Rural Hospitals Retreated From Childbirth; Small Towns Pay The Price

Living deep in the Minnesota woods near the Canadian border, Tamer and Yvette Ibrahim pride themselves on being ready for anything the wilderness can throw at them.

Then baby Zein, a blizzard and white, arrived at the hospital.

Yvette Ibrahim’s complicated pregnancy created unexpected challenges, including having to drive five hours to Duluth and back each month for checkups. Everything was mostly manageable until the night in December 2016 when her water broke. Snow fell thickly across the darkness of Arrowhead, but Zein did not wait.

When the phone broke and there was no way to get medical advice, the couple felt they had to take the risk. Departing for Duluth at 1 a.m., they arrived at the hospital four hours later.

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Yvette Ibrahim gave birth to Zein safely after 46 hours of labor. But recently, as she sat at home, holding her 2-year-old child in her arms, she wondered about the dangerous trip that could have been avoided if there had been a maternity hospital closer to home.

Mười tám tháng trước, vợ chồng Ibrahim có thể đã lái xe đến Grand Marais để sinh con tại bệnh viện North Shore Health. Thay vào đó, họ lái xe qua đó vào đêm hôm đó vì North Shore đã ngừng sinh con vào năm 2015 – một phần của xu hướng đáng lo ngại khiến các phòng khám ở nông thôn và lãnh đạo thị trấn nhỏ thất vọng trên khắp Minnesota và cả nước.

Ngày càng nhiều bệnh viện ở nông thôn sẽ không thực hiện các ca sinh nở theo kế hoạch, với lý do chi phí pháp lý và bảo hiểm. Ngoài ra còn có thách thức trong việc thu hút bác sĩ đến các thị trấn nhỏ và yêu cầu của hệ thống bệnh viện trong việc củng cố các trung tâm sinh nở. Tất cả những điều này đều xuất phát từ một vấn đề cơ bản: ngày càng có ít trẻ em ở nông thôn.

Đó là một chu kỳ tạo ra các vấn đề chồng chéo cho cộng đồng nông thôn và các cặp vợ chồng, tạo ra rủi ro mới cho phụ nữ mang thai, những người phải di chuyển hàng giờ để sinh con và khiến việc giữ thanh niên ở thị trấn nhỏ Minnesota trở nên khó khăn hơn nhiều.

Grand Marais tận mắt chứng kiến ​​điều đó.

Trong khi North Shore vẫn giải quyết nhiều nhu cầu chăm sóc sức khỏe của cộng đồng, bao gồm cả chăm sóc trước và sau sinh, việc đóng cửa trung tâm sinh sản đã mở ra cánh cửa cho một tình thế tiến thoái lưỡng nan của người dân và không có giải pháp dễ dàng.

Cánh cửa đóng lại, nỗi lo dâng cao

Các thị trấn trên khắp Minnesota và cả nước đang phải đối mặt với những áp lực tương tự.

Số bệnh viện trong bang cung cấp dịch vụ sinh nở đã giảm gần 18% từ năm 2000 đến đầu năm 2015. Vùng nông thôn Minnesota bị ảnh hưởng nặng nề nhất: 15 bệnh viện nông thôn của bang đã ngừng đỡ đẻ trong thời gian đó – giảm gần 38%.

“Tất cả những yếu tố này phối hợp với nhau khiến một số cộng đồng rất dễ bị tổn thương trước những kết quả tồi tệ… Đó là thứ thực sự có thể hủy hoại một cuộc đời. Nó có thể hủy hoại một gia đình, có thể hủy hoại một cộng đồng.”

Điều đó khiến những chuyến đi dài hơn và những lo lắng lớn hơn đối với những người sắp làm cha mẹ. Một nghiên cứu gần đây của Đại học Minnesota cho thấy nỗi lo lắng tăng vọt khi các bệnh viện Grand Marais và Ely, Minn., ngừng cung cấp dịch vụ chuyển dạ và sinh nở vào mùa hè năm 2015.

Những phụ nữ được chăm sóc trước khi sinh tại địa phương cho biết mức độ lo lắng tăng gấp 10 lần từ năm 1990 đến năm 2016, một năm sau khi cơ sở này đóng cửa. Nghiên cứu cũng tiết lộ những lo lắng của phụ nữ về tương lai của cộng đồng khi các bệnh viện ngừng sinh con. Một người trong nghiên cứu trả lời: “Tôi cảm thấy mình như một công dân hạng hai… Tôi cảm thấy chính phủ không quan tâm đến cư dân nông thôn”. “Tôi rất phẫn nộ, vô cùng buồn bã, sợ hãi (tôi đang mang thai đứa con thứ hai) và lo lắng! Đây chắc chắn là một mất mát lớn cho cộng đồng”.

