• FPs Are Answer to Rural Maternity Care Crisis

    Delivering babies in a small community has been my greatest honor and source of professional satisfaction as a family physician. The joy in the room as a newborn is brought to a mother's arms still brings tears to my eyes.

    I have been blessed with practicing obstetrics in my community for nearly 25 years and have experienced the joy of watching the babies I delivered grow into adults, a privilege granted only to parents and family physicians.

    I have also helped hundreds of women go through miscarriages, from uncomplicated to frighteningly dangerous. One patient in particular comes to mind. Arriving in the middle of the night, she looked at me owlishly and said, "I think I'm bleeding."

    Then she passed out.

    I remember racing with her on a gurney down the hallway from the ER to the operating room, leaving a trail of blood and grabbing a scratch surgical team on the way for a 12-week miscarriage. If I had not known how to perform a dilation and curettage procedure, I would have lost my patient. As it was, we had to transfuse nearly all our community's blood bank supply.

    I am deeply concerned about the erosion of obstetric care in rural communities, where such services have historically been performed by family physicians. There are many reasons for this change. Sadly, one of them is a bias among some metropolitan subspecialists and hospital leadership that all obstetric care should be performed in high-volume,metro hospitals. The result of this shift has been the implementation of policies that have led to closure of rural obstetrical units.

    Medical students who might have matched into family medicine and settled in rural communities where they could use all their training have been talked out of pursuing this dream. As a result, we have seen a rapid growth of obstetrical deserts and corresponding increases in maternal and neonatal mortality.  

    I remember another patient, who was 31 weeks pregnant with twins when she arrived at our hospital two days before transferring her care to Anchorage. Her pregnancy had gone well to that point. I had just seen her the previous day in clinic. Now she was feeling pelvic pressure and wanted to be evaluated again to make sure nothing was wrong. On exam, I realized I was feeling pulsating membranes. I have no poker face, and she knew immediately that something was wrong.

    I grabbed a bedside ultrasound and found that she was 7 centimeters dilated, and the membranes hourglassing through her cervix were filled with umbilical cord. I looked outside, and the wind was blowing hard. Transferring her to Anchorage was out of the question. It is a six-hour trip by ambulance in good conditions, more if the weather is poor. Air ambulances require a minimum ceiling and visibility, which were not in the cards. And if her membranes ruptured en route, we would likely lose one of her babies.

    It was a moot point in any case. There was no travel in or out. We managed to keep her pregnant with membranes intact for 10 hours until the weather lifted and a neonatal team came in from Anchorage. We performed the C-section in Valdez. It was my second set of twins, despite my professional goal of delivering none.

    This case ended well because we had the capability and experience to handle issues like this, as well as a tertiary care hospital and perinatologists who worked well with us. The problem is that many women aren't as fortunate. Regardless of whether their communities have labor and delivery units, women will continue to get pregnant in rural communities, which represent 20 percent of our nation's population. The pregnant women often are low-income, and a high percentage are from minority populations.

    Many states do not offer Medicaid for their pregnant populations. Travel can be expensive, as is staying in a city until delivery. Removed from their social supports, patients often don't fare well. Studies have shown that many pregnant women do not make it to a tertiary care hospital if their travel is greater than two hours. Instead, they deliver at home, on the road, or in a facility that has lost the ability to take care of them, even if the family physicians in those facilities are competent and trained.

    In Alaska, we have midwives who perform home deliveries in communities where there is no obstetrical backup, a trend I suspect is happening in other states. The mother of my first set of twins was a prime example. The weather was so bad the midwife couldn't get through Thompson Pass for a home delivery, so the patient came to our hospital instead. She was 34 weeks pregnant and, on exam, had twins in a breech, vertex lie and a cord prolapse.

    It was "all hands on deck" that night, with three family physicians, a medical student and our nursing staff. After the spinal anesthetic, and as we were laying the patient on the operative table, I saw one twin's fetal heart rate drop into the 40s. My partner of 25 years and I work well together. We delivered two healthy baby boys, a feat we could not have done if we had not developed the nursing and physician expertise for just this kind of case.

    When I first moved to Valdez, only emergency cesareans were being performed. This meant that when difficult cases arose, neither the nursing staff nor the physicians felt comfortable, and there was greater risk for the patient. My partners and I started working with the nursing staff, having drills with Resusci Annie. That mannequin had many cesareans -- and every other obstetrical emergency we could devise.

