The Labor of Bringing a Baby Into Appalachia

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Brittany Walters, tethered by an IV tube and fetal heart monitor, fidgeted in her bed at Grant Memorial Hospital in Petersburg, West Virginia. She was craving Chinese food as she waited nearly five hours for a Cesarean section. This was baby number six for the 28-year-old single, unemployed mother.

A nurse came by to check her vitals. “Got a name picked out for this one, Brittany?” the nurse asked.

“Brynleigh Sage Walters. We already got four cheerleaders and one football player,” she said of her daughters and lone son. She laughed and rolled her eyes when asked if the baby’s father will be here for the birth.

“He might stop by later. I really don’t know.”

Grant County women like Brittany Walters don’t rely on men because a lot of guys don’t stick around after they’ve fathered a child. Instead, women rely on a sisterhood of grandmothers, aunts, and neighbors. They are rural America’s economic backbone—women cobbling together two or three part-time jobs to feed their kids and pay the rent. The median income is about $39,000, 15 percent below the national figure.

Little has changed here since Walters gave birth to the town’s first baby of 2015. The rise and fall of the stock markets, promises of higher wages and tax reform bonus checks seem a million miles away from the kitchen table economics of juggling utility, food, and rent bills each month. Everything is the same despite the 2016 presidential election inspiring pundits to pay lip service to this “other America” as if it were a new planet. It’s the same despite Donald Trump winning the White House on promises of helping average Americans. West Virginia natives just shake their heads when they hear they’re now in vogue.

“Most people don’t see the gut-wrenching poverty unless they go off the beaten trails,” said Rev. Richard Cardot, the pastor at the Petersburg Presbyterian Church. “That’s the Appalachian story.”

To make a buck, the women here slather mayonnaise on hoagies at Sheetz Convenience Store. They screw together cabinet drawers at the American Woodmark furniture plant. They eviscerate chicken livers and hearts at a Pilgrim’s Pride Corp. poultry processing plant. They dish out the $7.95 lasagna dinner special at Family Traditions Diner.

Cardot sees how women struggle to pay their bills as many of the men “join the military, get a minimum wage job, or move someplace else.” Women of Appalachia are “independent, strong and intelligent. They are the ones making the decisions.” Indeed, when he gathers his group of church volunteers each month, 17 of the 20 assembled are women.

The male flight to find jobs has gotten worse, as global trends have battered the state’s coal and timber industries. Few factories or distribution centers come here anymore.

“The few jobs that exist are poorly paid service work,” said Ann Tickamyer, a Penn State University rural sociology professor.

Not much of rural Appalachia ever enjoyed America’s boom times. One big reason: It’s hard to get here. The anti-poverty pledge of the 1960s to connect the area with highways remains unfinished. And the digital highway is more like a gravel road, with unreliable cell phone and internet service. Even car radios don’t pick up music or news in some hollows.

The ripple effects of unemployment are profound: The state has the highest rate of drug-related deaths, claiming more lives than car accidents.

“Women get depressed and get antidepressants,” said John Hahn, a local obstetrician. “When men get depressed, we give them funerals.”

Even a local minister killed himself. Another guy jumped off a cliff.

“People are hurtin’ big time,” said Hahn, who joined the National Health Service to repay medical school bills in exchange for four years service in Grant County, close to his childhood home. That was 31 years ago.

Indeed, Hahn travels between three clinics to see 60 women a day. If there’s a January blizzard, the birth rate soars nine months later, forcing Hahn to sleep on a twin bed in his office for two weeks, sometimes delivering 20 babies in 10 days. He’s delivered nearly 9,000 babies, but he has lost count of the exact number.

He rarely goes beyond a 30-minute drive, fearing he won’t get back in time for an emergency. A bookshelf in his office is stocked with dried fruits, canned pears, 4C Iced Tea mix, and Tic Tacs. “I live here,” he said, noting that he sleeps there at least once a week.

Medical specialists like OB-GYNs don’t usually stay long because they set up boutique practices in neighboring states. They can treat fewer patients and charge more.

West Virginia is the top state in terms of highest share of its population enrolled in Medicaid. About 564,000, or 29 percent, of its 1.8 million residents are on the public health system. More than 70 percent of Hahn’s patients are on Medicaid, which pays a fraction of what doctors and hospitals get from private insurers.

