Rural Obstetrics Readiness Act (S.4079) Introduced in Senate
As a member of the American College of Obstetricians and Gynecologists (ACOG), I received an email drawing my attention to S.4079, titled the Rural Obstetrics Readiness Act, a bill intended to improve emergency obstetrical care. As an obstetrician, ACOG was encouraging me to contact my Senate representative and encourage my Senator to vote for the bill.
So I looked up S.4079 to see what was being put into place if this bill is enacted. At this time, the bill has only been introduced.
I have written a number of times here on Substack about how to improve the U.S. maternal mortality rate and how to bring safe prenatal care and delivery to rural areas (please see list of my Substack posts on this subject at the end of this article).
Unfortunately, the proposed suggestions in S.4979 do not provide any real solutions to improving maternal care in this country, emergency or otherwise. Once again, as with previous attempts by various government organizations, in this bill committees are to be created to oversee maternal care and be sure in rural areas that those providing prenatal, delivery, and postpartum care to women have been educated and trained well in how provide this care.
Committees cannot solve the problem with the lack of access to obstetrical care in this country because they do not understand why emergency obstetrical care is so inadequate in this country. This is a problem involving many factors, factors which aren’t even recognized by those studying the problem.
When I look back over the last 76 years, the times I remember most fondly have to do with the year after my first birthday. I would sit on mother’s lap, look at the pictures and listen to her read nursery rhymes. What comes to mind today is the story of Humpty Dumpty. We all know that Humpty Dumpty sat on a wall and had a great fall, and we know that all the king’s horses and all the king’s men couldn’t put Humpty Dumpty back together again.
Today I compare healthcare—all the fractionalized U.S. healthcare system—to Humpty Dumpty. Sometimes the king’s horses and king’s men actually try to put Humpty together again, as with S.4079. I have read the nine pages. It seems to me this is one more example of what our federal and state governments do best, dispense money and belligerence.
One of ACOG’s knew goals is recommending better management of emergencies involving pregnant women. This is a rather backhanded way of admitting that the presently practicing obstetricians and gynecologists are not handling emergencies well, or at least, not as well as ACOG thinks they ought to be handling them. The media has documented a number of maternal deaths which were preventable. The public seems to be sending the clear message that they think the management of obstetric emergencies is dismal.
These stories of Lauren or Chaniece Wallace are all horrible and deadly examples of not really inadequate emergency care for pregnant women, but rather gaslighting, blaming the patient for not understanding supposedly that nothing is going on to merit the attention of an obstetrician. These stories are examples of never events, that is events which should NEVER happen. Bill S.4079 lets the world know that ACOG and the some in the U.S. Congress actually care enough to talk about how to fix the problem, but the proposed solutions will not accomplish any substantive change.
What is the problem needing repair?
First of all, this is not one problem, but many, and it isn’t caused by any particular group, but by the contribution of many. The correction to these problems are readily available. The bad news is that nobody is going to take the responsibility necessary to begin fixing the current the problems because big business medicine and insurances do not want to decrease their profits by allowing obstetricians to provide the kind of care which prevents maternal mortalities. The only solution to maternal mortalities is the one-on-one relationship between a patient and an obstetrician which creates trust. This is not critical to obstetrics only. A trusting relationship with a physician is the basis of good primary care as well.
What is an obstetrical emergency?
In obstetrics, an emergency means that something has gone wrong and the opportunity to prevent it has been missed or neglected. There is always a potential for something to go wrong, but if you have a good patient-provider partnership with one provider who knows you and your family well—that’s your best opportunity to avoid trouble. This kind of relationship prevents obstetrical medical emergencies 99 percent of the time.
Unfortunately, there’s not a lot of thanks for obstetricians who make something like deliveries look easy, normal, and natural. Medicare and other insurances want to pretend they care about good outcomes and good care, but they are unwilling to address the fragmentation of medical care, the fundamental problem with poor obstetric outcomes. After practicing obstetrics for more than four decades, I know that there is very little appreciation for a good outcome, for the emergency that didn’t happen, except maybe from the parents.
I have delivered, approximately 6000 babies with no maternal mortality and no permanent injuries. I have never had a mother who converted from preeclampsia to eclampsia. This is not to say that I didn’t have my share of preeclamptic patients, but I can tell you this, I managed them well and avoided eclampsia.
If you are worried about emergencies, you have already missed the best and most powerful lesson of obstetrics and that is not having emergencies.
