FOSSTON — When Hillary Paulson thought her water broke, her husband Ryan drove 80 miles from tiny Trail, Minnesota, to Essentia Health St. Mary’s Hospital in Detroit Lakes.
The 29-year-old first-time mother said the hospital ran tests and told her she wasn’t ready for labor. The Paulsons drove an hour-and-a-half home and made the trip again the next day for Hillary’s scheduled induction — only to learn that her amniotic sac was already ruptured.
With 4-month-old Saige in her arms, Paulson was one of several Fosston area residents who gathered in City Hall on Jan. 30 to share passionate testimony on the loss of labor and delivery services at Essentia Health’s Fosston hospital. A virtual public hearing on the health care provider’s decision drew dozens to watch in person and nearly 150 more online.
“It’s not as smooth as you guys probably would think it would be,” Paulson told four Essentia Health leaders.
“ ... I know they’re all doctors. They know what they’re doing. But I don’t want just some kind of random person that I’ve never met being with me in such an intimate time as delivering a baby.”
Like many expectant mothers in the city and surrounding area, Paulson received prenatal care in nearby Fosston — a service Essentia Health vows to continue there, along with postpartum care. But in discontinuing labor and delivery and moving to a “shared care model,” leaders said they’re prioritizing the safety of mothers and babies while acknowledging workforce challenges and a declining population in the rural northwestern Minnesota city.
“Things have changed and evolved, even in recent years, in both birthing and population demographics. And at the same time, the industry has changed from a health care delivery standpoint,” said Callen Weispfennig, administrator of Essentia Health-Fosston.
“Operations, recruitment and resource management are all more complex than they have ever been. And the reality is also that liability risks have changed. ... So not only has the bar been raised, but the stakes have been elevated as well.”
Dr. Mark Thompson, president of Essentia Health West Market, said when it comes down to it, it’s about the mothers and babies.
"They’re our first consideration as we have this conversation around creating safer systems,” Thompson said. “We really want to put our best thinking and resources together in pursuit of safe, reliable mom and infant care.”
Fosston city officials see things quite differently. An affiliation agreement between the city and Essentia Health to operate the nonprofit hospital requires it to continue providing core services, including obstetrics. But it’s been more than 600 days since a baby was born in Fosston, starting with Essentia’s “temporary redirect” in June 2022 — originally expected to last through September of that year, according to the original news release.
The contract dispute is headed to arbitration this spring. With Essentia expected to maintain its closure plans, however, city leaders have already made clear their intent to end the agreement and return control to the nonprofit First Care Medical Services as an independent hospital.
"Essentia was not brought into the picture to rescue a failing hospital. Just the opposite,” said Mayor Jim Offerdahl to those in City Hall after the hearing. “ ... What did Fosston get? Fosston got some promises. Those promises have now all been broken.”
Beyond the contract, city officials and residents are skeptical of the conclusions drawn by Essentia Health from data on maternal outcomes and population.
One anonymous online hearing participant said despite the challenges, the provider must uphold its obligation to the Fosston community by continuing to provide labor and delivery services there.
“It is Essentia’s responsibility to meet the challenge of making this happen with high-quality services and to continue its contractual commitment, rather than to shirk its responsibility by saying it’s too hard to do,” the comment stated.
“That is, frankly, not an option. ... Fosston is an excellent geographic center between larger cities. It is the ideal place among the various surrounding small towns to be the one place in the area that delivers babies.”
Behind the numbers
Essentia Health leaders pointed to a study showing the risk of serious complications almost doubles in otherwise low-risk pregnancies, when mothers deliver their babies in rural, low-volume hospitals. Fosston averaged 72 births each year between 2017-21 — placing it squarely in the low-volume category.
Complications arise in 8% of all pregnancies and can include conditions such as gestational diabetes or preeclampsia and childbirth complications including eclampsia and sepsis — or more seriously, failure to thrive and death of newborn or mother. Because complications can’t always be predicted, having the necessary resources available during labor can mitigate those risks, leaders said.
"Not only has the bar been raised, but the stakes have been elevated as well."Callen Weispfennig, Fosston hospital administrator
“Time is of the essence,” Thompson said. “When I go back to kind of opening that hood on these small centers [with] low volumes, for physicians working extremely hard, covering all needs of the health care community and stretched, on call ... They do their absolute best.
“ ... It’s resource issues. No one person can be in multiple places and meet needs at all times. We have to have redundant systems to decrease harm.”
Still, the incidence of severe maternal morbidity — a measure indicating serious or potentially life-threatening maternal health problems — is overall a low number in both rural and urban settings. The same study published in the Journal of American Medical Association’s Health Forum showed less than 0.75% of the 11.5 million births analyzed resulted in severe outcomes in any setting.
In bolstering its point, Essentia Health’s team also listed a survey of hospital leaders published by the JAMA Health Forum. Of those surveyed, 34% lead critical access hospitals like Fosston’s in rural areas, and 65% are in rural counties. When asked to cite the number of deliveries a facility should oversee in a year to maintain a safe level of care, respondents gave a variety of answers, but the median was 200.
