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Rural hospitals retreat from delivering babies; small towns pay the price

January 23, 2019
Yvette Ibrahim holds 2-year-old Zein while her husband, Tamer, heats up dinner in their home outside of Grand Marais in December.
Yvette Ibrahim holds 2-year-old Zein while her husband, Tamer, heats up dinner in their home outside of Grand Marais in December.

Living deep in the Minnesota woods near the Canadian border, Tamer and Yvette Ibrahim took pride in being ready for whatever the wilderness could throw at them.

Then came baby Zein, a blizzard and a white-knuckle ride to the hospital.

Yvette Ibrahim’s complicated pregnancy created unexpected challenges, including five-hour drives to Duluth and back each month for checkups. It was mostly manageable until the December 2016 night when her water broke. Heavy snow blew across the Arrowhead darkness, but Zein wouldn’t wait.

With their phones down and no way to get medical advice, the couple felt they had to chance it. Taking off for Duluth at 1 a.m., they made it to the hospital four harrowing hours later.

Yvette Ibrahim delivered Zein safely after 46 hours in labor. But sitting at home recently, her 2-year-old on her lap, she wondered about the treacherous drive that could have been avoided had there been a birthing hospital closer to home.

Eighteen months earlier, the Ibrahims might have been able to drive to Grand Marais to deliver at North Shore Health hospital. Instead, they drove past it that night because North Shore stopped delivering babies in 2015 — part of a troubling trend that’s left rural clinics and small town leaders frustrated across Minnesota and the country.

A growing number of rural hospitals will not do planned baby deliveries, citing legal and insurance costs. There’s also the challenge of attracting doctors to small towns and the demands of hospital systems to consolidate birthing centers. All of these spring from a fundamental problem: fewer rural babies.

It’s a cycle that’s created cascading problems for rural communities and couples, creating new risks for pregnant women who must travel hours to deliver and making it that much harder to keep young adults in small town Minnesota.

Grand Marais sees that firsthand.

While North Shore still handles many of the community’s health care needs, including prenatal and postnatal care, closing the birthing center opened the door to a small town civic dilemma with no easy solution.

Doors close, anxieties rise

Towns across Minnesota and the country are dealing with similar pressures.

The number of hospitals in the state offering birth services fell by nearly 18 percent between 2000 and the start of 2015. Rural Minnesota has been hit the hardest: 15 of the state’s rural hospitals stopped delivering babies in that time — a nearly 38 percent decline.

That’s brought longer drives and bigger worries for would-be parents. One recent University of Minnesota study found a huge jump in anxiety when the Grand Marais and Ely, Minn., hospitals stopped providing labor and delivery services in the summer of 2015.

Women who received prenatal care locally reported a tenfold increase in anxiety from 1990 to 2016, the year following the closures. The study also revealed women’s worries about the future of their communities when hospitals stop delivering babies. “I feel like a second-class citizen ... I feel that the government does not care about rural residents,” one person in the study responded. “I was outraged, extremely sad, scared (I was pregnant with my second child), and nervous! It is definitely a major loss for the community.”

Nationally, more than half of rural counties lack obstetrics care, and the number is rising as rural hospitals struggle with pressures that are forcing many to close altogether.

Rural areas where people are poorer, of color, in worse health and more likely to be on low-paying public programs like Medicaid or Medicare are more likely to lose health services.

“These factors all work together to render some communities deeply vulnerable to poor outcomes around the time of childbirth,” said University of Minnesota professor Katy Kozhimannil, who studies rural health care trends.

“And when I say something like poor outcomes around the time of childbirth, I’m not sure that fully conveys the tragedy of losing a mother or losing a baby,” she added. “It’s something that can really destroy a life. It can destroy a family, can destroy a community, and it’s happening more often in some communities than others.”

Kozhimannil’s research confirmed that preterm and out-of-hospital births rise when a community loses hospital-based obstetrics care. She’s also found a troubling increase in the rate of emergency room births in hospitals.

“You may not have a clinician there who has done a delivery for quite some time,” she said. “It’s not set up to have all the infant monitors and equipment that’s generally available to support birth.”

‘Sobbing in front of the nurse’

One of the biggest worries for expectant parents is getting to the hospital before the baby is born, even when the hospital is just a few minutes away.

It can be a nightmare when the baby comes early and the birthing center is hours away.

Erin Petz said her 2018 pregnancy in Grand Marais was easy and uncomplicated, which meant she could do most of her prenatal care there with familiar doctors.

She grew up in the area and was used to its remoteness. Still, it was hard to tamp down her anxiety over a 110-mile drive to the hospital in Duluth. What if the baby came early? What if Tyler’s job as a forester near the Canadian border meant she’d have to deal with labor alone?

“I was, like, sobbing in front of the nurse and the doctor ... what is the plan going to be like in case I go in early?” she said, recounting an earlier clinic visit. “I just I wanted some clarity — ‘OK, what is the best contingency plan here?’”

Tyler played out nightmare scenarios in his mind. “We could be delivering the baby in the back of the car by ourselves in the dark at 20 below,” he said. “These are things that happen.”

Then her labor started early. It was hard to decide if what she was feeling was real or a false alarm. With North Shore Health no longer offering birthing services, she went to the emergency room for guidance.

The doctors thought Petz’s condition required a trip to Duluth in an ambulance. “We kind of fought them a little bit on the ambulance thing,” she recalled. “Just because the thought of being strapped down for two and a half hours while having contractions on a bumpy highway sounded miserable ... It was not pleasant being strapped down.”

Corwyn, their first child, was born in Duluth in November, a few weeks ahead of schedule and healthy but with complications that prolonged the anxiety.

Corwyn was jaundiced, a common condition in newborns. As they got ready to head back to Grand Marais, the pediatrician in Duluth told them the baby might need light-therapy treatment, which is standard care in urban hospitals.

“The doctor said, ‘If he needs to go under lights, you can take care of that up there,’ ... so we went home,” Tyler said.

Corwyn needed light therapy, but there was no light treatment in Grand Marais. “And so our doctor says, ’Hey, don’t panic or anything, but I need you to go home, get your things packed up again and drive to Duluth so he can be under the lights,” Petz said. Heading back to Duluth, they grew worried. Corwyn couldn’t stay awake enough even to eat.

Then the car started to bark.

“We’re going up hills and it’s like shifting kind of erratically, and the transmission went out like on the way down, you know,” Petz, 33, recounted. “And it’s December. And there are places on the road where there is no reception. And we have a 3-day-old in the car.”

They broke down in Two Harbors, Minn., about 30 minutes from Duluth. But they had cellphone reception and were able to call their doula, who picked them up and brought them to the hospital.

Tyler, 37, said he accepts the risks that come with living in a remote part of Minnesota in exchange for more independence, but he says the health care hassles there are much worse than his friends living in cities deal with.

“There is a big gulf,” he said. “If we want our rural communities to be strong and to carry on, that gulf needs to get closed somewhat, because otherwise these communities are going to die if there’s no way to have babies here.”

Minnesota Public Radio News can be heard at KZSE 91.7 FM in the Rochester area, or go online to MPRnews.org.

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