Training family practice doctors to
work in rural obstetric deserts
Another suggestion in this bill is to train family practice doctors to do obstetrics well in rural areas. From 1986 to 2000 I was the obstetric director and eventually associate clinical professor at the University of North Dakota Medical School (UND), which has had a long-term commitment to the problem of healthcare deserts.
UND’s program began in the late 1960s and early 1970s. It took us about 20 years to discover that training family practice doctors to do obstetrics well in rural North Dakota wasn’t working. Training young doctors was not sufficient to overcome all of the adversities of working in rural areas. The majority of these students and residents remained in the urban areas and only one or two actually went into rural obstetric deserts to practice.
It’s possible that state and federal programs could make several inducements to persuade young doctors to go to rural communities. They could accelerate loan forgiveness, they could limit medmal or they could make medmal affordable and available from the state. They could cap lawyers fees at $500 as Worker’s Comp does and cap insurance payouts at $50,000. But S.4079 does not make any recommendations of this nature and evidently the drafters of the bill think training doctors for rural service is going to make a difference in access to good emergency care for pregnant women in rural areas.
Team Commitment
Another issue addressed in S.4079 is promoting team commitment to offering safe obstetrics in rural areas. Again, this is not going to solve the problem. I eventually moved to a small town to help the local hospital revitalize their obstetrical program. I told the CEO who hired me that to do obstetrics well, I needed 24/7 anesthesia and ultrasound. By the time I arrived at the hospital three months later, the CEO who had hired me had been fired and replaced with a person who did not understand the importance of 24-seven anesthesia coverage in obstetrics. The risk of not being able to do an emergency C-section was great. A rural hospital’s commitment to doing obstetrics well is one issue I can agree with ACOG about, but I found commitment to doing obstetrics well and understanding what’s necessary to do obstetrics well are two very different situations.
The new CEO’s idea of anesthesia was calling the town 80 miles away and trying to find somebody who would come make the trip on an as-needed basis. In North Dakota, the weather can make this trip life-threatening.
Experienced obstetrical nurses may be unavailable
in rural areas
There was an old head nurse in charge of obstetrics at this hospital who was considered to know it all and need no additional training. She was still gavaging newborns even when told her not to. I was not allowed to train the nurses in obstetrics. None of the nursing staff could tell high risk pregnancies from low risk pregnancies. They at times sent out lower risk pregnancies while at other times they kept high risk pregnancies, all without consulting with me.
Spending time with laboring mothers requires a special person. They must have the right temperament, the right training, the right confidence, and the ability to act appropriately with efficiency, competence, and dignity during a crisis which can occur at any time.
ACOG does not allow boarded obstetricians to see men
ACOG obstetricians practicing in rural healthcare deserts run the risk of losing their boarding when they see men anywhere but in the ER when they are on call. Obsetricians are considered to be women’s healthcare specialists. They would jeopardize their boarding if they saw men on a voluntary basis. The problem then becomes do you pay an obstetrician for sitting around seeing a patient here and there or does the obstetrician have to see men and run the risk of losing boarding? ACOG is in part responsible for there being no boarded obstetricians in rural deserts. They need to own their part in this problem and offer more than just providing back up consult privileges for the physician in the rural trenches.
S.4079 will not fix Humpty Dumpty
The current healthcare system is controlled by the medical-industrial complex composed of groups which are not going to let the source of their profits decline to provide the kind of care patients need. Until state or congressional committees address this problem, adding committee oversight to address the high cost of healthcare in this country is going to do nothing but throw good money after bad.
As Elizabeth Rosenthal says in her book, An American Sickness:
…patients-consumers-voters must crusade to take back their healthcare by standing up against the interests of business and politics.
Do call your state and congressional representatives, but like Eizabeth Rosenthal suggests, pressure your representatives to take the profiteering out of our seriously dysfunctional healthcare system.
My Other Substack Posts on Maternal Healthcare
I have written numerous posts on the U.S. maternal mortality rate and what it would take to fix the problem. Rather than try to link to the many articles in this post, I have listed some of them below.
1. Profiteering the Medical-Industrial Complex Way
2. U.S. Maternal Mortality Rate Continues to Climb
3. Can Fragmented Medical Care Be Fixed?
4. How to Mend Obstetric Deserts in the USA
5. Maternal Mortalities Are Often Caused by Systems Problems
6. The Art of Medicine is not in Your Video
7. Centers of Excellence and Maternal Mortality
8. The Conversation on Maternal Mortality Continued….
9. Reduce Dismissiveness, Reduce Maternal Mortalities
10. Maternal Death is No Mystery
11. How to Prevent Obstetric Deserts
12. Gaslighting Kills