Even the steady income from delivering babies and Grant County Memorial Hospital itself could be the next casualties of rural West Virginia’s woes. The Grant County Commission recently hired outside accountants and attorney to investigate the hospital’s finances. The Internal Revenue Service is investigating, too.

One of the hubs of Grant County’s matriarchal society is Family Traditions restaurant, where owner Tonya Ketterman, a 48-year-old single mother, unlocks the back door every day precisely at 5:15am. On a Sunday in May 2016, a waitress started the coffee pot as Ketterman tied her blue apron and plopped a gallon of milk and a box of bacon on the table. Three cases, or 90 eggs, will feed each morning’s breakfast customers. She cranks on the deep fryer and lobs a giant spoonful of shortening into a cast iron skillet to cook the sausage.

Ketterman is proud of her restaurant and the role rural women play in her community.

“I’ll make 10 of these today,” she said of her batch of popular white sausage gravy. “I’ve been dragging that skillet out every morning.”

“I’ll take an unsweet tea as soon as possible,” she yelled to the waitress, as she poured milk and flour into the cast iron skillet of simmering sausage. By 5:31am, she had a 32-ounce glass of tea and stirred in four packets of sweetener.

Her boyfriend, Melvin, wandered back to the kitchen to ask what’s for breakfast. She may marry him, but plans to always stay independent financially because she knows that men can come and go. Women keep things going. “Guys don’t want to do it,” she said.

Many mornings, the diner’s regulars are greeted out front by a smiling and chipper waitress, Jacie Boucher, 34, who has spent much of her grown life as a single mother to 10-year-old daughter Paislee. Boucher had been working here for six years. She was making $3 an hour, plus tips. “Some days, I walk out of here after five hours and make $30,” she said.

She made $13.25 an hour at the furniture plant, but got laid off some years ago. She tried babysitting: “Not for me.” Besides, the restaurant hours allow her to work while her daughter is in school. Most of her friends are single mothers, working two or three jobs. Her mother, Jean, a widow, is in the restaurant’s kitchen washing pans.

“They’re my babysitters, too. My gosh, if I had to pay for daycare, there’d be no point in working.”

Child care is expensive for most single-parent or even two-parent households, but it’s especially difficult in rural areas because there are fewer licensed day-care centers and public transportation than in urban areas. The situation is even worse for women who work evening or later shifts because many daycare providers are tailored for the 9-to-5 workday.

Constant pressure to cut federal aid for single mothers and children means less cash aid. The old welfare system of giving out checks with each baby is history. Women must now seek retraining and employment. Cash grants are capped at a maximum of five years. The Center for Budget and Policy Priorities reported that a single mother of three children in West Virginia gets about $340 a month in assistance.

At the same time, enforcement of child support laws is spotty, at best. And cuts to health care and food programs are expected as the Trump administration endorses short-term, limited health insurance plans as an alternative to the Affordable Care Act. Trump also backs deep cuts to Supplemental Nutrition Assistance Program, or SNAP, the prepaid card that replaced the old food stamp programs for low-income families.

“What’s going on in Washington is a nightmare,” said Elizabeth Catte, a public historian and author of What You Are Getting Wrong About Appalachia. Trump “deserves lots of blame,” but she added that “things holding the region back were set in motion so long ago. Both political parties had a hand in it.”

Money is always tight for single mothers like Boucher. “My clothes are rags when I’m done with them. I don’t go and spend money on clothes.” She traded her Durango for a Ford Edge to save money back in 2015. “I was going into debt for gas. I paid $90 a week. It was awful. This one is $25 a week. That pays the car payment.”

It takes a lot of shifts to make ends meet. She works five days, taking Sunday and Tuesdays off. “I do everything. I can even cook. I wash dishes. It doesn’t bother me. Money is money.”

Nurses and techs prepared the operating room for Walters’ C-section and birth of her sixth child. Hahn scrubbed his hands and arms before putting on blue gloves. Kathy Walters was dressed in blue scrubs and talked to her daughter during the surgery. It was a familiar scene; Hahn had delivered two of her other children.

The incision was made on the abdomen, revealing muscle and tissue. Hahn tugged them apart to pull out the baby, who was covered in a white, waxy substance that serves as a natural barrier to keep the baby’s skin from drying out.

“She’s beautiful,” Kathy Walters said to her daughter.

