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Dr. Jonathan Sticca and Dr. Liz Wood are OB Fellows at Altru . photo by Eric Hylden/Grand Forks Herald

Long-distance delivery: Lack of obstetrical services in rural areas mean women must travel to give birth

GRAND FORKS — For women in rural areas, having a baby has become more complicated than it used to be.

For years, more rural hospitals have been shutting down maternity units, forcing expectant mothers in small rural and farming communities to travel longer distances to deliver their babies.

It didn't used to be this way.

"Virtually every rural hospital in North Dakota, probably 40 years ago, was doing obstetrics," said Brad Gibbens, deputy director, UND Center for Rural Health.

Much of the reason for the downturn in rural hospital OB care "has to do with demographics," Gibbens said. "You've had this continual decline of population in North Dakota, particularly in rural North Dakota, combined with the cost element, not only for the physician in terms malpractice and liability (insurance), but for the facilities, having to have backup services and everyone who's trained in it.

"It just became cost-prohibitive," he said.

Because of reduced access, "women of childbearing age today, if they're in rural areas, really have to think ahead about where they're going to receive care. They start to think about things like scheduling the birth or inducing the birth.

"Anecdotally, I've heard of women who, as their due date approaches, go to that town and stay there for awhile," he said, to be close to their health care provider.

"There's kind of an acceptance of it — a mindset of, this is what you have to do," he said. "It's kind of known and understood."

Preparing for rural practice

Dr. Jonathan Sticca, a family physician, is preparing for a rural medical practice that will include obstetrical care.

After completing three years of family medicine residency training in June in South Carolina, Sticca is taking an additional year of training in the obstetrics fellowship program offered by Altru Health System. He practices at the Altru family medicine residency program's clinic in Grand Forks.

Sticca decided to take the fellowship because, although his residency program offered "a pretty good OB experience, there just wasn't a lot of high-risk OB and there wasn't any surgical OB training," he said.

"I knew early on I wanted to go to a very rural practice setting initially where I was going to be responsible for doing prenatal and maternity care, and I just wanted to make sure I had as much experience as possible before I went out into practice in that setting."

His goal is to provide more care to his future patients.

"I made the decision that if I was going to offer obstetrical care to my patients, I wanted to be able to take care of them no matter what complications arose. And if I was going to be managing their entire pregnancy, the simple fact of them needing to have a delivery by C-section, I did not want that to preclude me from continuing their care," Sticca said.

In his future practice, he's likely to encounter some high-risk cases that must be referred to a specialist, he said, "but, in general, I want to be able to take care all of my patients — if they get pregnant — basically, from the day they find out they're pregnant to the day they deliver, and then take care of the child as well."

Filling a need

Sticca plans to join a medical practice at Emmetsburg, Iowa, population 3,900, which is drawing more patients, due to closure of obstetrical units in the area, he said.

He will be helping to fill a need that has been growing as rural hospitals stop providing OB services.

From 2004 to 2014, the proportion of all rural U.S. hospitals lacking hospital obstetrical services rose from 45 to 54 percent, according to a study by the University of Minnesota Rural Health Research Center.

The loss of services is primarily the result of OB unit closures rather than full hospital closures, researchers found.

North Dakota has seen evidence of that downward trend, with many of the OB unit closures occurring before 2004, said Gibbens.

Only five of North Dakota's 38 rural hospitals, located outside the state's four largest cities, still offer obstetrical services. They are Devils Lake, Hettinger, Jamestown, Dickinson and Williston, he said.

The latter two communities have been impacted by the influx of young people drawn to jobs in the Oil Patch. Additional younger residents means more demand for OB services, Gibbens said.

The Devils Lake medical community serves the Spirit Lake Indian Reservation where the median age is younger than that of the state's population.

Economic impact

In addition to the convenience for the patient, the economic side of the question also affects rural areas.

Women who have to travel to stay in another community before giving birth, unless they have family or friends to stay with, may have to shoulder hefty hotel bills, Gibbens said.

Closure of obstetrical units in rural hospitals has meant the loss of jobs in small communities, he said.

"One thing rural hospitals struggle with is the idea that, 'No, we don't do deliveries but, don't forget, your local providers can do a lot of prenatal care.'"

But some women figure if they're going to have a distant physician deliver their baby, they might as well start their prenatal care with that person as soon as they become pregnant, he said.

The net effect is that income from services rural clinics could provide ends up going elsewhere.

Lack of access to OB care also puts pressure on rural health care providers who may have to deliver babies in rural hospital emergency rooms, Gibbens said.

Also in emergency situations, rural ambulance crews, police and fire department personnel may have to deliver babies who arrive on their own schedule — not the doctor's.

Exception to the norm

At least one rural community in North Dakota is reversing the trend, thanks to the influx of young people who've migrated to western parts of the state for jobs in the booming oil industry.

For years, Watford City's population hovered in the 1,200 to 1,500 range, but at the height of the oil boom it swelled to 12,000 to 13,000, Gibbens said.

In recent years, the population has dropped a few thousand, but remains at a level that has prompted administrators of the McKenzie County Healthcare System to seriously consider offering OB services again, Gibbens said.

After careful analysis, administrators have determined that it would require 250 births a year to make that step worthwhile, he said.

"They think they can do that."