Rural birthing options decrease
GREGORY -- Heather Parkis has had the luxury of having the same family practioner deliver three of her children in Gregory.
If it was up to her, she would choose Dr. Richard Kafka to be in the delivery room for her fourth.
But when her baby arrives next month, she will use a different physician 26 miles away in Winner.
Parkis, 26, was forced to make that choice after Avera Gregory Healthcare Center discontinued newborn delivery services last spring. She even decided to switch from Kafka to Dr. Anora Henderson in Winner for her prenatal care.
"I'm more comfortable with Dr. Kafka -- he's been my doctor since I was 12," Parkis said. "(But) I wanted to get to know her before putting my life in her hands and my baby's life in her hands."
Avera Gregory is the latest rural hospital in south central South Dakota to no longer provide the option for young couples to have their children delivered in a small hospital setting.
The number of rural South Dakota hospitals offering the service is declining, from 27 in 2005 to 19 in 2009, according to the South Dakota Association of Healthcare Organizations in Sioux Falls. Yet, the number of hospital births rose from 11,816 in 2005 to 12,371 last year.
Dale Gillogly, regional administrator for the Gregory hospital, said the decision was driven by physicians who questioned whether they could maintain the standard of care there if a family practice physician who provides c-section backup retires in a few years. The technology and care available at larger community hospitals also factored into the decision.
"Can we continue to offer this service when we're not able to provide the same standard of care (compared to) a larger facility?" he said.
When asked if another physician could have been recruited to fill that slot, Gillogly replied that most family practice residents have no desire to work in obstetrics.
"They have trained in communities like Sioux Falls where more and more of the OB doctors are doing the OB service and that's not a part of their practice that they want to do," he said.
Out of 12 small hospitals in The Daily Republic's coverage area, those in Armour, Chamberlain, Parkston, Platte and Winner still deliver babies.
Other than Gregory, hospitals in Burke, Freeman, Scotland, Tyndall, Wagner and Wessington Springs no longer provide that service. Burke quit in 1997, with Wessington Springs dropping it in the last three years.
The hospitals in Parkston, Platte, Scotland, Tyndall, Wagner and Wessington Springs are affiliated with Avera Health. Those in Burke, Chamberlain and Winner are aligned with Sanford Health, with Douglas County Memorial Hospital in Armour and Freeman Regional Health Services being county-owned or independent.
Some factors involved in rural hospitals' decisions to cut the service include hospital administrators, board and medical staff looking at how many deliveries they perform annually, and if they have a family physician with the skills to perform a cesarean section.
Dave Hewett, SDAHO president/chief executive officer, said hospital officials and physicians might determine that the latter cannot keep up with their competencies because there are insufficient birth numbers to perform those procedures.
Declining populations and the ability to recruit younger physicians to replace retiring baby boomers also is a factor in rural areas.
"In a case where there is a need for an emergency c-section, that's what a hospital has to look for as far as its capability and whether it can recruit physicians who have that expertise," he said. "If they have a surgical specialty and are serving a rural community and there isn't a lot of people with the demand for that service, that poses a challenge for many of our rural facilities."
Other factors at play
Gillogly said it had been important to maintain newborn deliveries in Gregory as long as it did because of its remote location.
At the time the hospital quit births, two family practice physicians with obstetric skills worked there, aside from the one who could provide c-section backup. Any patients with risk factors were referred to doctors in Yankton or Sioux Falls, he said.
But Gillogly noted that Avera Gregory saw its births fall from an average of 50 a decade ago to roughly 20 now. The greater malpractice liability insurance premium faced by doctors who provide obstetric services and the costs involved with deliveries were never discussed, he said.
"Anytime a decision like this is made, it is not made lightly," Gillogly said.
The hospital is still providing prenatal and postnatal services. Gillogly is unaware of patients such as Parkis who have switched to a doctor in Winner or elsewhere for continuity of care during pregnancy and delivery.
For Freeman Regional Health Services, the declining number of births, concern about liability and competence in high-risk pregnancies played contributing factors in its decision to stop providing deliveries in 2005, Administrator Dan Gran said. The hospital, which serves a 25- to 30-mile area around Freeman, also was spending $250,000 a year for round-the-clock anesthesia coverage.
