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Wednesday Apr 06, 2016

Shutting Rural Labor and Delivery Units Threatens Access, Health

I started writing this blog post at the OB nurses' desk at my rural hospital while waiting for two patients to deliver. Not surprisingly, I did not finish it there because I was interrupted to help bring two healthy babies into the world.

As I waited, an article about rural hospitals closing labor and delivery units(khn.org) made me wonder where these two patients (soon to be four) would be if I wasn't here to deliver them. Without our hospital in rural Kansas, these women would have been forced to travel to the next big town to deliver. For one of these patients that would have meant a 45-minute drive, for the other an hour. And we're not just talking about the day of delivery, but the trip there and back for every OB visit, which are numerous, especially at the end of pregnancy.  

Here I am with Cassandra Prediger and her son, Emerick, who I delivered via water birth. Cassandra chose my facility because it offers this delivery option.

With the visit and drive time, women in my community would be looking at three hours out of their day if everything goes smoothly, which is a half day off work (or three hours that you have your other children in day care or in the car and a doctor's office). Such a distance could preclude regular visits if time off work is hard to come by. It also could mean that significant others are unable to accompany the patient to office visits.

Throw in the patient with complications who needs weekly or bi-weekly ultrasounds, blood work or non-stress tests, and the time spent on the road becomes astronomical. For many of my patients, the drive to the next closest delivering hospital would be closer to two hours one way, a daunting proposition for any patient, and a terrifying one if there is bad weather or a labor that progresses quickly.

We are lucky here. Our patients can choose to have care that is close to home, and due to our hospital's strong commitment to excellence in obstetric care many of my patients actually drive from the bigger city to me to deliver.

In these times when it can be difficult for rural hospitals to thrive, I don't think the answer is closing down units but finding ways to make them viable. Our OB unit has grown greatly in the past four years because of the time and effort we have put into it. We have incorporated more complimentary medicine practices such as water birth (as far as I know I am still the only doctor in the state that provides this, and we are the only hospital where this is offered), nitrous oxide for labor analgesia (same with this), and the option to have the services of a doula that is employed by the hospital free of charge to the patient.  

Patients know that we're grounded in making every labor process one that follows the patient's wishes to the best of our ability; to have the patient delivering with the doctor who has cared for her throughout her entire pregnancy and will continue to care for her after; and to provide a supportive environment for birth, bonding and breastfeeding.

The statistics on rural hospital closures are distressing. These closures don't mean just longer drive times, but severely decreased access to care, which will lead to poorer health outcomes for the patients in the areas affected. About 500,000 women give birth each year in rural hospitals, but this number is declining as labor and delivery units close. An analysis of 306 rural hospitals in nine states(onlinelibrary.wiley.com) with large rural populations found that 7.2 percent closed their units from 2010 to 2014.  

I have heard time and time again from our hospital's administration that the OB unit is expensive to run and insurance payments are low, especially Medicaid, which pays about half as much as private insurance for childbirth. Labor and delivery units in rural hospitals, especially those like mine that deliver fewer than 100 babies per year, are not revenue makers for the hospital.  

Thankfully our administration and hospital board understand that having access to local obstetric care is important to the health of our community, and it also brings in patients and services. Skeptics can speak to any family physician who delivers babies because we can recount the number of fathers, children, grandparents and aunts and uncles we have received into our practices after a family experiences the care provided during the birth experience.  

But the bottom line and the bills are still there, so what are rural hospitals to do?

Advocates for preserving access to rural obstetric care have come up with a number of things that could help bolster labor and delivery services. One is encouraging medical professionals to move to rural areas. A bipartisan bill introduced in Congress last year(www.congress.gov) would require the federal government to designate maternity care health professional shortage areas. The National Health Services Corps gives scholarships and provides loan repayment to primary care providers who commit to serving for at least two years in designated shortage areas.  

The hope is that that once physicians move to a community and put down roots, they'll stay. Many of our surrounding communities have ceased providing obstetric care because of the huge investment of human resources, both physician and nursing, required. You must have someone on call 24 hours a day 365 days a year, both a physician and nursing staff.  If you are in a one- or two-physician community, this leads to extreme fatigue and little time off.  

Finding nurses with obstetric experience can be difficult, as well, and because the staffing with OB patients is one-to-one, more nurses must be staffed when a labor is in progress. Rural hospitals may be able to band together to share resources, such as those to keep staff trained in complications.  

We must continue to ensure that rural voices are heard in the ongoing national dialogue on health reform. Research on reforms to improve rural health care is greatly lacking, and should be encouraged.  

Those of us in rural areas with viable facilities need to be willing to help those who are struggling, if possible, discussing changes that have been made to increase productivity and revenue and offering resources and advice.

The process of pregnancy and childbirth is one of the most special, and vulnerable, times in a patient's life. The ability to provide care for our own patients in our own communities is something everyone in rural practice should strive with all our might to maintain.

Beth Oller, M.D., practices full-scope family medicine with her husband, Michael Oller, M.D., in Stockton, Kan.

Posted at 10:38AM Apr 06, 2016 by Beth Oller, M.D.

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