Living in a maternity care desert: Fillmore County residents confront barriers to prenatal, postpartum care
With no obstetric medical facilities or providers in the county, Fillmore County residents face cost, time and travel barriers when seeking maternity care. But area health systems and independent midwives are working to make that care more accessible to all.
LANESBORO — When Alayna Sobieniak was pregnant with her second child, she knew she wanted a low-intervention birth. She was able to have that experience with the birth of her first child at a Twin Cities hospital nine years ago. But since then, the Sobieniak family has moved to Lanesboro, Minnesota, changing what options were available for maternity care.
“I received my early prenatal care at a clinic in Kasson,” Sobieniak said, referring to Full Circle Wellness Clinic. “I found that provider who was really supportive of that, but I was traveling about an hour and 15 minutes one way to see her. I was teaching preschool at the time, and I was needing to basically take the whole day off work just to make it to an appointment.”
Sobieniak considered traveling more than two hours to a birth center in the Twin Cities metro, but as she reached the end of her second trimester, she sought out Brenda Burke, a Decorah, Iowa-based certified professional midwife. In August, Sobieniak gave birth to her son, Finn, at her Lanesboro home.
“My daughter is 9 years old, and she was really eager and excited to be there for the actual birth, which wasn’t an option in a lot of other birthing environments still as they’re limiting visitors,” Sobieniak said.
While Sobieniak was really happy about how her home birth went, she said if delivering at a freestanding birth center was an option, she probably would have chosen that. But there are none in the greater Rochester area, and though surrounding hospitals such as Olmsted Medical Center and Mayo Clinic deliver thousands of babies each year, barriers such as transportation and child care can complicate access to maternity care for Fillmore County parents and their babies.
In its 2022 report , March of Dimes calls Fillmore County a maternity care desert, defined as having zero hospitals or birth centers offering obstetric (OB) care and zero OB/GYN physicians or certified nurse midwives based in the county. This lack of close-to-home maternity care impacts hundreds of Fillmore County families each year — in 2020, 222 infants were born to county residents. A majority of those babies (57.1%) were delivered in Olmsted County, with only 44 recorded home births in Fillmore County that year.
“I think the maternity care desert thing is only going to get worse and worse, and it very much plays into our maternal mortality rates, unfortunately,” said Katie Duerr, a certified nurse midwife at Winona Health in Winona. “It’s scary.”
Barriers to care
Transportation is a common issue when accessing medical care, said Jessica Erickson, director of public health for Fillmore County.
“From geriatric all the way down to pediatric or prenatal, transportation can be a barrier in our rural county,” Erickson said.
Pregnant patients typically see their OB providers for check-ups and sonograms between nine and 14 times over the course of their pregnancy. Visits are especially important for pregnant patients with other health conditions.
“Our OB patients have more medical issues including obesity, diabetes and high blood pressure,” said Dr. Melissa Richards, an OB/GYN and chair of the Obstetrics and Gynecology Department at Olmsted Medical Center. “One in 10 women will have high blood pressure issues in pregnancy. These medical conditions will often require more clinic visits to help ensure the healthiest pregnancy as possible for both mom and baby.”
The travel time required for many Fillmore County patients prompts difficulties beyond needing a vehicle to make the trip.
“Obviously, winter weather can be a barrier at times,” said Dr. Jon Kammerer, a family medicine physician with OB training at Cresco Medical Clinic in Cresco, Iowa. “Sometimes even the coordination of schedules can be difficult, you know — we try really hard to make sure that if people are coming that they can try to get everything done that they need.”
Taking time off of work and finding child care for other children are other barriers that impact care. Additionally, providers say living an hour or more away from a hospital can be concerning for people with high-risk pregnancies or if an emergency happens.
“There’s just the access to care if there’s any emergency,” said Dr. Yvonne Butler Tobah, an OB/GYN and medical director of Ambulatory Obstetrics at Mayo Clinic, where roughly 2,500 babies are delivered each year. “There’s also access issues when there’s an urgent obstetric clinical concern, because oftentimes our emergency departments are great at handling most general emergency conditions, there are some unique conditions specific to pregnancy that … are better cared for by obstetricians than, say, an emergency room physician.”
“I very much worry about women who have a history of having precipitous births, especially when they live over 30 minutes out from any hospital,” said Duerr, speaking about births where labor progresses very quickly. “For those women, I worry very much about highway babies.”
Telemedicine, insurance and clinic coordination
Despite the barriers, Fillmore County is in a relatively good position in regard to maternal health, with several OB-capable hospitals in the surrounding area that are working to fill in the gaps.