When the hospital discontinued its service, two male family-practice physicians with obstetrics and c-section experience delivered about 50 babies a year and patients had benefitted from two labor/delivery/recovery/postpartum suites. The two doctors still provide prenatal and postnatal care at the local clinic.
"The numbers were dropping because of our proximity to Sioux Falls and Yankton," he said, adding women were choosing female physicians. "It was a very labor-intensive, very costly service to provide."
As a result, the community became upset to lose the service, particularly the older generation who might have been born there and their children and grandchildren had been born there, Gran said.
"It was a service they felt was synonymous with being a hospital," he said.
Making it work
Hospitals in Platte, Armour and Chamberlain are examples of health care facilities where administrators and physicians have made the investment to continue providing newborn deliveries.
Platte Health Center Avera, which serves 6,000 people within a 25-mile radius of town, has seen its birth numbers fall and slightly rise in a 10-year period ending in 2008. Nineteen births took place in 1998, with just eight in 2003 and 10 two years ago.
In August 2009, a family practice physician who specializes in obstetrics and cesarean sections joined the staff, said Mark Burket, who has been administrator for 15 years. Since last December, the hospital has had 23 births.
"In the 15 years here, we've sat around tables similar to this and discussed, 'Should we be doing OB?'" he said. "The conclusion we come to every time is because of our geographic location and the added risk that is associated with a normal newborn delivery, it's better that we continue to do this."
In the wake of the Gregory hospital ending newborn deliveries, the Platte hospital has gained some former Avera Gregory patients from the eastern part of Gregory County, Burket said.
The Platte hospital also conducted an extensive remodeling and addition project three years ago in which a separate labor/delivery room and recovery room for mothers were built.
Douglas County Memorial Hospital in Armour, one of two independent hospitals in the area, has seen its births virtually double after adding epidurals -- a service demanded by patients -- three years ago. Last year, the hospital had 46 births, compared to 20 to 25 in 2004, Administrator Heath Brouwer said.
The hospital's family practice physician with obstetrics experience, Dr. Marlys Lubke, has a good reputation in her 20 years there, Brouwer said. Dr. Manual Ramos, a private general surgeon from Scotland, and Dr. Richard Honke at Parkston's hospital cover when Lubke is off. In fact, the hospital is trying to recruit two more physicians with those skills.
Hospital board officials have established newborn deliveries as one of the priorities as a full-service hospital that serves 3,200 people in a 15- to 20-mile radius around Armour.
"We just feel we want to be cradle to the grave," Brouwer said. "We want to take care of everybody. ... Where we are located, we feel we can provide that service in the future."
For some hospitals, such as Sanford Medical Center Chamberlain, geographic location plays a factor in offering birth services.
"From some parts of our service area, it's quite a distance to another hospital that does do newborn deliveries," Administrator Maureen Cadwell said.
The hospital, which serves about 11,000 people in Brule, Buffalo and Lyman counties, is roughly an hour from Mitchell and Pierre.
At one point in 2003 and 2004, the hospital had no obstetricians when two providers departed and it had recruitment difficulties, Cadwell said. That left a family practice physician who could deliver babies and offer prenatal and postnatal care, but not perform c-sections. Patients who needed the latter were referred to Mitchell, Pierre or Sioux Falls.
Now the hospital has two obstetricians and a family practice doctor with those skills. Roughly 70 babies were born at Chamberlain last year, compared to 23 births in 2004.
"It has not always been easy to recruit physicians to our service area, but it is something we have committed to do," she said.
Some Gregory residents disapprove of the hospital discontinuing newborn deliveries, saying the service should still be made available.
Bev Gassen said she understands the economics of the decision in that it's expensive for the hospital to offer.
Yet, she knows that it's hard to be so far away from services in a rural area. Gassen's niece-in-law traveled to Winner to deliver her baby.
"I know it's a hardship for young couples to have to travel if they want to stay in the Avera system," she said.
Some in the community didn't see the change coming. As a result, some didn't react well to it.
"It is hard on small communities when those type of services are taken away," Gassen said. "You want your community to grow. You want your young people to stay in your community."
Page Schaefer said she thought community input should have been obtained first.
Parkis said other expecting women she knows in the community are somewhat concerned if they go into labor and can't make it to Sioux Falls or Yankton in time, though they know that they could be seen in the local hospital's emergency room.
"It's the fact that you have been doctoring with somebody for so long and, kaboom, if you can't make it, then you have to deal with a whole other person," she said.