“Grandma, do you want to cut the cord?” a nurse asked.

One snip, then a nurse quickly wrapped the baby in a warm receiving blanket, cleaned her mouth with a syringe, and listened to her heartbeat.

“Thank you, thank you, thank you,” Hahn said to his team of nine nurses and techs and headed down the hall to speak to Brittany’s father.

“Everything went great,” the doctor reported. “She’s going to recovery for about an hour.”

The doctor has four more surgeries today. “It’s a slow day,” he quipped.

“Brittany, we’ll see you next year.”

“I’m not having any more,” said Walters, adding that she’s going back on birth control.

“We’ll see,” the doctor said.

Just after noon, mother and baby were back in her room, along with Brhayeannon, who was five years old at the time. Brhayeannon sat cross-legged on the bed touching her newborn sister.

“See her tiny little toes,” Walters says to Brhayeannon, who tries to pick up the baby.

“Easy, easy. You’ll make her sad,” she said softly.

Her hospital bills were covered by Medicaid, just like 70% of Hahn’s patients. Walter’s only income in 2015 was from occasional hours at Petals, her mother’s floral shop. She receives about $200 a month altogether from the three daddies. In early 2015, she lived with Grandma Diane Teter, along with her then-two-year-old daughter Blakelyn. Three of the older children were with their fathers most of the time. After Brhayeannon’s father was killed after his four-wheeler flipped on top of him, she went to live with Grandma Kathy and Grandpa Mark.

Like many others, Walters had her first baby as a teenager. Grant County’s teen pregnancy rate is 56 for every 1,000 births, compared to the U.S. rate of 34. Part of the problem, Hahn said, is the explosion of meth and opioids: “They have pill parties, share needles, get drunk and pregnant,” Hahn said.

At times, Hahn can come across as scathing and sarcastic. But his patients see only compassion. Indeed, nurses recall how he has delivered second and third babies even when a family hasn’t paid the bills for the first. On many Wednesdays, surgeries include no-charge hysterectomies for women who don’t qualify for Medicaid or lack funds to pay their insurance deductibles. One woman routinely pays him in vegetables from her garden.

Still, when the subject of drugs comes up, Hahn goes into full rant mode. He misses the days when his small town didn’t have the big-city issues of drugs.

“Now we got drugs out our ass,” Hahn said. “They’re suckin’ pills. They’re smokin’ dope. Meth, heroin, coke” and most recently, opioids like Oxycontin, something that is easily found by prescription or in a family member’s medicine cabinet. People joke that the West Virginia mating call is the sound of shaking a bottle of opioids.

Research by the National Campaign to Prevent Teen and Unwanted Pregnancy confirms the link between substance abuse and unplanned pregnancies: More than one third of 15 to 24-year-olds said alcohol influenced their decision to have sex, often without birth control. Here, the problem is worsened by the nearly non-existent sex education. Even the Grant Memorial Hospital top administrators acknowledge the problem; in the non-profit hospital’s annual letter to the IRS, the hospital’s chief executive officer wrote that the hospital, school, and community must do more to address drug abuse and teen pregnancies.

Drug use is inextricably connected to poverty and family chaos, and Walters was no exception. Her life got off to a rough start. Her birth mother tried to self-induce an abortion before a distant relative Dianne Teter talked her out of it. Dianne’s daughter, Kathy, and her husband, Mark Walters, raised the baby. “She’s ours,” Kathy said with a smile.

Growing up, Walters didn’t hear the whole story of her birth mother until she was in her twenties. “It hurts to know that,” she said.

When she was in her early 20s, one of her boyfriends went to jail for making meth, a drug that Walters admits she used with him. Her drug problem meant she lost custody of her children. She has been pregnant nine times and had three miscarriages.

Walters said she hasn’t touched illegal drugs in several years. “Only thing I take is Excedrin, aspirin. I’m as clean as clean can be,” she said. “I don’t go out and party.”

Walters has tried various birth control methods, which have sometimes failed, she said. The nurses discuss and offer various contraceptives to any patient who asks. Walters knows that the most reliable prevention is a tubal ligation, known as getting your tubes tied. But she shuddered at the thought of that surgery. “It scares me.”

She doesn’t believe in abortions. Hahn, a father of seven children with two different wives, said he has never done an abortion and never will.

