Study Highlights Grim Realities of Rural Obstetric Access

Lynda Waddington

In 1985, over 87 percent of hospitals in remote areas provided obstetric services. Seventeen years later, less than half of existing hospitals offered obstetric services to their communities.

In 1985,
over 87 percent of hospitals in remote areas provided obstetric
services. Seventeen years later, less than half of existing hospitals
offered obstetric services to their communities.

Although the overall number of hospitals across the nation have
declined since 1985, a study by the Walsh Center for Rural Health
Analysis indicates the overall percentage drop is dwarfed by the number
of rural hospitals that no longer offer obstetrical (labor and
delivery) services.

The research
made public this week was conducted for the U.S. Office of Rural Health
Policy, and examined the declining availability of hospital-based
obstetric services in rural areas from roughly 1985 to 2000. 
Researcher and author Dr. Lan Zhao fleshed out potential causes for the
trend and attempted to explore the effects of medical malpractice
reforms.

A special news report
from Rewire in March detailed the same occurrence of
declining rural obstetrical services on the state level, highlighting
the most recent decision by an eastern Iowa hospital to stop providing
this care and Iowa’s ongoing battle with doctor drain.

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“This is an issue of concern for policymakers and public health
researchers, as it may reduce access to obstetric services in some
rural communities and, as a result, adversely impact maternal and
infant health,” Zhao wrote.

While specifically targeting the years 1985, 1990, 1995 and 2000,
Zhao concluded that “the decline in the number of hospitals and the
number of beds per hospital nationwide has been accompanied by even
more pronounced declines in certain types of health services provided
by hospitals.” According to figures assembled from national databases,
the number of hospitals that provided obstetric services dropped by 23
percent from 1985 to 2000. As a result, more than one-third of U.S.
counties lacked hospital-based obstetrical services.

Physicians interviewed as a part of the study most often spoke of
increasing malpractice insurance premiums as their reasons for
discontinuing to offer obstetrical services in certain geographic
regions or for closing their practices. During the time period of the
study, there were three significant spikes in malpractice insurance
rates, and each one was answered legislatively by way of tort reform.
Unfortunately, due to non-precise data, Zhao could not with certainty
say that such reforms had or would be successful.

“Even though there was limited evidence from our … analysis that the
mandatory offset of collateral source rule and caps on total or
non-economic damages increased the likelihood that a county had
hospital-based obstetric service, we cannot draw firm conclusions about
the effectiveness of tort reforms due to lack of sufficient precision
in our estimates. Further research is needed on the effectiveness of
alternative measures that are designed to improve the availability of
malpractice insurance and curb premium spikes.”

Discussions with hospital administrators were also conducted to
capture local perceptions of the impact of the loss of hospital-based
obstetric services.  The most frequently cited reasons for closing
obstetric units were low volumes of deliveries in rural communities,
financial vulnerabilities due to high proportions of patients on
Medicaid, and difficulties in staffing obstetric units.  Reasons for
difficulties in staffing obstetric units include malpractice burdens
for physicians, changes in physicians’ attitudes toward work and
quality of life, and the costs involved in recruiting supporting
specialists such as anesthesiologists and surgeons.

Zhao found that more than 60 percent of hospitals that closed their
obstetric units were within a 30-minute drive to another hospital that
provided at least basic obstetric services, suggesting that, in most
cases, closures of hospital obstetric units may not have caused serious
access-to-care problem. However, the researcher also noted that women
at high risk for complications during labor and delivery may have had
to travel longer distances to obtain specialized care.

The Maryland-based Walsh Center for Rural Health Analysis
was previously one of eight research centers funded by federal Office
of Rural Health Policy. It is part of the Health Policy and Evaluation
division of NORC – a national organization for research at the
University of Chicago.

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