Saturday, November 1, 2014
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Patients get caught in middle of health care choices
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Jessica Sundjalm wants a water birth and she's willing to travel to get it. She's frustrated because the clinic told her she couldn't. (Cara Hetland)
When a woman is pregnant, there are lots of decisions to make. She needs to choose a doctor and the kind of care that's best for her. There are more methods of delivery than the traditional, woman in hospital on table, approach. Jessica Sundjalm lives in a small town but she was willing to travel to get what she wanted. Right before her due date, Sundjalm was told things would have to change. This is a story about rural health care and competition and the times patients can get caught in the middle.

Ortonville, Minn — Jessica Sundjalm says there's nothing like the peaceful feeling she gets when she gives birth to a baby under water. It's the way she delivered her second daughter.

"This is what it looked like when she was born," says Sundjalm while flipping through a scrapbook. "She was just the biggest baby I've every seen. Ten pounds, two ounces," she says.

That's what Jessica wants for her third delivery too. To have a water birth, she's needed to make some sacrifices .

Jessica lives in the western Minnesota community of Ortonville, near the South Dakota border. The closest water birthing facility is in Olivia to the southeast, an hour and forty minutes away.

Shortly before her delivery date, Jessica's plans unraveled. She received a letter from the clinic in Olivia saying the certified nurse midwife she had been seeing, was leaving the clinic. Jessica would have to see one of the male doctors at the clinic or change providers. Jessica didn't want to see a male doctor. She wanted a water delivery with a midwife.

Edi Weiss-Holzbauer, Jessica's certified nurse midwife, started at Prairie Family Practice in Olivia seven years ago. The clinic is attached to the Renville County hospital. When she started, the hospital and clinic wanted to expand obstetric care.

"When I started there were only about 50 births being done a year by all five docs practicing at that time," says Weiss-Holzbauer.

Edi helped design two birthing rooms. They look like bedrooms with a regular queen size bed. Pictures on the wall hide hospital equipment and in the bathroom is a jacuzzi tub big enough for two.

Weiss-Holzbauer says this hospital provides birthing options most rural hospitals don't. While she was at the clinic, she delivered more babies in a year than the five physicians combined. She attracted more women for obstetric care.

As a certified nurse midwife she spends time with her female clients and gets to know them. She also spends the entire labor with them. The physicians act as a back up in case she has a medical emergency. Weiss-Holzbauer says spending time with a laboring mom is not something a doctor can do.

"They also have demands on their time to cover the ER to take care of the grandma that's in CCU that had a heart attack. So it's not necessarily that they don't want to provide the care that midwives do," says Weiss-Holzbauer.

Edi Weiss-Holzbauer says she doesn't know why she was fired from the clinic. She says it may be because she wanted to add another certified nurse midwife to help her with her client load. She was talking about opening her own clinic with the doctors sponsoring her practice for difficult cases.

Some of this may be about competition. The competition comes at a time when some of the doctors in the practice are looking to retire and the clinic needs to recruit new physicians.

None of the doctors at the Prairie Family Practice in Olivia returned repeated phone calls to talk about this story.

In the seven county metro area, 12% of babies are born with certified nurse midwives. Statistics aren't available for just the rural areas but the statewide average including the metro is 8.5%. Melissa Avery, director of the midwifery program at the University of Minnesota, says low numbers in rural Minnesota drags down the statewide average.

There are a hundred certified nurse midwives in Minnesota. Not all deliver babies. Avery says it isn't fair to generalize midwifery practices. She says there are many places where midwives work well with family practice doctors.

"In a lot of rural communities there may not be a lot of access to midwifery care and it could be because no midwife ever tried to start up a practice there," says Avery. "Or because the hospital didn't say, gee we don't have a midwife and we should," she says.

Avery says midwifery is slow to grow but it is growing.

Jessica Sundjalm wonders why rural areas even bother attracting young families when they can't get the kind of health care or delivery options they want.

"I'm sorry if you're as old as my grandfather or you're a male or I don't like the cologne you wear - whatever frivolous reason I want to give because I'm hormonal and I'm pregnant and this is one of the most unpredictable experiences a person can go through that's my decision if I don't choose you," says Sundjalm.

Mary Frank, president of the American Academy of Family Physicians, says patients can only choose from what's available.

"Just as patients have choice, health care providers have choice as well and if they choose not to go into the community or not provide a certain type of care that's within their perview as well," says Frank. "What the patient unfortunately has run into is the conflict of two choices. But sometimes that's what happens and I know that's not a very good answer but sometimes that's what happens," she says.

The American Academy of Family Physicians advocates a team approach for health care. Mary Frank says that includes certified nurse midwives and nurse practitioners. She says it's especially important in rural areas where there's a shortage of health care providers and competition to attract new doctors is fierce. Frank says there's a wide range of reasons why medical school graduates don't want to start practices in rural areas.

"It's partly misperception. It's partly economics. It's partly lifestyle. And I think when you look at sub-specialists, the cardiologist, the rhumatologist it becomes a matter of are there enough patients for that physician to one, keep his or her skills up, and two, stay busy," says Frank.

Frank says not only are geriatric specialties more in demand in rural areas, obstetrics is a high risk kind of practice. Medical liability is costly and back up for the difficult cases can be tough to find. That makes recruiting obstetricians difficult.

Jessica Sundjalm had her baby. A girl.

"Oh, she's a sweetheart," says Sundjalm. "She was 9 pounds 15 ounces when she was born. She's got gorgeous black hair and I think she has my eyes," she says.

It happened the way Jessica wanted. Ella Sundjalm was born at the hospital in Olivia, underwater. Certified Nurse Midwife Edi Weiss-Holzbauer was there. Weiss-Holzbauer was given privileges to deliver babies through the month of February. She now has clinical rooms in near by Bird Island.

Another hospital in the region wants to provide alternative delivery choices. Weiss-Holzbauer is designing birthing rooms at the hospital in Willmar. She will soon be sponsored by area doctors to deliver babies there.

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