“Two wrongs don’t make a right,” Hahn said.

No one ever mentions that men can take responsibility for birth control. Nurses list condoms as one of many birth control choices, but few patients request them or more permanent remedies. “We don’t do vasectomies here,” Hahn said.

“The mentality here is they think [a vasectomy] will make them less than a man,” said Gina Hinkle, who runs the local Women, Infant and Children (WIC) office. “They’re Neanderthals!”

Hinkle, who has counseled new mothers since 1981, sees more than 1,500 women a year at this office. She counsels them about the importance of using birth control to avoid more unplanned babies.

Marriage is not a priority. “About 90 percent of them are single moms. If they get married, they’ll lose their medical card,” Hinkle explained.

Sociology research confirms that more U.S. women from all economic and ethnic groups are choosing to stay single. Marriage’s “economic necessity isn’t as urgent as it used to be,” said Elizabeth Catte, the historian and author. For some, “it’s easier to negotiate social service benefits as a single person rather than a married person.”

Rural sociologist Ann Tickamyer said the growth of women remaining single after giving birth reflects the ripple effects of fewer jobs. “The reasons are the same—crappy economics and a lack of mates who present an opportunity for any kind of financial or emotional gain. They’re just not there.”

If the father of the child shows up for an appointment, Hinkle doesn’t hesitate to lecture mom and dad about parenting and marriage.

“If the dad is present, I ask them: ‘Are you going to tie the knot?’”

The typical response: “We don’t think we’re ready for that.

Hinkle says she screams back: “Not ready for THAT?”

Hinkle still has a conventional view of love, marriage, and babymaking. But times have changed. Even young women recall that unwed, pregnant women were scorned not long ago. But that stigma is gone.

“It’s not like when I was young,” said Brittany Reel, a nurse in Hahn’s office. “If I got pregnant, my Mom and Dad would’ve beat my ass. Now it’s very social. They bring their relatives and friends to see the ultrasound.”

The matriarchal society of mothers, grandmothers, and sisters step in and raise the babies. “They grow up with them,” Hahn said. When the crying and pooping start, the older generation often takes over raising the child. Tammy Bland, the owner of Your Sister’s Closet, a consignment store in Petersburg, sells baby clothes to grandparents, such as the couple who needed basics because the mother “dropped the baby off without a coat or shoes in the dead of winter.”

Walters is constantly battling the fathers about the kids. Disputes about custody, child support, and drugs “just tore my family apart,” she said. “We’re just now getting back together. Without them, I’d be out on the street in a cardboard box.”

Around 12:30 pm. on the day Walters gave birth, Josh Chaney, father to the youngest two girls, came into the room wearing torn, faded jeans over thermal underwear and a West Virginia University sweatshirt. At age 22, Brynleigh was his third child with two women.

“All girls,” he said.

Walters didn’t smile or say a word. She just handed him the newborn. He sat in the chair staring at the child in his lap. Chaney said he spent the morning repairing a friend’s truck.

“The fuel pump went out on us,” he said. Full-time work is hard to find, especially in the winter. “Around here, if you don’t cut timber, work as a mechanic or drive a truck, you can’t make it.”

Chaney held the baby for a while, and then went home. Mark Walters had a Subway ham and cheese delivered for Brittany before she drifted off to sleep.

As she recovered on Thursday, Hahn and his two nurses finished their morning appointments at the Petersburg office before driving to the Keyser clinic, one of Hahn’s “Doc in a Box” offices in Grant and Hardy counties. They lugged a fetal monitor, sonogram machine, and laptops into the backseat of his blue Chevy pick-up truck.

“We’re one valley over from what John Denver was singing about in Shenandoah,” said Hahn, as he drives past Possum Hollow Road on the commute to Keyser.

A quick stop for sodas and the team was ready to see 19 patients in less than three hours. They already saw 20 at the Petersburg office that morning.

This clinic is a remodeled house where a tiny kitchen now serves as the staff’s office. That day, medical assistant Ruth Redman greeted a full waiting room. A petite woman with gray hair stepped up to ask for a doctor’s note so her pregnant granddaughter could be excused from classes at the junior high school.

Women in their early twenties tote two or three toddlers and babies when they visit the office for check-ups on baby number four. The only man here that day was one patient’s father, dressed in camouflage hat, shirt, and pants, looking tired and agitated.

