Women on Hiiumaa haven't been able to to give birth on their home island since July. However, no clear arrangements have been made for transporting expectant mothers to the mainland and back or covering the associated costs.
Kärolyn Kivistik, who lives in Kärdla, is expecting her fifth child on November 8 and her hospital bag is already packed. This time, however, packing it was more complicated than before.
Kivistik said that in the past, her husband had been able to quickly bring her anything she needed. "Now I have to think everything through carefully because I'll be in the city and there won't be any way for someone to bring me things I've left at home," she explained.
Since Hiiumaa Hospital stopped providing maternity services on July 1, Kivistik will have to travel to the mainland to give birth and she does not want to make the journey while in labor. As a mother of a large family, she wants to stay home as long as possible, but she will likely have to head to the capital a week before her due date.
"These children like to be born at night," Kivistik said, adding that ferries do not operate at night, making it difficult to wait for labor to begin on Hiiumaa.
The family has budgeted nearly €1,000 in additional expenses, as renting an apartment near a Tallinn maternity hospital alone costs almost €500. But what bothers her even more than the extra expense is the uncertainty surrounding the arrangements.
Staff shortage to blame
In fact, Hiiumaa Hospital has all the facilities needed to provide maternity services. What it lacks is staff. A pediatrician retired on July 1, there was no gynecologist available on four days in September and in October the hospital will have to manage for about a week without an anesthesiologist. Yet all of these specialists are essential to ensuring that childbirth is as safe as possible.
On Monday, a proposed plan outlining what the journey to give birth might look like was presented to the board of the hospital in Kärdla. According to Hiiumaa Hospital Director Riina Tamm, these are still only preliminary recommendations and do not address the main concern: how expectant mothers will get to the mainland and back and who will cover the costs.
"Where will she stay in Tallinn? Who will pay for her accommodation? She travels to Tallinn, gives birth, but how does she get back? Who will bring her home? Does she have to make her own way back? Should the municipality arrange it or should the hospital? And again, who pays for it all?" Tamm asked. She acknowledged that these are important questions that must be resolved before such a change can be implemented.
As a midwife, Tamm has helped deliver hundreds of babies on Hiiumaa, but she now admits frankly that she would no longer want her own loved ones to give birth on the island. Complications during childbirth can become critical within minutes and the hospital is not equipped to handle such emergencies. This is also why women with high-risk pregnancies have been sent to the mainland for years. But what awaits women on Hiiumaa who do not want to travel to the mainland ahead of time to await labor?
"If everything goes smoothly — the woman arrives, we have an ambulance available and a ferry is just about to depart from Hiiumaa — the patient can reach the Women's Clinic at East Tallinn Central Hospital in three hours and 45 minutes. The ferries are already operating on their winter schedule, with three hours between departures," Tamm explained.
Transport by helicopter would take two hours to reach the hospital, but only if weather conditions permit flying, a helicopter is available and its allotted flight hours have not been exhausted.
A problem of regional policy
Tamm believes this is not just a problem for the small Hiiumaa Hospital or Hiiumaa Municipality. "This is actually a regional policy issue," she added.
In Tamm's view, the state has failed to do its job. The possibility of closing maternity units was first discussed back in 1998, yet the decision on whether to close them has ultimately been left to individual hospitals.
Vivian Arusaar, head of midwifery at East Tallinn Central Hospital, said women who have already gone into labor will not be turned away, but the hospital cannot offer extended accommodation. However, if maternity services continue to be concentrated in larger centers, a solution will have to be found.
Arusaar suggested that the Estonian Health Insurance Fund could be given the option of funding hotel-style accommodation at hospitals. "It is common elsewhere in the world for people to travel hundreds of kilometers to receive healthcare and many large hospitals of regional importance actually have patient hotels," she explained.
According to Heli Paluste, a healthcare network expert at the Ministry of Social Affairs, the decision to close a maternity unit rests with the hospital's board, not the ministry, because hospitals operate autonomously. To ensure high-quality maternity care, a hospital should handle at least 300 births a year, a threshold met only by hospitals in Tallinn, Tartu and Pärnu.
Paluste did not rule out similar decisions being made in the near future. Time will tell whether this happens and which counties might be affected.
Hospital boards in charge of decisions to close wards
Hospital board leaders met at the ministry on Friday where, according to Paluste, it was again emphasized that decisions on any potential maternity unit closures would remain the responsibility of hospital boards.
Where maternity services have been discontinued at Estonia's general hospitals, it has been due to declining birth numbers. The closures have been driven either by financial considerations or staff shortages.
Paluste said patient hotels had been discussed before, but funding them would come at the expense of already scarce healthcare resources. The ministry believes that providing financial assistance to expectant mothers facing economic hardship should be the responsibility of local governments.
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