Trên toàn quốc, hơn một nửa số quận nông thôn thiếu dịch vụ chăm sóc sản khoa và con số này đang tăng lên khi các bệnh viện ở nông thôn phải vật lộn với áp lực buộc nhiều nơi phải đóng cửa hoàn toàn.

Các khu vực nông thôn nơi người dân nghèo hơn, da màu, sức khỏe kém hơn và có nhiều khả năng tham gia các chương trình công có mức lương thấp như Medicaid thì có nhiều khả năng bị mất các dịch vụ y tế hơn.

Giáo sư Katy Kozhimannil của Đại học Minnesota, người nghiên cứu các xu hướng chăm sóc sức khỏe ở nông thôn, cho biết: “Những yếu tố này phối hợp với nhau khiến một số cộng đồng dễ bị tổn thương sâu sắc trước kết quả kém trong thời gian sinh con”.

Cô nói thêm: “Và khi tôi nói điều gì đó như kết quả tồi tệ vào thời điểm sinh con, tôi không chắc điều đó có truyền tải đầy đủ bi kịch mất mẹ hay mất con hay không”. “Đó là thứ thực sự có thể hủy hoại một cuộc đời. Nó có thể hủy hoại một gia đình, có thể hủy hoại một cộng đồng và nó xảy ra thường xuyên hơn ở một số cộng đồng hơn những cộng đồng khác.”

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.”

‘A maelstrom’

Grand Marais Mayor Jay Arrowsmith DeCoux took office shortly after North Shore Health announced it would stop delivering babies. He’s heard concerns repeatedly since then about the long trip to Duluth for pregnant women, and the worries about what the end of local baby delivery might mean for Grand Marais.

“I don’t know if calling it a maelstrom would be out of line,” Arrowsmith DeCoux said as he worked in his downtown bike shop. “But man, there were a lot of people up in arms about that … There’s a lot of pride of place up here. ‘I’m from this place. I was born in this place.’ That sort of thing.”

That helps Grand Marais remain vital, he added. When people feel deep emotional ties to the area, it’s easier to keep them there in spite of the remoteness, the weather and high housing costs.

The end of obstetric services at the hospital has been a deal-killer for some people thinking about settling in Grand Marais, he said. “We’ve had a number of people choose not to call this place their home because they’re afraid of the life-spectrum care that’s available.”

When young people leave Grand Marais, it erodes the workforce, which makes it harder to attract businesses, which threatens the region’s economy, which makes it harder to attract young people — a cycle that many rural towns face as they try to sustain themselves.

The town batted around ideas to make the situation easier on families — providing a house in Duluth where pregnant moms can stay for a while, or encouraging employee policies that accommodate women who need extra time for doctor visits in Duluth. But it’s been difficult, Arrowsmith DeCoux said.

“That’s a system we plainly do not have set up in the United States,” he said, “which is strange because we are such a rural country.”

Broken economics

Maternity care is expensive to provide. It’s a common refrain when the discussion turns to why hospital labor and delivery services are disappearing in rural Minnesota and even some smaller cities.

North Shore Health stopped doing planned deliveries in Grand Marais in 2015 because it couldn’t afford the added staff, equipment and training to do a cesarean section — an emergency procedure to rescue a birth going badly. Its insurer warned it was out of compliance with current medical standards.

But the pressure to be C-section ready had the perverse effect of stranding Grand Marais women two-plus hours from a place they could deliver, and changing medical risks rather than reducing them as intended.

“We couldn’t blame the hospital board, we couldn’t really blame the insurance company. This is just the way the world is changing.”

The hospital felt it had no good options, said Kimber Wraalstad, North Shore’s administrator. It could keep delivering babies without offering C-sections and risk a devastating lawsuit if something went wrong. Or, it could build an operating room and staff it round the clock.

Wraalstad said that would have cost $1 million more each year in a hospital that was averaging only 10 births a year and has many other needs. Plus, the new obstetrics team wouldn’t be able to keep up its skills.

“It’s not that a decision like this comes easy,” she said. “The funnest thing that I used to do was to sign the birth certificates with these little-bitty feet on them. But that’s second to the safety of those little itty bitty feet.”

Elsewhere, changes are happening because decisions about the services hospitals provide are increasingly out of the hands of local residents.

