On Wednesday night, Dr. Jenny Delfs sat in a civic forum about the future of obstetric care on the Gunflint. On Tuesday night, she lived it — a 110-mile ambulance ride from Grand Marais to Duluth with a pregnant patient experiencing labor pains.
Births have been dwindling at Grand Marais' Cook County North Shore Hospital, but labor runs down Hwy. 61 to Duluth will be increasing soon — a result of Friday's decision by the hospital board to stop offering scheduled deliveries.
While local doctors will continue to provide prenatal care after the decision takes effect in July, the community will lose a service that is becoming difficult for remote hospitals to maintain due to rising costs and stiff professional guidelines.
"It has been a wonderful option for our families," said Dr. Sandy Stover, who along with Delfs has performed most of the recent deliveries at North Shore, "but we are bumping into the real world of what is considered the standard of care."
At least seven Minnesota hospitals have stopped, or planned to stop, scheduling deliveries since 2009. Nationally, University of Minnesota researchers found a 7 percent decline between 2010 and 2013 in hospitals that schedule deliveries.
Some have lost doctors capable of delivering babies and haven't found replacements. Others have been warned by liability insurers that they don't perform enough deliveries, or aren't close enough to emergency surgical services.
The decisions are painful for small towns, despite evidence that low-volume hospitals have higher complication rates, said Katy Kozhimannil, a U researcher on reproductive health. "Birth is one of the only happy events that happens in a hospital. It's really valuable in a community to have births in that community."
The decision in Grand Marais followed a finding from a liability insurer that the hospital did not conform to safety standards set by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. Specifically, the hospital can't perform Caesarean sections or get pregnant women to other hospitals within 30 minutes of needing those surgical deliveries. Hospitals that perform C-sections in Duluth are two hours away.
The hospital can't afford to spend more than $2 million per year to add C-section capabilities, said hospital administrator Kimber Wraalstad, especially when it performs fewer than 10 of the more than 40 deliveries for women in Grand Marais and surrounding Cook County each year. The lack of epidural anesthesia at North Shore already had many women choosing Duluth hospitals.
Ignoring the insurance guidance wasn't an option, she added. "If something horrible happened, which is what you want to avoid, we would be held to those standards. You don't get a pass just because you're in Grand Marais."
Snow, ice, deer
Kristin Wharton gave birth to her third child at North Shore, 20 miles from her rural home, and remembers "what it's like to drive in labor down Hwy. 61."
She argued that many women would gladly pick the shorter drive and use North Shore again if it invested in the staff and equipment to provide C-sections and epidurals. She led a Facebook campaign against the hospital's decision.
"There is an inherent risk to choosing to deliver your baby in an area without C-section capabilities," she said. "On the flip side, our hospital has been delivering babies for 55 to 58 years."
Leslie Olson wanted to give birth in Grand Marais — in the hospital where she was born in 1988 — and avoid the possibility of a three-hour drive in labor from her home in Grand Portage to Duluth. "Winter time, deer — it's hard enough to drive down there just for shopping," she said.
But she ended up in Duluth hospitals for deliveries in 2007 and 2010 in part because she wanted the option of pain medication — though as it turned out, the induced deliveries happened so quickly that she never received any.
Delfs and Stover said pre- and post-delivery care will continue at their Sawtooth Mountain Clinic, which is separate from the hospital, and that they will brainstorm transportation or even housing options to get their mothers safely to Duluth.
Births could still take place at North Shore; the doctors intend to maintain their training and the hospital will be ready for emergencies.
If laboring mothers appear within two hours of birth, an ambulance ride would be too risky, Stover said. "We have to guess two hours ahead of time. The choices you make in rural health care have to be different from the choices you make living across from an urban medical center."
Guidelines on safe side
The Grand Marais and Ely hospitals will halt planned deliveries on the same date. Small hospitals in Appleton, Springfield, Baudette and Wheaton are among those no longer providing deliveries, according to the Minnesota Hospital Association.
Of course, the evidence isn't clear that small is bad. One study found an increase in maternal bleeding following deliveries at lower-volume hospitals, but Kozhimannil's research at the U found that higher-volume hospitals were more likely to induce labor or perform episiotomies to expedite deliveries when not recommended. Even the obstetric and pediatric trade groups acknowledge that evidence is "lacking" behind their 30-minute rule for a woman's proximity to surgical backup during childbirth.
Still, Kozhimannil said she favors guidelines that protect against even rare complications. Also a doula, Kozhimannil participated in a birth Tuesday in which an umbilical cord was unexpectedly wrapped three times around a baby's head.
"It's very rare, but when it happens," she said, "it's very important that there be capacity available to handle an emergency circumstance."
Gwen Danfelt wants to deliver her first child in Grand Marais, but with a June 25 due date shortly before the hospital will stop conducting planned deliveries, her plans might change. Maybe the 28-year-old will get a hotel in Duluth before her due date.
"I'm not very interested in that, nor is my husband," she said. "[We'll] probably just be paying attention and hoping those first couple of hours of labor are really low-key [during the drive to the hospital]. At least it'll be summer."