine in Iowa often assist with natural deliveries, but usually depend on general surgeons to handle cesarean section deliveries.

Offering prenatal care and deliveries as part of a family medicine practice does not require extra certifications, but interest has declined, as becoming the only physician to offer those services, especially in small hospitals, is not typically desirable for new doctors.

In 1988, around 68% of family physicians in Iowa were willing to or planned to practice obstetrics upon completion of their residency. That figure dropped to 18% by 2018.
Do businesses have a responsibility to help pay for child care costs? Iowa leaders weigh in
Each year, the Business Record puts out its Leaders Survey, which asks business leaders to share what they feel are some of the top issues affecting business in Central Iowa.

This year, we included questions about child care. Below are a sampling of their responses:

Agree or disagree: Businesses and organizations have a responsibility to help pay for their employees’ child care costs.
Agree. Businesses have a responsibility to pay their employees a fair and livable wage; that includes a wage that can cover health, housing, food and child care. Jaime Nicolet Rutan, curator, Salisbury House Foundation

Agree. It is both economically prudent and ethically responsible to ensure the evolving needs that people carry with them into the workplace are addressed. Not only is the child care crisis affecting workplace productivity with an increase in unplanned absenteeism, the data today is very clear the caregiving issue disproportionately impacts women – creating a cumulative and long-lasting impact related to the gender wage gap, promotability, special projects and travel opportunities, and a gender wealth accumulation gap into retirement. A commitment to gender equality must equal a commitment to addressing barriers that limit equal opportunities. Beth Shelton, CEO, Girl Scouts of Greater Iowa

Agree. The easy answer is yes. The hard answer is how. If we are paying employees a livable wage (as we should), the cost of child care, food, clothing, housing, etc. can all be covered by the employees’ compensation. Paying a livable wage is true for some, but clearly not all employer/employee relationships. In situations where wages are not adequate, intervention/assistance is required. Should that be mandated at the employer level and/or at a governmental level? Great question. The current demand for employees may force businesses into a decision on this matter before waiting to see what, if any, government solution can realistically be passed. Rod Foster, office managing partner, RSM US LLP

I’m not sure. This is a slippery slope. If businesses pay child care costs for employees with children, what are they offering to employees without children? A fair wage and a community that offers viable options for child care are imperative, but I’m not sure that directly paying is the answer. Better promotion of dependent-care flexible spending accounts and easier processing of reimbursements, however, could help many. Carrie Woerdeman, director of development, Kading Properties

I’m not sure. This is something the government should take on as businesses are already struggling with increased costs. It’s also not fair to the employees that don’t have children. Brendan Comito, COO, Capital City Fruit Co.

Disagree. Child care assistance is a great benefit for businesses who can offer it and will likely lure people away from other businesses. It is a great recruiting tool, but not necessarily a responsibility. Jessica Dunker, president and CEO, Iowa Restaurant Association

Disagree. This is not a private business function or responsibility. This is a state and federal government responsibility due to the government’s ability to influence social infrastructure. Hannah Inman, CEO, Great Outdoors Foundation

Left: Cedar Rapids mayor-elect Tiffany O'Donnell. Center: Honduras president-elect Xiomara Castro. Right: UConn basketball player Paige Bueckers.
In the headlines
A voice heard: Reyma McCoy McDeid

McCoy McDeid has become one of the foremost advocates for marginalized communities, particularly those on the autism spectrum like herself. She’s run for political office, worked on national administrations, led nonprofit organizations, and started her own business to help others learn and improve. All of those actions have been with the same goal — making sure communities recognize and value input from all people.
Worth checking out
How SCOTUS’ ruling on Mississippi abortion case would impact Iowa (Axios Des Moines). These vintage photos of Venus and Serena Williams reveal the truth of ‘King Richard’ (Smithsonian Magazine). Female founders are crashing the billionaire club (Fortune). UI students express the complications and challenges faced when reporting sexual violence and misconduct through university resources (Daily Iowan). Four Times opinion writers debate abortion at the Supreme Court: ‘My guess is they overturn’ (New York Times Opinion). You should ask for a raise – now (Fortune Worksheet). This Hanukkah, learn about the holiday’s forgotten heroes: Women (Iowa Capital Dispatch).
University diversity officers discuss how to make new diverse hires feel included
Picture this: Your house is a mess. There are dog toys on the floor, crumbs on the counters, mail scattered all over the coffee table and your kids have somehow managed to leave their entire collection of shoes at the front door. You wouldn’t invite guests over without cleaning up first, right?

Bringing a diverse hire into your workplace – especially if they’ll be a "first" or "only" – should be thought of with the same mentality, two university diversity officers said.

Chiquita Loveless, interim director of diversity, inclusion and social justice at the University of Northern Iowa; and Margo Foreman, vice president and chief officer for diversity, equity and inclusion at Clark University in Massachusetts; discussed the need to be intentional about recruiting and retaining a diverse workforce during a recorded panel discussion with the Business Record earlier this fall.

Watch the conversation on our YouTube channel to learn more.
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