Hahn knows that some folks aren’t happy about having babies. It’s one reason he keeps a loaded .45 pistol in his desk drawer: Angry fathers flick lit cigarettes at him as he walks from his truck to the Romney clinic. “Some days I go into the clinics and wonder if I’ll make it home,” Hahn said. Everyone on his staff is trained in “conceal and carry” gun laws; he held the training session in the Petersburg clinic waiting room. Many pack their own pistols in their purses.

“One woman left this office, then killed her husband that night. She wrapped him a carpet and threw him in the river,” Redman said. “She missed her next appointment because she was in jail.”

“Nobody in their right fucking mind would come and work here,” Hahn said with a laugh.

On a Wednesday evening in June 2015, Brittany Walters was at her sister’s house waiting for two ex-boyfriends to drop off her kids for a twice-weekly visit. She was visibly upset when one of the men failed to show up with her daughter, Maliyah. Her oldest daughter, McKenley, was nine years old at the time. She’s wearing broken glasses patched together by foam glue, leaving large white bubbles on the edges of the lenses.

There is a bruise on her son McKylin’s face.

“Was you being a monkey, jumping on a bed?” she asked the three-year-old.

He nodded yes, earning a kiss from mom.

Grandpa Walters arrived with a giant Fox’s pizza and a bag of Doritos for the crew. The youngest, Brynleigh, was snoozing, while Walters used a curling iron to give McKenley’s straight hair some bounce. That past year, friends and family had been commenting on Walters’ natural flair for doing hair. With the help of her parents, she enrolled in cosmetology school, one of her many attempts to find steady work.

Getting good grades in school bolstered Walter’s self confidence. She seemed to smile and laugh more often, especially when she talked about doing her first haircut in class. “I was scared to death,” she said. To her fear, her instructor replied: “Quit underestimating yourself, Brittany.”

The next lesson was on hair removal, then more intense classes on anatomy of the skin, hair, and nails, required so cosmetologists can spot infections or other problems.

Nearly six months after the baby’s birth, Walters saw signs that Chaney was determined to be a good father to her two youngest children. He visits with Walters and the girls as often as possible. He, too, has worked to find a better job. He started his own tree-trimming business. The two still spend time together, but Walters swears off dating. She occasionally wears a wedding band and engagement ring “when I want (men) to leave me alone,” she explained.

Her mother interrupted: “She wears them when she’s getting along with him, referring to Chaney.

Her daughter is quick to insist she has no desire to get married.

“I’ve seen too many marriages fail. I’m scared of marriage. Never been married or even come close to being married. When a guy says, ‘Let’s talk about marriage,’ I say: ‘Talk to yourself.’” That’s fine with Chaney. He admits they both have a temper.

Chaney could relocate permanently to another city or state to find a better job, but he works odd jobs locally. And he knows firsthand the impact of a father leaving his children.

“That’s what my dad did to my mom. I was seven months old,” Chaney said. He described his childhood as abusive.

One community activist who helps the homeless find shelter and food recalls one young man getting thrown out of his house by his stepdad on his 18th birthday. “My dad did that to me, so that’s what you’re gettin’” were his parting words to his stepson.

The young man was about to graduate from high school. But he couldn’t afford to rent the cap and gown to wear to commencement. When folks at the Community Action Agency offered to pool their money to rent one, he declined because no one from his family would be in the audience, so why bother?

Even when the men show up with the women for their doctor’s appointments, they lament that money is tight because they have multiple families to support. Twenty-four-year-old Matthew Hart joined Shelby Hose during her visit to the doctor. At just 20 years old, she was pregnant with his third child. Unlike many in the area, he had a job with Pilgrim’s Pride, working night shift “in the bloody part. Evisceration,” he said. “Do 240 birds a shift.”

He did what he could to support Hose and his son, Kyle, who had just turned one. She has another son, Nathan, who was three years old at the time. Hart has a child with another woman. “Shelby uses her money to buy stuff for him. I pay child support for my daughter—$353 a month.” Hose gets a social security check for a disability and a father’s death benefit. Hose gave birth to her first child at age 16. “It wasn’t planned,” Hose said, but she took it in stride.

