SIOUX FALLS, S.D. (AP) — Holding her baby boy in her arms, Julie Larson laughed softly when she saw his tiny face break into a smile.

Even sitting in a neonatal intensive care unit in Sioux Falls, miles away from the family farm, miles away from her husband and two daughters, Julie was happy.

She had Jack. And she had Rudy. Twin boys. Distance is just a reality for the Larsons. Especially when the family adds new members.

The family's Willow Lake farm is a two-hour drive from Sanford Health in Sioux Falls and 45 minutes away from the Watertown hospital, where Julie gave birth to her daughters.

"You do worry about it a little bit in case something randomly happens," Julie said. "It was always in the back of mind."

Mothers who live in rural South Dakota face one of the biggest provider gaps in the United States when it comes to finding a hospital with doctors trained to treat pregnancy and birth, according to 2017 research from the University of Minnesota.

And rural maternity care is disappearing.

Meanwhile, high infant mortality rates continue to haunt South Dakota as the state's only medical school sends young aspiring OB-GYNs elsewhere to finish their training, the Argus Leader reported.

Physicians have responded by taking an active role in training and improving rural maternity care, but the job is daunting.

"Unfortunately, I think it will always be an issue, and it should always be something we're striving to improve upon," said Dr. Erica Schipper, an obstetrician-gynecologist for Sanford Health.

Providing hospital-based care to rural families is difficult, regardless of geography. But moms in rural South Dakota are worse off than most of their counterparts in other rural parts of the country.

Nearly two-thirds of the state's 58 rural counties don't have a hospital with an OB-GYN. Only Nevada and Florida were worse off, according to University of Minnesota researchers, who studied 10 years of data to determine rural access to maternity care across the United States.

During those same 10 years, from 2004 to 2014, rural counties lost maternity care services. Rural programs continue to disappear due to financial and workforce-related problems.

Maternity wards in general are usually just trying to break even, and rural maternity care usually loses money, said Dr. Kimberlee McKay, an obstetrician-gynecologist for Avera Health.

"Right now the big thing is to just keep these smaller facilities from shutting down," she said.

Avera has stopped doing births at its facilities in Platte and Sibley, Iowa, though both centers continue to offer prenatal care.

Katy Kozhimannil is one of the Minnesota-based researchers who worked on the study. Responding to maternity care concerns from Alabama, Kozhimannil's team received funding from the Federal Office of Rural Health Policy to conduct their research.

New mothers such as Larson expect to drive. Running the farm just means being farther away from some services, including screenings and ultrasounds all pregnant women need in the weeks and months before giving birth.

"We're used to that," Larson said. "That's no big deal."

But significant drive times can become a big deal for pregnant moms and the unborn baby, said McKay, an advocate for rural maternity care, and member of the state task force examining the causes of South Dakota's higher-than-normal infant mortality rate.

"What we talked about was this access to first trimester care," McKay said. "There are places like Buffalo, South Dakota, and Newell, South Dakota -- they're three hour drives from Rapid or Pierre. Some of them go to Billings (Montana). I don't even know where all those women go."

South Dakota's infant mortality rate spiked last year to 7.8 deaths per 1,000 live births, after dropping to a nearly 20-year low of 4.8 the year before.

Since the task force issued its recommendations, state officials have taken an active role in making infant mortality a public health concern.

Much of the focus has been on educating parents in an effort to reduce SIDS rates: safe sleep practices for baby and encouraging prenatal health for new moms.

But obstetricians also play an important role from the beginning. By seeing a doctor early, moms can avoid risks to the baby, McKay said.

Doctor visits, with all their blood tests and ultrasounds, reduce risks for both mother and baby-- that's the whole idea behind prenatal care, McKay said.

Proximity is important.

"The main thing is getting medications in timely fashion," McKay said. "Having all the tools that you need at the ready."

Nearly 40 percent of infant deaths in South Dakota occur in the first 24 hours of life.

Infant mortality is more than an indicator of community health. It's used internationally as an indicator of health care in general, including the availability of care.

Doctors at Sanford found a blockage in the stomach of Julie Larson's son, Rudy, before he was delivered.

They were able to immediately fix the condition - known as duodenal atresia - because they knew what to expect.

Rudy is making a slower recover than his twin brother, Jack, but Larson said everything went great and she expects to take him home soon.

"We had lots of time to prepare and meet with a surgeon," she said. "None of this was a surprise when the twins were born."

The University of South Dakota trains about 60 future doctors per year.

A handful go on to provide care to pregnant mothers.

And while the state has been good about attracting these young doctors back, all must first leave South Dakota to continue their training.

There is no residency program in the state.

"They can complete medical school here but they have to leave the state to do four years of training in OB-GYN before they can come back to practice," said Schipper, who is also an associate clinical professor for USD.

The five OB-GYN graduates in 2018 are heading to Pennsylvania, Omaha, Kansas and Iowa to continue their training.

McKay is a Belle Fourche native and USD grad. Like all future obstetricians, she had to leave South Dakota to follow the passion for maternity care she developed while serving rural communities around the Rapid City area as a medical student.

McKay looks at her residency and time away from the state as a positive, even though she knows such a program could improve care in South Dakota.

"We like to leave the state and then come back because it's good to get a good perspective, that didn't hinder me," McKay said.

USD ended its obstetrics residency in the late 1980s amid budget concerns and other complications the school was facing at the time.

There has been some conversation about reviving the program, but adding a residency program requires funding, Schipper said.

"Training doctors isn't free," she said.

South Dakota has still been able to slightly increase the number of OB-GYNS serving patients in recent years, but not enough to keep up with population growth.

South Dakota has the third-highest ratio of adult women per OB-GYN in the U.S., according to 2015 workforce analysis by the American Congress of Obstetricians and Gynecologists.

"South Dakota obviously has a challenge of having a small population and a very large land mass and that does make it harder to provide obstetrical care," Schipper said.

Doctors with both Sanford and Avera said the key to improving maternity care in remote parts of the state has been communication and collaboration.

"In a lot of cases in South Dakota, the rural family medicine doctor or nurse midwife will provide a lot of the prenatal or postpartum care and the hospitals will do the delivery and neonatal care," Schipper said.

McKay came away from the task force with a number of ideas for how Avera could improve its services for women across the state.

The biggest thing that stuck with her was how rural communities were struggling to address pregnancy risks caused by high blood pressure and gestational diabetes

"They just weren't as controlled in areas where we don't have access to obstetrics," McKay said.

In the years since the 2011 task force, Avera has examined and tried to improve rural maternity care by increasing communication between all of its hospitals in the region.

Avera eCare and other forms of communication have allowed the health care system to educate physicians and improve protocols across the state, at facilities with or without a trained obstetrician, McKay said.

There is a gestational diabetes management program for all of Avera's rural facilities. There is a fetal monitoring system that allows all providers to be interconnected. There are ultrasound outreaches, so OB-GYNs are reading almost every single ultrasound for all patients in the system.

That type of approach holds the key for improving care in this state, McKay said.

"Connectivity will save us," she said.

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Information from: Argus Leader, http://www.argusleader.com