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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 The Iowa Independent 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.
“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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