Aimee Cardot—who runs the Community Action Agency and is Rev. Richard Cardot’s wife—worked the phones trying to find emergency shelter for homeless women and children. Grant County lacks a homeless shelter or much public housing. Even Habitat for Humanity stopped building houses here. The nearest homeless shelter is a two-hour drive, if the weather is good.

Tucked in a cramped office beside a pizza shop and liquor store, Cardot worked without air conditioning on a hot summer day in May 2016. The broken AC is held precariously in a hole in the wall with duct tape. The client waiting area is a worn orange vinyl couch. A poster advertises free clothing at Cornerstone Family Fellowship church.

“Smiles are hard to come by in this office,” said Cardot, a college educated counselor who moved here when her husband was hired as the Presbyterian minister in 2003. The mother of three sees the need every hour.

“The jobs here are mostly part-time, minimum wage,” she said. “They don’t pay a lot. You can maybe sustain yourself, but not a family.”

“What’s most shocking is the people who work at the chicken plant,” Cardot said. “A family of four with that paycheck still qualifies for benefits,” such as food stamps and a Medicaid supplement to the limited insurance provided by Pilgrim’s Pride. She is outraged that taxpayers are subsidizing giant corporations like Wal-Mart and Pilgrim’s Pride.

With changes in federal aid programs, many families try to get their children diagnosed with a disability so the family gets a monthly check through Social Security.

“It’s the new West Virginia welfare,” Hinkle said. “They keep finding different things wrong with them or their children. It’s an art form to figure out a way to get a check. Some get diagnosed as autistic.”

She paused, then added that some diagnoses are probably correct because “the family is so dysfunctional.”

Hahn sees the loss of jobs and flood of drugs every day in his office.

Drug enforcement officials shut down a local doctor’s practice after finding he was prescribing unnecessary doses of Oxycontin and other hefty painkillers. “Dr. Feel-good was giving out crap,” Hahn said.

The Charleston Gazette’s Eric Eyre won the 2017 Pulitzer Prize for his investigation into the state’s opioid crisis. He found that West Virginia tops the nation in pharmacies dispensing opioids.

Nor has the federal government done much to combat opioids. President Trump has called it a public health emergency, but hasn’t labeled it a “national emergency,” which would speed up release of federal money to fight the epidemic.

The strongest drug Hahn prescribes to a pregnant woman is Tylenol with codeine, which angers some who want the hard stuff. And all of Hahn’s patients are tested for drug use.

“If we find drugs in the baby’s stool, child protective services rolls in” to the mother’s hospital room, Hahn said. Most times, the baby is just left with the mother, Hahn added. In some cases, the women deliver and then sneak out of the hospital, abandoning the newborn. “They just leave the child. They just leave the room. They leave it to be adopted,” Hahn said, shaking his head. “Probably the best in the long run.”

Babies born to women using drugs suffer from a lower birth weight, fetal stress, and other developmental problems. In some cases, Hahn and the nurses have seen a patient in an exam room, and then send her to another room for an ultrasound. In between the two doors, the woman slips into the bathroom and shoots up. In one case, Hahn recalled a patient tried to hide the evidence by flushing the syringe in the office toilet, causing it to clog and flood the hallway.

Afterwards, the mother’s ultrasound showed that the baby’s heartbeat was irregular. “The babies are stoned, cruising like their mothers,” he said.

For many, getting a nursing degree at nearby community colleges is one of the few career paths that allow West Virginians to stay in their home state. Thanks to an aging population and the high birth rate, nurses can find good-paying jobs here. Jerica Bobo is one of the area’s success stories. She earned her nurse’s degree while working three or four days a week at Pilgrim’s Pride.

“I worked in evisceration where the chickens were just killed and they’re still hot, pulling their guts out,” Bobo said. “My arms hurt so bad that I couldn’t roll down the windows in my car. I had rashes on my arms from chicken shit. I had a rash around my neck from something in there.”

She remembered telling herself: “I’m not doing this for my entire life. I’m not going to be around chicken shit all my life.”

But now even nurses are worried about the future, despite the booming business of delivering babies. Grant Memorial Hospital’s finances rise and fall with every change in health insurance laws and federal reimbursements.

Even Hahn sees the boom and bust times. In good years, he has made $800,000 from profits of three clinics. Other years, he couldn’t pay his phone bill because of high malpractice insurance premiums, lower reimbursements, and unpaid hospital bills.

