GRAND MARAIS, Minn. -- Pregnant for the first time, Gwen Danfelt was looking forward to giving birth close to home at Cook County North Shore Hospital in Grand Marais.
"Everyone that I've talked to has just glowed about the service they got," said Danfelt, 28, who lives with her husband 10 miles outside of town. "It was very special. It was very homey. It was as natural as possible. They felt very safe and cared for."
But Danfelt, who is due June 25, is changing her plans.
She has accepted as inevitable that the hospital's board will decide on Friday to end obstetrics services at the 57-year-old hospital, effective July 1. That's too close to her due date to go ahead with her plans to have the baby in the hospital where she and her twin brother were born, Danfelt said.
It's an unwelcome reality residents of many small communities are facing.
Obstetrics services will end this summer at Ely-Bloomenson Community Hospital, it was announced last month. Nationally, the number of hospitals offering obstetrics dropped by 23 percent between 1985 and 2000, according to a study by the Walsh Center for Rural Health Analysis.
For Cook County's hospital, the tipping point came in the form of a report received in late October from Coverys, its professional liability insurer, said Kimber Wraalstad, the hospital's administrator.
The hospital's level of obstetrics care falls short of current accepted standards in five areas, the report from Coverys found.
The report couldn't be pushed aside, Wraalstad told about 60 people who packed a hospital classroom during a hospital board meeting on Thursday morning.
"The insurability of our organization is in jeopardy without making the recommended improvements," she said.
Meeting them, Wraalstad said, would be like going through a series of hurdles -- until No. 5, which is more like a brick wall. According to the standards established by the American College of Obstetricians and Gynecologists, access to an emergency cesarean section must be available within 30 minutes. From the Cook County hospital, the nearest available C-sections are in Duluth, 110 miles away.
The hospital has no surgery suite, Wraalstad said.
"Even if we did, we estimate to have anesthesia and surgery capabilities -- not including the surgeon -- would be a million dollars a year," she said in an interview. "That does not include a surgeon or an OBGYN or a family practitioner who's trained to do a C-section."
Dr. Milan Schmidt, the hospital's medical director, told the audience at Thursday's meeting that's just not feasible in Cook County.
"C-section availability within 30 minutes is unimaginable," he said.
But those standards don't make sense in a community like Grand Marais, said Betsy Jorgenson, a transplant from Minneapolis who has had her two births at the Cook County hospital within the past two years.
"The tangled web of liability is reaching into the community where maybe the same rules shouldn't apply," Jorgenson said in an interview. "You can't apply the same logic to every situation."
Dr. Bruce Dahlman, a family physician in Grand Marais, made much the same point when he addressed the audience and board on Thursday.
Dahlman has spent large parts of his career in Africa, where he has worked to bring birthing services closer to rural communities, he said.
"Here in my own community, where I established my care and practice, we're going the other way," he said. "That seems very ironic."
The hospital has an excellent record of safely delivering babies, Dahlman said.
"If you look at evidence, there's no reason for an insurance company to say that you're unsafe," he said.
But Wraalstad said a childbirth emergency that the hospital isn't equipped to handle would be devastating for all concerned, even if that hasn't happened during her four years as administrator.
People have suggested changing insurers, she said. But that wouldn't address the core issue of not being able to meet currently accepted standards.
She also noted that only about 20 percent of Cook County's births occur in Cook County's hospital, and that on average only 9.5 babies have been delivered at the hospital per year over the past 13 years.
"When you have 10 deliveries, how do you maintain the experience?" she asked.
If the obstetrics unit is closed, the Sawtooth Mountain Clinic in Grand Marais will continue to offer prenatal and postnatal care, Wraalstad said, and babies still will be delivered at the hospital under emergency circumstances.
A key to the transition will be to make sure there's continuity of care between Cook County and the Duluth hospitals, Schmidt said in an interview.
"The doctors and the hospital remain committed to do everything we can to make sure patients in Cook County get excellent obstetrical services," he said..
Kristin Wharton, a community member, nurse and mother of three, developed a Facebook page calling attention to the issue after she became aware of it.
Many of the Cook County women who choose to give birth in Duluth do so because they want an epidural, which is not available at the local hospital, Wharton suggested.
But a segment of the county's women don't want pain medications and like the respect for natural birth they are given at their hospital, she said.
"It's just the kind of women we have," Wharton said. "That's what you see represented in those 10 birthdays a year."