Hospital board to make decision on elective birth services

With every seat taken and people standing shoulder to shoulder or sitting in the aisles, the hospital board listened intently to speaker after speaker passionately—sometimes tearfully—explain why the hospital board shouldn’t vote to discontinue elective deliveries at the hospital.

The audience, mostly women with young children in tow or many who are pregnant or of child bearing age, gathered in the board’s meeting room on January 22 at 9:30 a.m. after learning via a Facebook posting by Kristin DeArruda Wharton that the board was considering ending elective obstetrical services (OB).

Impassioned as the speakers were, the decision by the board might well be out of their control.

Cook County North Shore Hospital & Care Center Director Kimber Wraalstad laid out the case for why the hospital should drop its obstetrics services.

“Why is this a topic of discussion now?” said Wraalstad. “Because we received a report from our medical malpractice or professional liability insurer (Coverys) that stated we do not meet the standards of care for OB services.”

Those standards for perinatal care, said Wraalstad, are set by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

“The doctors and nurses have provided excellent quality obstetrical care since 1958. This issue is not about the quality of care provided but whether we can meet the expected standards of care for elective obstetrical services in a hospital,” said Wraalstad.

“In August of this year, Coverys visited our hospital and completed an analysis of our OB services, as OB is a high risk area. We received a report from them in late October and since that time we have been reviewing this report with OB committee members, management and the medical staff,” Wraalstad said.

Covery’s report showed five areas that need improving: quality review processes and findings; OB credentialing, privileging, proctoring and peer review; OB registered nurse training and competency; fetal monitoring; and emergency cesarean section.

Of those problems, Wraalstad said, “The most significant and daunting issue regarding our OB services involves emergency cesarean sections. We do not have the room, equipment or staff to provide an emergency C-section.”

Wraalstad said conservative estimates to meet Coverys’ recommendations are over $1 million per year. “These costs are predominantly anesthesia and surgery employees and we do not even have an operating room at this time,” she said. However, an OB room is in the works for the new expansion/renovation of the hospital and care center.

A big issue is that few babies are born each year at Cook County North Shore Hospital. From 2002-2014 an average of 9.5 babies were delivered in county while on average there were 46.6 deliveries to Cook County residents per year.

“That shows that 20 percent of the deliveries take place at Cook County North Shore Hospital, with 80 percent of the deliveries going elsewhere,” said Wraalstad.

“Without making the recommended improvements [from Coverys] and meeting the standards of care, the insurability of our entire organization is in jeopardy,” she said.

Hospital staff shares standards of care concerns

Dr. Milan Schmidt spoke next. With 35 years of experience in rural health care behind him, Schmidt said from a values aspect, elective births should continue at North Shore Hospital, but from a standard of care viewpoint, “that is altogether different.

“While physiology and biology have not changed, if anything, the standards have continued to get more restrictive and prescriptive. It’s been a long gradual arc, and it’s not a pendulum swing. However we might not like it, it is not likely to swing back.

“To bring North Shore Hospital to standards seems insurmountable. A C-section within 30 minutes is unimaginable. On balance I don’t see how we can meet planned deliveries at North Shore Hospital, but we will remain committed to making sure patient safety is paramount. We can view this as an opportunity to hone our services with Duluth. This approach can help us keep our values true,” Schmidt said.

Running late for appointments, Dr. Jenny Delfs spent a few minutes trying to reassure the young women in the audience that they weren’t being abandoned.

“It’s been my privilege to deliver babies here,” said an emotional Delfs, an 18-year employee of Sawtooth Mountain Clinic.

“But I can’t meet the standard of care. There is no way we are going to get to that 30 minute standard. But I can make transfer care as quick as possible. It’s better to have a baby in a hospital than on the road. We will make efforts to make this the best service we can for the community and keep up the training for the staff.”

Delfs also said that even if all women gave birth in Cook County every year, “There would not be enough volume to support the hospital.”

That said, Delfs promised, “We will make sure patients in Cook County get exceptional obstetrics care. Patient safety and comfort must be paramount. Pre-natal education and prenatal care, we must beef these up.”

Linda Peterson, a registered nurse with 35 years working at the hospital said, “I came when we had 50 deliveries a year here and it was really fabulous. Guidelines weren’t as strict or confining as they are now. There are more responsibilities now. I love OB but having the experience of doing it for so many years, it gave us the experience and gave us confidence….

“We have so few births here now. I think I was in on two last year and felt fortunate to be on those,” she said.

But as Peterson pointed out, when there is a birth at the hospital the thin nursing staff has more to attend to than mother and baby. If there is an emergency room patient, or someone comes in bleeding or with a cardiac problem, the nurses must attend to these patients, too.

Kathy Nevers, an RN at the hospital for 4½ years, said she had previously worked at one of the busiest birthing centers in the country, with as many as 10,000 babies born in a year.

Nevers said, “We cannot offer the extended care that both mom and babies need and deserve. I want to say that I support what Kimber, Dr. Delfs, Dr. Schmidt and my colleague Linda Peterson said.”