“Some years, I was paid $175 for a vaginal delivery,” he said. “If it was a C-section, it was $225. For the whole pregnancy. You can’t physically do that. That’s 371 deliveries a year just to pay the malpractice bill, not the rent, not the heat. It’s indentured servitude.”

Even now, he gets about $375 from Medicaid when he does a hysterectomy, compared to $1,000 from private insurance companies.

Most days, Hahn doesn’t have time to pay attention to the bickering 180 miles away in Washington, D.C. In the 2016 election, he voted for the Democrat, Jim Justice, a billionaire coal baron who owns the posh Greenbrier Resort, for West Virginia governor. He supported Republican candidate Ben Carson in the 2016 presidential primaries because “he’s a doctor, the smartest one out there and he’s got my back,” Hahn said. After Carson was defeated, Hahn echoed what his working class neighbors did at the polls: “Trump is a son of a bitch, but I’m voting against Hillary.”

On top of the turmoil in Washington, there’s financial trouble at Grant Memorial. The Grant County Commission, which oversees the non-profit hospital, hired accountants and an attorney to investigate billing and other financial issues.

The outside review of the hospital’s finances show it has been operating at a loss for the past five years. The county commissioners hired a management consulting firm in 2017 to oversee the hospital. Hahn said the hospital owes him a lot of money. He filed a whistleblower letter with the IRS. The hospital kicked him out of his office. Hospital management didn’t return phone calls and emails seeking comment on the issue.

As of now, he is still delivering babies at Grant Memorial. If he relocates to another hospital, Grant Memorial will lose about 40 percent of its annual revenues and could be forced to close.

“I have to keep working,” Hahn, now 61, said, “so the sons of bitches can pay me back.” He hopes for resolution of the billing issue because the region needs Grant Memorial. Indeed, few others take so many Medicaid patients.

Nurse Reel in Hahn’s office has never looked at whether a patient has private insurance.

“Dr. Hahn told us it doesn’t matter. They’re our patients,” Reel said. “The poorest ones are the nicest people because they appreciate our care.”

By the summer of 2017, Walters’ parents had rented out a tiny store next to the flower shop so Brittany and her sister Tiffany can open their own salon. There’s a debate on naming the shop. For now, both names are on the sign: “Sassy Hair” and “Curl Up & Dye.”

Walters is grateful for all of the support she gets from her mother, grandmother, and her bigger network of women, including her cosmetology teachers.

“She’s taught us not to let people walk all over us,” Walters said. “It’s not all out of a book. I’d rather someone teach me that.”

Walters’ state cosmetology license is framed on the wall. The shop still needs some work so Walters took a part-time job as a home health care aide in the summer of 2017 and cuts hair some evenings. Chaney has found a better job as a mechanic, traveling to various power plants and other manufacturing sites. The work requires being out of town for weeks at a time, just like so many other men in Grant County.

“About 98 percent of my friends from high school all work away from here,” Chaney said. “They’re all leaving.”

One morning in June 2017, Walters had a break and gave daughter Maliyah a haircut and curls. The little girl fidgeted for her mother to finish. Her aunt Tiffany was going to take her to McDonald’s for lunch.

Walters paused from the haircut to reflect on her life. She grew up with lots of cousins and expected she would eventually have her own children. But “I never thought I’d have kids as early as I did. I was 19 when I had her. It was kind of scary.”

Parenting means “changing diapers, dressing them, bathing them, feeding them and making sure they have everything they need. But it’s rewarding, too. I’ve got six of them and get to watch them grow up and develop their own personalities.” Just hearing them call her “mommy” makes her smile.

The small-town culture of unplanned pregnancies is summed up best by her Grandma Teter: “Once you get over the shock, we’re always been happy with babies. I didn’t know Brittany would bless me with so many. Once you have a child, isn’t every day mother’s day? To me it is.”

Correction: A previous version of the story spelled Gina Hinkle’s name wrong.

Alecia Swasy is a professor and Reynolds Chair in Business Journalism at Washington & Lee University. Prior to earning her PhD, Swasy worked as a reporter and editor at the Wall Street Journal and Tampa Bay Times. She has been covering Appalachia for more than 30 years.

Stephanie Veto writes, shoots, and edits short films for Lehigh University as the videographer in the Office of Communications and Public Affairs. She also works as an adjunct professor, freelance photographer, and documentarian.