Albert Lea, Minn., found that out two years ago when Mayo Clinic, which operates the town’s local hospital, said it would close the maternity ward and move baby delivery and other services 30 minutes east to Mayo’s Austin, Minn., campus.

The news brought protests from angry Albert Lea residents. With a population of nearly 18,000, the southern Minnesota city is not rural but serves a largely rural part of the state. Mayo, though, said too few babies were being born at Albert Lea, contributing to millions of dollars lost between its Albert Lea and Austin facilities.

Obstetrics in particular can be a money loser for hospitals when the number of births is low, said University of North Carolina health care finance expert George Pink.

“You have to have a physician on standby, you have to have nursing staff, you have to have surgical staff,” he said. “All those costs continue whether you have patients or not, and that’s the basic source of unprofitability.”

Dr. Paul Terrill, a family physician who delivered babies for years in Grand Marais before birth services ended, said he understood the logic behind the hospital’s decision.

“We couldn’t blame the hospital board, we couldn’t really blame the insurance company,” Terrill said. “This is just the way the world is changing.”

Little ‘tolerance for risk’

The financial realities reflect a growing reluctance to shoulder the medical, financial and legal risks of a delivery that goes badly, said Dr. Jenny Delfs, who also practices in Grand Marais.

“Birth hasn’t changed,” she said, “but our society’s tolerance for risk has changed.”

“When I finally go in for my heart surgery, I don’t want the heart surgeon to be standing over me saying, ‘We’re glad to see you. We haven’t done one of these in a while.’”

And it’s not just insurance companies looking to shed risk. Mothers in Grand Marais, for instance, were increasingly choosing to deliver in Duluth because pain-reducing epidurals and C-sections were available there. Women with complicated pregnancies were automatically referred to Duluth, too.

Physicians coming out of medical school are also more risk-averse these days, with residents typically delivering babies in facilities with the staff and equipment to perform a C-section if problems get out of hand.

Delfs, who has been practicing in Grand Marais as a family doctor for more than 20 years, said when she was in school, the expectation was that family doctors would do deliveries without a C-section backup.

“It was just what we were trained to do,” Delfs said. “But as I’ve been here longer and go down to Duluth and teach at the residency, especially the younger residents would look at me like, ‘You do what?’ It was like I was a unicorn.”

Daniel Zismer, a former health system executive and professor at the University of Minnesota School of Public Health, said it makes sense for younger rural doctors to be leery of deliveries.

With fewer babies born in rural areas, it’s harder for doctors to keep up their skills and manage unexpected complications, he said.

“When I finally go in for my heart surgery, I don’t want the heart surgeon to be standing over me saying, ‘We’re glad to see you. We haven’t done one of these in a while,’” he said.

Frequency is one of the strongest predictors of the quality of any medical service, he added, so it makes economic and medical sense to consolidate specialized services like obstetrics in facilities that can reduce risks to patients.

“The bigger question for the sake of the public health is what can [rural hospitals and clinics] reasonably provide in this community in a high-quality way, affordably,” he added.

Zismer said traveling is better than having a serious complication in a facility that’s not qualified to manage it. He recalled the deposition of a physician involved in a terrible birth outcome who acknowledged she was in over her head. “Well, it’s kind of hard to restart the process at that point when the place that is qualified is, you know, 50 to 100 to 200 miles away.”

Still, standards meant to reduce risks for mothers and babies — and lawsuits against doctors and hospitals — can also create other problems for rural women.

In Grand Marais, pregnancies involve new risks for patients, their families and the doctors managing those pregnancies, said Delfs. That includes unexpectedly having babies in the North Shore Health emergency room, which isn’t fully equipped for delivery.

“It felt like we took the risk off the hospital insurer,” she said, “and we put that risk both on my patients, and took some of their choice away, and put some of that risk back on me.”

Life and death decisions

While it might be easy to shrug off the worries of rural parents-to-be, research shows the concerns are deadly serious.

Studies done nationally and in states outside Minnesota suggest that a lack of access to rural obstetrics care is associated with a higher rate of preterm delivery and infant mortality.

“The logistics start to really overshadow the actual act of being pregnant and giving birth itself.”

A 30-year-old study done in rural Florida found a 2.3 percent increase in infant mortality when a community lost a family physician providing maternity care. The same study showed that the loss of one OB-GYN in a rural community increased infant mortality by 9.6 percent.

A separate 2017 report in Scientific American magazine found maternal deaths to be 60 percent more likely in the nation’s most rural areas than in large metro areas, although the role of distance is unclear. There could be other factors at play, such as underlying health conditions like hypertension or diabetes.

