Despite cuts at hospitals, state still delivers on rural obstetrics

Just two months after moving to a farm in Minnesota, Morgan LaSalle got pregnant and made a discovery about her new home in Onamia — its hospital didn't deliver babies.

Online research put her at ease, as she found birthing centers to the northwest in Brainerd, to the east in Mora, and to the south in Princeton and St. Cloud. But none was closer than 30 miles. And the California transplant was going to be due in February, in her first full-blown Minnesota winter.

"I was a little nervous about that," she said.

LaSalle's experience exemplifies rural obstetrics in Minnesota: There are still options, but they are diminishing and leaving expecting mothers with concerns and risks.

A report released Wednesday reveals Minnesota to be a paradox in rural obstetric care. No state has had more hospitals stop delivering babies in the past decade. And yet, Minnesota still has a higher rate of rural hospitals providing obstetrics (OB) per women of childbearing age than almost any other state, according to research by the Chartis Center for Rural Health in Massachusetts.

Presenting the data in Washington, D.C., Chartis' Michael Topchik said Minnesota's top status is a dubious honor.

"Only 46 percent of rural hospitals provide OB," Topchik said. "So the fact that Minnesota is the best means you're the … best of something bad."

Insurance or accreditation standards have forced many small hospitals to surrender baby deliveries — even though they're a beloved community service — because their doctors don't perform enough to be considered competent, or because they aren't close enough to large hospitals able to perform emergency C-section deliveries.

Chartis has tracked 134 rural hospitals that stopped scheduling deliveries since 2011, including 13 in Minnesota. They are in Baudette, Onamia, Madelia, Ely, Grand Marais, Appleton, Dawson, Canby, Springfield, Lake City and Wabasha. OB services ceased in Albany as well due to the hospital's closure.

Impact on birth outcomes

National research shows that such closings have an impact on birth outcomes. Katy Kozhimannil, director of the University of Minnesota's Rural Health Research Center, found that rural hospital closures are associated with more out-of-hospital births as well as births that take place in emergency rooms.

Closures also appear associated with a slightly elevated rate of preterm births, perhaps because women have to travel farther for certain aspects of prenatal care, such as testing for gestational diabetes, she said. "If folks are not able to get in, or if they have to travel back and forth or take time off work, then that may be the mechanism" leading to more preterm births, Kozhimannil said.

Dr. Jen Pearson at the University of Minnesota-Duluth surveyed women in Ely and Grand Marais and found more anxiety among those who had given birth after their local hospitals stopped scheduling deliveries.

"It makes where I live feel incomplete," one woman responded, according to the study published in the journal Birth. "The hallmark of a community is where its citizens can be born and die there."

Minnesota continues to have more rural OB options for women than other states because it had more hospitals providing the service before the national closure wave began, Topchik said. But that finding is based on Chartis' broad, population-based analysis, which favored large states with smaller populations.

Problems emerge at community levels, Topchik said, even in Minnesota. North Shore Hospital in Grand Marais was originally built as a county hospital so that women on the Gunflint Trail didn't have to travel 100 miles or more to Duluth for childbirth. But it stopped scheduling deliveries in 2015 because of insurance requirements.

Even before the closure, many women were already receiving prenatal care locally, then delivering in Duluth, said Dr. Jenny Delfs, a family practitioner at the Sawtooth Mountain Clinic in Grand Marais. But she said it was frustrating to lose the local option with women for whom it would have been the safest and most convenient option.

Delfs said the risk of the nightmare scenario — giving birth in a car on a winter night en route to Duluth — is relatively low given the typical timing of labor. But she has had to ride in the ambulance with mothers to Duluth, and she said there have been emergency births in the local ER in the last three years.

"It is the rare baby that doesn't give you time to get there," she said. "Labor and delivery, there a lot of cribbage-playing time to it."

The Grand Marais clinic has focused on prenatal care and employs a nurse coordinator who helps plan deliveries for local patients, Delfs said.

Grand Marais is unusually remote, and more options exist in communities such as Onamia, where the Mille Lacs hospital recently halted scheduling baby deliveries.

And yet expecting mothers there such as LaSalle worry. She chose St. Joseph's Medical Center in Brainerd as her birthing center, even though her farm was closer to other hospitals, in part because of positive reviews online. And over time, the distance became an afterthought as she drove back and forth to Brainerd for prenatal visits.

"I came from San Diego," she said. "I could be in traffic there for an hour and a half."

LaSalle's birth story ended without winter drama or hair-raising drives. Her doctor ordered an induced delivery after LaSalle was a week past her due date. She gave birth on Feb. 23, 2017, to a daughter.

Though she never needed them, LaSalle had contingency plans in case she arrived at the hospital with false labor and was told to return home.

"I would just go and get a hotel room," she said, "and just wait it out."

Jeremy Olson • 612-673-7744