Difficulty in attracting doctors of all kinds to rural areas like Fosston means the resource shortage isn’t likely to improve, Essentia leaders said. Dr. Stefanie Gefroh, an obstetrician-gynecologist who serves as associate chief medical officer for Essentia Health West Market, said some open OBGYN positions across the system haven’t been filled for years.
“As you can imagine, life balance — ‘work-life integration,’ people sometimes call it — it is becoming increasingly important, particularly to new grads,” Gefroh said. “So they want to be in a facility where they can share on-call [duties] and not be on call 24/7.”
Even if a new graduate were willing to work in Fosston, the birth volume there is too low for physicians to meet the requirements to become board-certified, according to Gefroh.
“That’s a huge factor that you have to consider when you’re trying to recruit new talent,” she said.
Looking into the future, Essentia Health said the data shows Fosston’s birth volume isn’t likely to increase. The city’s population declined by 9% between 2000 and 2020 to 1,434 residents, according to the U.S. Census. Health care market analysis data prepared by Syntellis shows the number of women of childbearing age in the Fosston area is expected to decline by almost 5% by 2028, while the state as a whole would see a slight increase.
“I wish there were more people moving to Fosston. I wish more people came when we were providing OB services,” said Thompson, Essentia West president. “I wish we heard more about jobs and growth from Fosston, to tell a different picture than what we’re seeing in the data and the projections.”
Essentia isn’t alone in making these calculations. Between 2011 and 2021, 267 rural hospitals ceased providing OB services, according to an analysis by health care advisory firm Chartis. Nearly a quarter of those hospitals made the change during the height of the COVID-19 pandemic, marking a dramatic escalation in closures.
Minnesota experienced the greatest loss of rural OB units of all states during that decade, with 22 closures. That includes the hospital in nearby Bagley, which, under Sanford Health ownership, moved its labor and delivery services to Bemidji.
'Big decisions need to be made’
For the Fosston area residents who spoke during the public hearing, the risks associated with the labor and delivery unit’s loss were more tangible. Long drives in the snow and wind. A lack of trust or familiarity in the person delivering their baby. Even the city’s economic future itself.
Aside from Paulson, two other mothers who recently gave birth in the Detroit Lakes hospital shared their stories. One woman described waiting for her husband to come home from work a half-hour away so he could drive her there. But with a history of fast labors, she said the trip put her in a very frightening position.
“I did not feel like my safety was really being prioritized when the doctors basically said, ‘Oh, we hope you don’t have your baby in the car,’” the woman said.
Another recent mom, Kate Moore learned while hospitalized for her C-section that her desire to be sterilized at the same time wouldn’t be possible in Detroit Lakes. The facility’s origins as a Catholic hospital mean that procedure isn’t performed on moral grounds, leaving the woman to undergo a second invasive surgery back home in Fosston.
City officials and others involved in the task force formed to work on bringing OB care back to Fosston see Essentia Health’s decision as a disinvestment in the region. Hospitals in Bemidji and East Grand Forks operated by other health care systems are located along interstate routes and are closer than Detroit Lakes, meaning women might leave Essentia Health in favor of convenience.
They also see the decision as an about-face by the provider. A May 15, 2023, memo from the Essentia Health West Market executive team to Mayor Jim Offerdahl and City Administrator Cassie Heide said it was “fully committed to resuming OB services in Fosston in accordance with the terms of the affiliation agreement.”
After the hearing, Heide said the trust in Essentia is broken.
“That was a very strong legal agreement, but to the mayor’s point, they don’t care. It’s an agreement they’ve broken,” Heide said. “What other parts of that agreement are they going to break? ... This is why big decisions need to be made.”
Evan Fonder, chairman of the First Care Medical Services Foundation and a task force member, pointed to statistics showing 38 other hospitals with similar patient volumes in the state continue to offer labor and delivery. Fonder said if there were one more doctor in Fosston, the volume would increase. City officials said another doctor had already agreed to come to Fosston, before Essentia Health leaders discouraged them from doing so.
“Prior to their pause [in 2022], that would have solved the issue,” Fonder said. “ ... This is not a ‘your volume is too low as a region’ [and] this is not an ‘ability to deliver safe care’ question.”
“It’s leadership,” Heide continued. “It’s Essentia leadership in the west.”
With the City Council and mayor already committed to ending their contract with Essentia Health if OB care doesn’t return, planning is underway for what happens next. Leaders said an independent nonprofit hospital, profitable before Essentia’s involvement, would be viable. It would also provide the opportunity for more jobs in the community, as centralized services like human resources would come back to Fosston.
Michelle Landsverk, director of the city’s economic development, said she supports terminating the agreement.
“I think if we do not see these services resumed, to me, it is the beginning of a decline of our community,” Landsverk said. “ ... This is a quality-of-life issue. And if we want people to live here, if we want people to work here, they need health services.”
