Rural Health Policy Institute

Maintaining Maternity Care Vital to Rural Hospital Stability

February 13, 2019 01:56 pm Sheri Porter Washington, D.C. –

At the National Rural Health Association's Rural Health Policy Institute held here Feb. 5-7, an afternoon breakout session on maternity care on the opening day revealed some sobering statistics.

During a panel discussion on rural maternity care at the recent Rural Health Policy Institute, AAFP President John Cullen, M.D., points out that babies keep a community young. "We talk about the graying of rural communities, and one of the reasons is that they're not delivering babies, so people are going elsewhere."

For instance, attendees learned that since 2011, 134 rural hospitals have dropped obstetric services and 18 rural hospitals offering obstetrics have closed.

That means that in the past eight years, 152 rural communities across the country have lost access to maternity care.

Patient Impact of Hospital Closures

Panelist Amanda Howard, a senior analyst at the Charter Center for Rural Health, shared additional information about what what's going on nationally with the OB crisis in rural communities, and she provided some context about various pressures rural hospitals face.

"There are a variety of financial pressures from Medicare and Medicaid exerting downward pressure on rural hospital markets," said Howard. And unfortunately, policies associated with both of those public systems "disproportionally affect rural hospitals," she added.

Story Highlights
  • A panel discussion during the recent Rural Health Policy Institute focused on issues associated with rural hospital closures and the provision of maternity care.
  • In the past eight years, 152 rural communities across the country have lost access to obstetric services.
  • Panelist and AAFP President John Cullen, M.D., discussed the success of his practice and the rural hospital in Valdez, Alaska, and noted that the ability to provide maternity care, including cesarean sections, has increased the overall level of services physicians in his community are able to provide.  

Howard noted that 46 percent of rural hospitals are operating at a loss in 2019, and that percentage has been steadily increasing over each of the past several years.

Other hospitals are barely hanging on, with operating margins of 1 percent to 2 percent -- "razor thin margins," said Howard. "That's been a huge driver of the 95 rural hospital closures since 2010," she added.

What's more, hospitals are terminating some service lines to make up for losses.

"One of those particularly vulnerable is OB," said Howard. In fact, 54 percent of hospitals that eliminated OB were in the red. She spoke of "maternity deserts" -- the three states with the lowest access to OB services -- New York, Florida and Virginia.

And she pointed out that not a single rural hospital in Florida provides OB services. Zero.

The very real impact on patients is that they must travel further for care. "When you're trying to get to the nearest hospital, that extra 30 minutes makes a tremendous impact," said Howard.

Finding Solutions

After that avalanche of stark reality, co-panelist and AAFP President John Cullen, M.D., of Valdez, Alaska, took to the podium to share the success his practice has had in a community of 4,000 that sits 300 miles away -- six hours by car -- from the nearest tertiary-care hospital.

He described the town's 10-bed critical-access hospital that's co-located with a 10-bed skilled nursing facility and a frontier community that provides physicians with more than their share of emergencies and diseases. "And then there's transportation -- if we have a problem we can't manage, we can be limited by weather and distance," said Cullen.

Low infant mortality rates are a true source of pride for Cullen. "Ours is about 3.1 per 1,000, not quite half of the national average," he noted. "This is actually a county-by-county issue, and some counties are losing 40 babies per 1,000, and that is unconscionable for us as a country."

Cullen pointed out that rural community hospitals have a lot of similarities -- the ER, inpatient care, surgery, outpatient clinics and obstetrics -- but it's how they handle those pieces that makes the difference.

Rural Health Policy Institute co-panelist Robin Rose, R.N., M.H.A., chief operating officer and chief clinical officer of Gibson Area Hospital & Health Services in Gibson City, Ill., tells audience members that the most important point she has to offer is this: "Family practice is the foundation and cornerstone of health care. Period. And that is a message that everyone needs to hear."

"In terms of maternity care, you have to recognize that you are going to be doing obstetrics. If you close your OB unit, you're still going to be doing obstetrics -- you're just not going to be capable of handling the emergencies," said Cullen.

Then there's premature labor, miscarriages and cesarean sections to consider.

"But the thing is, if you are able to do cesarean sections, then that increases your capability everywhere else in the hospital," said Cullen.

He explained that his physicians can administer intrathecal anesthesia. "It's quick, it's easy and having this skill means we can deal with appendectomies, ectopic pregnancies and cesarean sections," said Cullen.

Risk stratification is an important part of the health care equation in Valdez. Cullen and his colleagues try hard to avoid complicated deliveries such as vaginal birth after cesarean or twins -- although Cullen has delivered two sets -- and they recommend against home deliveries.

Cullen talked about "anticipatory management," such as bringing in extra people and getting the operating room ready when a patient is in labor. "We do a lot of drills, a lot of getting ready. We train everybody up, and not just the physicians, but also the nursing staff," said Cullen.

Creating Financial Stability

Cullen said having the ability to do anesthesia and surgery means he and his physician colleagues also can take care of major trauma. "It has increased the level of our capability enormously."

He continued, "All told, with four family physicians (a recent addition makes that five), we have 142 people employed through the health system. Every family physician brings about $1.6 million of economic activity to the community."

Simply put, the hospital is one of the community's biggest employers, Cullen said. "If we were to lose this -- well, we saw a slide earlier today with the answer. It said, 'How do you kill a community? You get rid of the hospital.'"

He went on to note, "You can do this stuff in a small town -- we're 4,000 people out in the middle of nowhere. Everything is built around a more confident nursing staff and a community with faith in the hospital because that's where they go to deliver their babies.

"Our hospital is the only hospital in our area that is financially stable," he said.

Related AAFP News Coverage
Rural Health Disparities Summit
Filling the Rural Gap With Good Recruiting, Telemedicine

(2/12/2019)

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