How to Prevent Obstetric Deserts
Rural hospitals, especially since many have become Critical Access Hospitals (CAHs) have increasingly shut down their obstetrical units, often claiming the cost of the malpractice insurance is excessive or obstetrics is too risky to be provided in rural areas. I have provided obstetric services in rural areas considered obstetric deserts for many years. When it comes to obstetrical deserts, I know what does and what does not work, and what should work, but doesn’t.
Most often when an administrator decides to close the OB unit, there is a specific reason. In one small rural hospital there was a high-risk delivery on Saturday and the doctor had gone out of town for the weekend. The nurse couldn’t get any other doctor to come to the delivery so she had to do the high-risk delivery herself. That was that for this hospital’s OB program. That tense problem for the nurse could have been avoided by the doctors being adequately trained and by having an appropriate and responsible physician backup system.
I have been an obstetric Associate Clinical Professor for the University of North Dakota (UND) medical school, assigned to train young family practice doctors to practice obstetrics safely in our rural obstetric deserts. UND was sixty years ahead of its time in recognizing that we could expect all sorts of healthcare deserts and trying to prevent them. Although the program was insightful, well-meaning, and ahead of its time, there were systems obstacles which weren’t anticipated.
I relocated to a town of 2500 people to try to save the local hospital’s struggling obstetric program. I talked with the CEO and local board about what I needed if I were to revive their obstetric program. I told the CEO I needed ultrasound and anesthesia 24/7. The CEO told me he would have those services available by the time I came on board. Before I left this interview, I visited the one remaining doctor in the town who said he would no longer do obstetrics if I would relocate and help revive their obstetrics program. I also visited with the hospital board members and the nurses. Everyone seemed committed to the idea of improving the hospital’s obstetrics program.
When I arrived for my first day on the job, trouble awaited. I discovered that the CEO I had come to know and trust was gone and had been replaced with a CEO who had made me no promises.
I quickly learned it was easy to run a-foul of one of the many layers of administrators in rural hospitals. The new CEO bluntly informed me there would no local anesthesia. Instead, there would be an on-call anesthetist 85 miles away who had to drive a heavily travelled two-lane road to reach our hospital. Not to mention this is North Dakota. Blizzards are commonplace during the winter. The new CEO, although affable, didn’t understand the problems and health risks created by not having an on-sight anesthetist.
The brand new delivery room at the hospital had been commandeered by the other physician for colonoscopies. The room I was assigned for deliveries was very small, dangerously small. By the time the bed, the fetal monitors, the maternal monitors, the instrument table, the neonatal warmer, the husband, the nurses, and the IV poles were in the room, we could barely move. And although there were two larger rooms nearby, in the six years I was there, I could never seem to manage to get the delivery room moved to one of the larger and safer rooms.
I had been at this hospital for about nine months when a 22-year old hypertensive woman presented at 40 weeks in early labor. I was afraid that she would have a seizure if she pushed. The anesthesia service 85 miles away was called, but we were told the anesthetist assigned to us was on call so they had to find somebody else to make the 85-mile trip. After 45 minutes, the anesthesia service found a replacement, but this replacement anesthetist sill had to drive the 85 miles to our hospital on icy roads.
To my great relief, the patient did not seize while we waited for the anesthetist to arrive. Worried that her pushing would cause a seizure, I started magnesium sulfate, which I didn’t like because there is significant uterine atony (floppy uterus) and bleeding associated with its use. Once the anesthetist arrived, my patient delivered a 7 lbs. 10 oz. baby with good Apgars.
I was then faced with trying to stop significant bleeding from the patient’s episiotomy and trying to stop the bleeding from her floppy uterus. The IV tubing became disconnected twice from the catheter in the patient’s arm. Nurses had to squeeze past me to get to the IV to reconnect it. Thank goodness the lab blood was ready for transfusion. The patient was given two units of blood, but the nurses set the rate of blood flow as if they were giving blood to a 90-year-old patient. The simple rule of thumb that these nurses didn’t understand was that the blood needs to go in as fast as it was going out. Eventually, between fundal message and episiotomy repair, the bleeding normalized. The patient became stable and recovered well.