Births that don’t go as planned can lead to mental health problems for some women, including post-traumatic stress disorder, said Dr. Sandy Stover, who teaches medicine at the University of Minnesota Medical School Duluth campus, a center for rural physician training.

“For women who have a birth that was not what they thought it would be,” Stover said, “I have a number of women who still deal with PTSD.”

Stover, who worked for decades in Grand Marais delivering babies at North Shore Health until the hospital ended obstetrics, said doctors worry about elevated anxiety during pregnancy because it is associated with a host of other complications, including postpartum depression.

Canadian researchers have found that women who live more than two hours from a hospital are more likely to have labor induced for logistical reasons, though inducing labor can make birth more complicated. Women who live between one and two hours away are more likely to deliver en route to the hospital.

The Canadians have also concluded that infant mortality is higher for mothers living more than four hours from a hospital. Newborns of mothers one to two hours away are more likely to need expensive neonatal intensive care.

Beyond the stress of driving hours to get to a hospital, families face extra costs if they choose to stay there until delivery. Parents may also need to find care for children still at home.

The entire pregnancy and delivery ecosystem is grounded in the idea that women live near the place they’ll deliver, said Grand Marais nurse Kristin DeArruda Wharton. That includes the typical video telling moms-to-be to head to the hospital when contractions are five to 10 minutes apart — impractical advice when the hospital is two hours away.

As part of a fellowship aimed at closing gaps in rural health care, DeArruda Wharton created a video with tips on a successful rural pregnancy, touching on topics like whether to stop at the local emergency room during labor, and coordinating care between local prenatal providers and the team that will eventually deliver the baby.

But she said distance is just one problem in rural pregnancies. Residents in Grand Marais face the added stress of managing the logistics of getting to and from Duluth for prenatal care and birth. And in some cases, they lose wages because of those trips.

“The logistics start to really overshadow the actual act of being pregnant and giving birth itself,” she said.

‘Tại sao điều này lại xảy ra với chúng tôi?’

Terrill, người hành nghề tại Phòng khám Sawtooth Mountain ở đó, cho biết quyết định chấm dứt các dịch vụ sản khoa ở Grand Marais đã gây khó khăn cho nhiều người trong thị trấn, bao gồm cả cộng đồng y tế.

Anh ấy nói, một trong những phần tốt nhất của công việc là đỡ đẻ cho rất nhiều đứa trẻ lớn lên ở Grand Marais.

Ông nói: “Có rất nhiều cảm giác mất mát” khi bệnh viện ngừng thực hiện các ca sinh theo kế hoạch. “Bạn biết đấy, ‘Tại sao điều này lại xảy ra với chúng tôi?’”

Ngày nay, các bác sĩ của Grand Marais tập trung vào việc chuẩn bị cho bệnh nhân sinh con xa nhà trong nhiều giờ.

Bác sĩ Kurt Farchmin nói chuyện với bệnh nhân của mình rất nhiều về những dấu hiệu chuyển dạ sớm vì ông không muốn họ lãng phí thời gian quý báu đến phòng cấp cứu Grand Marais, đặc biệt là vào mùa đông.

Ông nói: “Chúng tôi thực sự vạch ra cảnh chuyển dạ sớm trông như thế nào và nói, ‘Nếu bạn cảm thấy điều này đang xảy ra, chỉ cần lên xe và đến Duluth.

“Điều đó không lý tưởng,” anh ấy nói thêm, “nhưng chúng tôi cảm thấy nó sẽ đưa mọi người đi theo con đường và tiến gần hơn đến nơi chúng tôi muốn họ đến.”

Hiện 34 và 42 tuổi, Yvette và Tamer Ibrahim đang chuẩn bị chào đón đứa con thứ hai vào tháng tới.

Yvette Ibrahim, a biologist who traps and tracks wolves in the North Woods, said she was still nervous about the trip to Duluth; This time, she hoped, it wouldn’t start at 1 a.m. in a blizzard.

Now, they are looking for better ways to manage the dangers and worries of being pregnant far from Duluth. One option is to use vacation time to stay in Duluth for a few days before the due date. That’s a luxury for many people in remote northern Minnesota, Tamer Ibrahim noted.

“For those who are struggling financially or don’t have resources like friends and family to help, not having that kind of care here becomes a big challenge,” he said.

Did you experience similar challenges during your pregnancy?

More information about maternity care and women’s health

• Research: The risk of giving birth increases when rural hospitals stop delivering birth services

• Nearly dying in childbirth: Why preventable complications are on the rise in America

• Top 5: Questions about your maternity hospital