Last week’s News-Herald brought a very thoughtful editorial by Dr. Delfs, who identified the issues involved in the hospital board’s decision to end planned deliveries at North Shore Hospital later in this year. She said, “This practice [providing OB care in remote areas] is no longer acceptable in a world that has become increasingly risk adverse. The actual risks have not changed.”
What is changing is the business reality dictated to the hospital by a far-off insurer within the climate of an overall increasingly litigious society. Insurers look to the pronouncements made by specialty societies for professional “standards of obstetrical care.”
Delivery in a facility that can perform a “decision to incision” for C-section within 30 minutes is the standard because in 1988, the American College of Obstetrics and Gynecology (ACOG) found that the prior, arbitrary 15-minute standard was not achievable. The current, just as arbitrary, 30-minute “standard” has not been subjected to risk stratification of low-risk and higher-risk births (Rural Moms Losing Out.., Star- Tribune, Jan 31, 2015).
And, even with the full benefit of these standards in Duluth hospitals, where intervention with electronic fetal monitoring is the norm, newborns have died with obstetrician and anesthetist present in the building (Duluth obstetrician, personal communication, Feb. 2015). The lesson of the ages is that birth, as all of life, does not come with guarantees—anywhere.
Is this ACOG “standard” universal? Looking to our near neighbor to the north, where the remote practice of obstetrics is even more common, the Society of Obstetricians and Gynecologists of Canada have reviewed the evidence and in their Joint Position Paper #282 (October 2012 JOGC) they give this recommendation: “While local access to surgical and anesthetic services is desirable, there is evidence that good outcomes can be sustained within an integrated perinatal care system without local access to operative delivery. There is evidence that the outcomes are better when women do not have to travel far from their communities. Access to an integrated perinatal care system should be provided for all women” (emphasis ours). This describes perfectly the proven, quality obstetrical care that has been provided to Cook County mothers and their families throughout these last 32 years.
In her December 7 letter, Dr. Delfs announced the establishment of Birth Partners to further solidify that needed “integrated perinatal care system” in Cook County. This effort should be fully supported by all.
The Canadian evidence about an integrated system for the Cook County of the future means that all pregnant women here need to not only choose their birthing site and provider (Duluth or otherwise) but must also choose their local prenatal obstetrical provider who will remain a fully informed partner during the pregnancy. They must insist on this collaboration from their delivering midwife, family physician or obstetrician. Emergencies more likely become catastrophes when local providers are blind-sided without any prenatal information or personal connection to the mother.
At a time when the hospital is in the planning stages for a $20 million expansion/revision of its existing facility, it is ironic that one of the “essential services” (delivering babies) that prompted the building of this rural, community hospital 57 years ago, is now gone. Maybe we need to take a second look at the reasoned healthcare planning and the approximately 85 percent of Canadians that are very or somewhat satisfied with their single-payer health care system (http://www4.hrsdc. gc.ca/.3ndic.1t.4r@-eng.jsp?iid=7). At the very least, just as all health care providers are held to evidence-based standards, one would expect that hospital insurers should be held to the same.
Bruce Dahlman,
MD FAAFP MSHPE
Cook County North Shore Hospital,
Emergency Physician
Kate Dahlman, RN, MS
Grand Marais
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