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HEALTH CARE: A Stork Contrast: Days of Baby Delivery at Rural Hospitals Steadily Slipping Away

Posted on: Sunday, 15 January 2006, 12:00 CST

By Ryan Bakken, Grand Forks Herald, N.D.

Jan. 15--GRAFTON, N.D. - Laura Satterlund was born here and gave birth to her 2-year-old son, Tucker, here.

But when her second baby arrives in mid-February, she and husband Chad will need to travel to Altru Hospital in Grand Forks for the birth. As of Nov. 1, Unity Medical Center no longer delivers babies.

That disappoints her.

"I think it's ridiculous that a town the size of Grafton can't offer childbirth," she said. "They're always promoting that Grafton residents should do everything local. Having lived here all my life and having good insurance, I find it hard to believe I can't give birth here."

Believe it.

Unity is the latest in a long line of rural hospitals that have stopped delivering babies. The last birth in Pembina County Memorial Hospital in Cavalier, N.D., happened slightly over a year ago. Hospitals in Langdon, Northwood, McVille, Cooperstown, Hillsboro and Mayville, N.D., proceeded them in bowing out of obstetrics.

First Care Health Center in Park River, N.D., and Kittson Memorial Hospital in Hallock, Minn., are the only rural hospital in the upper Red River Valley that still offer the service.

All hospitals can deliver babies in an emergency. But only 13 of North Dakota's 38 rural hospitals defined as any that don't exist in the four urban centers routinely do it.

Inconvenience

Expectant mothers such as Satterlund and Daisy Torres of Grafton now are encountering the problems that expectant mothers in other rural areas of North Dakota have experienced before them.

One problem is the 45-mile trip to Grand Forks for checkups and the delivery. It's not only inconvenient, but expensive.

"My husband (Joey) works during the day, so I have to take my two other kids with me to the appointments," Torres said. "It's more expensive. Besides the gas, (1-year-old) Christa and (3-year-old) Joey Jr. see the McDonald's and say they want a Happy Meal."

Unity offers prenatal care up to six months of the pregnancy, then hands off the patient to Altru. However, most women want to deal with one doctor through the entire process.

Satterlund said the trips to Grand Forks for prenatal care mean she almost needs to take off a full day from her job at the post office rather than two hours. And husband, Chad, who accompanied her on the doctor visits before Tucker was born, can't attend because of his job.

But the minuses are about more than time and money.

"I know all the nurses and everybody else here," Torres said. "When you get used to somebody, it's hard to change. You trust your regular doctor and nurse."

Torres said it's possible that another doctor in Grand Forks besides her own may deliver her baby, due in early March. "You don't want that," she said. "You want your own doctor to take your baby out."

For Satterlund, there was comfort in having her doctor in Grafton live down the street from her home, her nurse live across the street and the hospital five blocks away.

She said she likes her new doctor in Grand Forks, "but I don't know her. I see her about five minutes every checkup. Giving birth is kind of private. You want to feel comfortable."

Although Unity can handle an emergency, the prospect of traveling 45 miles during labor especially during the winter causes anxiety.

"Chad is worried about the trip to Grand Forks," Satterlund said. "But as long as the delivery doesn't happen in the car, I don't care."

Developing trust

Marlene Miller of the Center for Rural Health at UND said trust is essential to soothe women in labor.

"There are all kinds of fears that come with giving birth," Miller said. "Having the same caregiver with you throughout the entire experience is important. Going to a new setting or new caregiver is scary.

"Having a child is a life-changing experience. It takes time, especially with the first child, to develop that relationship and trust with your caregiver."

Miller said another downside to traveling to give birth is that it might mean having less family support immediately. The other children or relatives may have more difficulty getting to the hospital.

The lower the income, the greater the concern, say Walsh County (N.D.) nurse Wanda Kratchovil and Brad Gibbens of the Center For Rural Health. The inability to travel or the expense of travel might mean that low-income expectant mothers will delay visits to a doctor.

"If it's tougher to gain access, people won't run to the doctor every time something goes wrong," Gibbens said. "When they do go, the problem is likely to be more serious, cost more and is more likely to be life-threatening."

Kratchovil said that Unity's change is just another example of a decrease in access to rural communities.

"It's really unfortunate," she said. "But I do understand that it's best that they not continue at Unity. I support their decision because it's based on safety issues."

Reasons the same

The reasons at Unity are the same as they are throughout rural America.

The big reason is that rural areas have a declining population, especially for people of child-bearing years. That has meant fewer births.

Fewer births have caused a spiraling effect, both for staffing and the bottom line.

The catalyst, Unity CEO Everett Butler said, was that a March retirement left only one surgeon to handle cesarean operations. That meant difficulty in fulfilling the requirement that a surgeon be available on short notice.

A shortage of OB nurses also contributed to the decision, Butler said.

When Unity warned expectant mothers in the spring of 2005 that they couldn't guarantee a delivery room, many went to Park River or Grand Forks so they could have one doctor throughout the pregnancy. That contributed to Unity dropping from 53 births in 2004 to 20 in 2005.

"In order to allow the staff to keep their skills in delivery, they need to have the opportunity to experience it," Butler said. "We don't have the numbers to keep them adequately trained and efficient."

Another reason was the cost of malpractice insurance, which is costly for OB work. Unity didn't have enough births to help pay the insurance premiums.

"OB was not a money-maker by a long ways," Butler said. "It was done at an overall loss."

Gibbens said rural areas have a higher percentage of residents who don't have health insurance. People without insurance are more likely to default on a major hospital bill.

Still, Butler said it was a difficult decision, not a slam-dunk.

"We saw it as a service to the community," he said. "A couple of physicians still enjoyed doing them. And any time you take a service that you've always provided, it's difficult."

Gibbens said it's an example of the changing face of health care in the world, nation, state and region.

"The population continues to get older in rural areas," he said. "As life lasts longer, there are more chronic-health situations, which places different demands on the health industry."

Same issues

Other area hospital CEOs understand what Butler went through. With so few births, it's difficult keeping staff competent and confident in deliveries, they say.

"Childbirth is a high-risk area," said Pete Antonson, CEO at Northwood Deaconness Health Center. "Insurance companies really don't want us doing them. They're nice to do, but it's just too hard."

Cavalier County Memorial Hospital in Langdon hasn't delivered babies since the mid-1990s. Mothers need to travel 65 miles to either Cando, N.D., or Devils Lake or 110 miles to Grand Forks. Most opt for Grand Forks.

"If you don't have the volume to offset the malpractice premiums, you can't subsidize it with another department," CEO Lawrence Blue said. "At a bigger hospital, you can subsidize one department with another."

Hanging on

Towner County Medical Center in Cando, despite being a smaller town than Grafton, Cavalier and Langdon, has kept obstetrics despite averaging only 15 to 20 births a year.

"We do it because it's an important aspect of trying to provide coverage in rural America," Acting CEO Bob Spencer said. "But that's changing. Just because we want to do it doesn't mean we'll be able to continue to do it.

"But we're committed for at least one more year."

Bakken reports on local news and writes a column. Reach him at 780-1125; (800) 477-6572, ext. 125; or rbakken@gfherald.com.

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Copyright (c) 2006, Grand Forks Herald, N.D.

Distributed by Knight Ridder/Tribune Business News.

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Source: Grand Forks Herald (Grand Forks, N.D.)

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