    It is so easy for a community to lose its obstetrical competence, and once lost, it is extremely difficult to bring back. I have seen this happen in rural hospitals across the country and have talked with many family physicians who had been practicing high-quality, full-scope family medicine -- including operative deliveries -- before community hospitals closed their obstetrics departments.

    Often the decision to close a department is a financial one on the part of hospital administrators who silo their hospitals into departments. The irony is that having one capability often transfers benefits to other hospital departments and to the community's readiness for disasters. For example, having cesarean capability means that there is an anesthesia and surgical capability that can be used for severe trauma and ICU-level medical cases. Another irony is that closing OB departments does not mean that hospitals will avoid obstetrical emergencies, just that they will not be competent at managing them when they happen.

    Family physicians are the best choice to provide obstetrical care in small communities. Our broad scope of practice allows for coverage of multiple areas in the hospital. Skills learned in family medicine residency can be honed with experience.

    A laborist model does not work where a lone obstetrician is on call 24/7, and midwives lack the surgical skills for operative obstetrics. On the other hand, three family physicians can safely provide obstetrical care, including operative obstetrics, if they and their nursing staff are well trained and committed. I speak from experience. Our infant mortality rate is low even by metropolitan standards, as is our maternal complication rate. Our cesarean section rate stays around 18 percent. Even though we have only a 10-bed critical-access hospital, the nurses and I will go from taking care of a major trauma to giving tissue plasminogen activator for a heart attack to delivering a baby, all without breaking stride. These are skills that rural family physicians and rural RNs must have, and they are additive. Obstetrical outcomes in rural communities cannot be measured solely in terms of infant and maternal mortality.

    I would like to thank the OB/Gyns who have helped me care for patients over the years, most especially those who helped me during my training as a family physician. The relationship between family physicians and obstetricians is vital in rural communities like mine. The training I received has saved lives and prevented catastrophe.

    I am deeply indebted to the perinatologists and obstetricians in Anchorage I use as consultants. I wish there was a method by which they could be compensated for their time and malpractice exposure, other than by my sending them patients as consults. Perhaps as telemedicine evolves, there will be. They have been a lifeline over the years, and we have dealt with some difficult cases. I could not practice obstetrics in my rural community without them, and I treasure their commitment to patient care and their presence on the other end of the phone line more than they could ever know.

    There is another side, though. As AAFP president-elect, I heard about many family physicians being denied obstetrical privileges. This is happening in urban as well as rural locations, and even when the family physician has demonstrated competence and experience. At a time when the number of obstetricians delivering babies has declined, there needs to be recognition of and collegiality for the role of the family physician in providing maternity care. Further, medical students and residents need family physician role models at academic institutions who practice full-scope family medicine -- including operative obstetrics -- if we are to reverse trends in rural maternal and infant mortality.

    As family physicians, we can only deliver obstetrical care to our patients with the cooperation of obstetricians and perinatologists. Conversely, obstetricians can only improve maternal and infant mortality rates, especially in rural areas, with the help of family physicians. OB/Gyns are not moving to rural communities. Although these communities need maternity care, they often lack a population large enough to support an OB practice. Frankly, rural communities need physicians with broader expertise, and family physicians have the broad training that makes for good outcomes in a small critical-access hospital.

    The AAFP, American College of Obstetricians and Gynecologists, National Rural Health Association, and CMS must work together on the issue of maternal and infant mortality. We cannot address this problem unless each has a part of the solution. We should be advancing payment and malpractice reform, promoting programs such as the Advanced Life Support in Obstetrics program (ALSO) and courses on postpartum hemorrhage, and using technology to work more closely.

    Looking back on 25 years of delivering babies and taking care of my community of 4,000 people, I can name many people who would have died had it not been for our ability to provide obstetrical care. The examples I chose here were cases that were true emergencies without possibility of transfer, requiring immediate and effective response. Being able to offer this for our community has been a source of pride for me and my colleagues and a joy when seeing the children I've delivered thrive. We can reduce the rural infant and maternal mortality rate, and family physicians are a necessary part of the solution.

    John Cullen, M.D., is president of the AAFP. His term begins today.


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