"I do feel like Fillmore County is getting the services that they need, because our birth rate is slightly higher, based on 2019 data, than Minnesota's," Erickson said. "I would say that we're not seeing significant negative effects from not having a hospital in our county."
One solution at play: expanding insurance access across the border.
“I would say a year ago, insurance would have been the primary barrier,” said Robin Schluter, CEO of Regional Health Services of Howard County in Iowa.
Minnesotans make up 4.5% of RHSHC’s patient population and 5.5% of births at Cresco Medical Clinic. Schluter said her health system has been expanding its insurance network to accommodate more Minnesota patients.
“Initially, we had some difficulty with getting Minnesota Medicaid contracts because we’re across the state line, but because of the broad services we offer, we’re in now with most of the Minnesota payers,” Schluter said. “We’re in the process right now with Blue Cross Blue Shield, the Minnesota Medicaid product — we have Blue Cross Blue Shield Minnesota, but the Blue-plus-Medicaid is in process.”
For health care providers in Minnesota, telemedicine can help reduce the frequency of in-person visits without compromising care for pregnant patients. At Mayo Clinic, Butler Tobah is the research program leader for OB Nest , a telemedicine model for low-risk pregnancies. OB Nest shifts about half of a pregnant patient’s visits to virtual ones, and providers show patients how to use self-monitoring devices, such as fetal heart rate Dopplers, to monitor their pregnancies from home.
“The distance to care, the practice of having to find parking, take time off from work, find child care for their kids — all of that eliminated by having those virtual, secure visits leveraging today’s communication technology,” Butler Tobah said.
A similar practice is in play at Olmsted Medical Center in Rochester, where 895 babies were born in 2021. Because OMC has clinics in Preston, Spring Valley and Chatfield, Richards said providers in those clinics can address pregnant patients’ needs.
“We have partners in our branch clinics who are able to see OB patients locally at times,” Richards said. “We are also able to utilize telehealth, when appropriate, to meet patients without having to drive.”
Bringing other providers into the picture
Another intervention for expanded OB care in the region: family medicine physicians with OB training like Kammerer who can provide much of a low-risk pregnant patient’s prenatal care.
“Basically, I will do all obstetrical care minus high-risk, so if someone’s super high risk for some reason, then we try to have them see a specialist,” Kammerer said. “And I don’t do C-sections, so in Cresco, we historically have had our general surgery department … come and complete the surgery. That has really worked quite well.
“I think that there is a role for family medicine and even midwifery to try to help fill some of those gaps,” Kammerer continued. “Because even if you can’t do everything, if you can take care of the 80% or 90% of pregnancies that are uncomplicated, then that really improves the experience for moms.”
As for midwifery, that is Burke’s specialty. She began her career in nursing but later became a certified professional midwife. She has worked as a home-based midwife for 22 years, delivering more than 1,200 babies along the way.
“We offer prenatal care all through pregnancy, labor and birth support, postpartum care, newborn care, breastfeeding support,” Burke said.
Burke serves clients across Southeast Minnesota, northeast Iowa and into the LaCrosse, Wisconsin, area. She sees a mix of rural and urban residents across all socioeconomic backgrounds. For her more rural clients, distance to hospital care is always a consideration in the planning process in case serious medical issues arise during a home delivery.
“People do speak about the lack of options, and what we want to do is to make sure that the person that chooses the option where they’re going to feel most comfortable and most relaxed,” Burke said. “It’s been a repeated conversation from families, wishing that they had another option in Fillmore County, specifically, whether that be a hospital or a birth center.”
Of course, medical care doesn’t stop once a baby arrives — postpartum appointments and pediatric visits are par for the course for newborns and their parents. Midwives can help reduce the travel burden after delivery.
“Brenda came back to my house within 48 hours for the first checkup,” Sobieniak said. “She came back to my house again within that first week and then came back again within the second week. I was able to just recover at home while me and baby were still getting checked up on and cared for. I can’t say enough how important that was to my recovery and me feeling supported and being able to heal.”
Social services can also help bridge the gap between providers and patients, Duerr said.
"We have social workers in each department who can help facilitate resources for any of our patients," Duerr said. "I know that our social worker has been in contact with public health nurses and social workers in Fillmore County to help my patients have access to all of the things postpartum and all of the things they might need."
While there are interventions and alternatives available for expecting parents in Fillmore County, the county’s status as a maternity care desert can impact families in big and small ways. Kammerer brought up how if a baby is delivered an hour away from home, it can be difficult for family members to visit.
“Our farmers, if they deliver here (in Cresco), I’ll see a mom and a dad in the morning, and then dad runs off and does chores, and then comes back to be together during the day,” Kammerer said. “It doesn’t seem like a big deal, but … to be close enough to kind of work some of those things makes a big difference for families.”