After a few months, we had a young woman come to the clinic who had had previous c-sections and was now pregnant with twins. The patient smoked and had asthma. On several occasions, she had been hospitalized prenatally with breathing difficulties. Eventually this patient reached 39 ½ weeks. None of these previous hospitalizations bothered the nurses, probably because they didn’t understand the risks involved. I talked to the other physician, the Chief of Staff. We agreed that this repeat c-section delivery would be like delivering two full term babies. No problem. I talked to the CEO; no problem. I talked to the head nurse who seemed to be okay with the plan.
Without telling either of us doctors or the hospital CEO, the head nurse and the obstetrical nurse reported our plans to the Chief Financial Officer (CFO). The three of them decided “no high-risk obstetrics here.” So, without talking to me, the other doctor, or the CEO, they called the malpractice carrier for the hospital. I was forced to transfer my patient to a distant hospital. The hospital had gotten rid of its risk, transferring the risk to my patient, and at the same time increasing the risk for my patient by putting her labor and delivery in the hands of people she did not know. There is little worse for a laboring mother than to suddenly be faced with strangers for her delivery.
With this surreptitious meeting of the head obstetric nurses and CFO and the insurance company, our struggling obstetrics program was dealt a serious blow from the “inside.” The upshot was that the malpractice carrier for the hospital wanted a “plan of correction.” I knew that nobody in the hospital had the slightest idea how to make a such a plan. So, I made a correction plan which was accepted by the malpractice insurance carrier. True to form, this plan of correction was never implemented, and nobody seemed to care, not even the malpractice carrier. No surprise here.
Obstetrics limped along this way for several years. He and his OB nurse liked Mepergan (a combination of Demerol and Phenergan) which years ago was given IV during labor. I was unable to get this doctor and his nurse to stop using Mepergan.
I was never able to bring about the changes needed to make obstetrics safe in this hospital and after six years, the hospital board decided to stop offering obstetrics.
The staff and hospital boards in rural hospitals need to understand the difference between a dysfunctional, high-risk obstetrics program and a well-planned low-risk obstetrical program. I and obstetricians like myself know what it takes to create a good obstetric program, a program which can reduce high-risk pregnancies to low-risk pregnancies. But we can’t build safe and effective obstetrical programs in rural areas as long as hospital administrators ignore the advice of those physicians who know how to structure a good obstetrical program.
When rural hospitals decide to stop offering obstetrical care to area patients because of what hospital administrators perceive as risk, the risk the hospital is trying to avoid does not go away. All that happens is the risk is pushed onto the patient—and her baby. That is, the rural hospital, by refusing to accept what is essentially imagined risk, simply transfers what becomes a very real risk to the mother and baby, a risk which is far more dangerous than the imagined risk of malpractice and high insurance costs.
In the first place there should be a CEO who understands that an anesthetist needs to be present at all times for safe delivery, because emergencies for either mother or baby can present at any time. Everybody needs to know from the get-go that doing OB well is a must and that doing OB poorly is NOT an OPTION. OB nursing directors should be committed to having all nurses trained in doing obstetrics well.
Sometimes there’s only 30 or 40 deliveries a year. Hospitals should deliver at least 60 babies a year to remain in good form. If there are fewer deliveries, the nurses, midwives and doctors should rotate through a busier OB unit so that they feel comfortable and learn their latest techniques. Nurses and doctors need to know how to start an IV and how to give blood. Then there is the hospital board which needs to be part of the commitment. Everybody needs to be sure the hospital has the right equipment and the right size delivery room.
The practice of obstetrics has changed radically over the past 30 years, and not always for the benefit of the mother, the new baby, or the family. These changes have been particularly hard on rural women with the development of the aggressive, one-day delivery in distant hospitals as rural hospitals cease doing obstetrics.
I believe rural hospitals need to provide obstetrical services for their communities, but they also need to take responsibility for building and maintaining obstetrical services which are safe for mothers and babies. It’s time to stop ignoring the need for good obstetrical programs in rural areas. Tragically, there have been few efforts on the part of the medical profession to work with rural hospitals to provide assistance and training to encourage rural hospitals to actively produce safe obstetrics programs. It’s time rural health organizations, medical schools, and the American College of Obstetricians and Gynecologists stepped up to the plate to bring safe obstetrics to rural areas.