Mothers—and mothers to be—saddened by change

About a dozen women asked questions and shared concerns.

Gwen Danfelt said, “I was born here. It sounds like the decision was all but made for us. My due date is June 25. Will I get to take Dr. Delfs with me? Or a doula?”

Rachel Seim said, “I had two beautiful births here. Two fast and furious births here. My first son came in five hours; my second was born within maybe two… My concern is for women who have quick labors like I did. If nurses are a little under confident, it makes me nervous. How do we keep the nurses’ and doctors’ level of confidence up?”

Nicole Nelson asked, “What is exactly a planned delivery?”

Dr. Schmidt answered, “Sometime babies don’t listen. Sometimes by the time they are 18 they still don’t listen.”

He continued seriously, explaining that births need to be conducted in a controlled, supportive environment. He stressed that training in OB services would continue.

“The good news with fast deliveries is that they are usually really easy,” he said adding as the audience broke out in laughter, “Which is to take nothing away from the pain of child birth!”

Betsy Jorgenson said, “I gave birth to two children. I feel so grateful that they were born here. A community where you can be born and die is a richer community.”

But she expressed frustration felt by many young people living here. “Gol darn it. Can’t be born here. Can’t buy land here. I can’t buy a home here. Why am I living in Cook County? And that’s sad because it’s a wonderful place to live with wonderful people.”

April Wahlstrom said she was 20 weeks pregnant and expecting in early June. “I’m concerned that if you are going to go down to Duluth on your due date, are you going to be subject to being induced because you are two days late? And you are wasting insurance? I’ve seen inductions go bad. It’s just another women’s rights issue.”

A concerned community

Beth Kennedy spoke of her gratitude to the hospital, which saved her life in a difficult delivery. As a business owner as well as a mother, she said, “I don’t see how as a business area we can attract young families to this area when we put this big obstacle in their way. I wouldn’t have moved here if I knew I couldn’t have babies here. We already have an employment issue. We are already bringing in international kids because we don’t have enough help. This is a really broad issue. This isn’t just a hospital issue. It’s a community issue.”

Tim Kennedy agreed, “This discussion should take place at the city council, the county board, in coffee shops, at businesses, we need to continue talking. I think there needs to be more in-depth, more focused meetings. There is ample opportunity for discussion before a final decision has to be made.”

As a Cook County commissioner and two-term state representative, Frank Moe offered his help, “I make a commitment to you, if you do not make this decision, I will work with you. I will go to the capitol with you and lobby the legislature.”

Allison Heeren, a Cook County Public Health Care nurse, said she hadn’t heard of anyone advocating for women with limited resources who have to work until they give birth.

Heeren pointed out that there are financial hardships for some people who will have to make the trip to Duluth. “I am advocating for access. I truly appreciate your open mindedness. That’s what we are all about, serving all.”

UMD Small Business Development Center Representative Pat Campanaro issued a challenge to the board to look at this as a marketing opportunity. “Look at this from a pure economic standpoint, so that when the really smart people decide to come here and work, they will come here.

“We can find the money to do this,” said Campanaro. “Let’s find the real need and find the money to support it. I would like to see a way for the dialogue to continue. A week isn’t enough time.”

Marco Good of Grand Marais said all three of his children are considering returning to live and work in Cook County, “But I am quite certain that by eliminating a place to have their babies would be a deal breaker.”

A retired midwife who delivered babies in Cook, Lake, and St Louis Counties starting in the 1980s, Melinda Spinler said she was granted birthing privileges at Cook County and at St. Mary’s Hospital in Duluth. “I have a lot of history behind delivery. I’ve also seen and been part of this scare before. Maybe it’s time for a birthing center. You have a responsibility to provide full services. You cannot lose birthing in Cook County.”

Dr. Bruce Dahlman began his career in Cook County in the early ‘80s, working to build up the OB services before going to Kenya as a missionary doctor. There, Dr. Dahlmlan and his wife Katy, a nurse, helped establish a hospital and improve birthing facilities for women living in rural areas.

“It would be very ironic for me to work so hard here and then go to Africa to see health care centers offer better care in rural care in Kenya than in in my home community where I established my practice.”

Dr. Dahlman argued that the hospital has an excellent rate of safely delivering babies.

Kristin DeArruda Wharton, an RN employed at Sawtooth Mountain Clinic, said, “Insurance companies apparently have us by the neck, and if that’s what it boils down to I understand that. But I am disturbed about all of this. If we make decisions based on insurance—even though they go directly in the face of medical evidence— then what kind of community are we?”

Regardless of the decision by the board, Wraalstad said the hospital and Sawtooth Mountain Clinic and their doctors and employees will continue to provide prenatal and postnatal care.

“Cook County North Shore Hospital will provide emergency deliveries for those babies who will just not wait,” she said.

Two public meetings have been held to discuss the issue, one on Sunday morning, January 24 at the Sawtooth Mountain Clinic and one on Wednesday night, January 28 in the hospital.

At press time the hospital board was slated to make its decision on Friday, January 30.