As a rural hospital Strive to maintain financial stability, Their leaders watched other small facilities shut down obstetric units Cut costsThey face a win-win dilemma: If the number of births is small, can we continue to operate the delivery unit safely? But if we shut down, will it endanger the health and lives of babies and mothers?
Another unresolved question in this debate is: how many births are too few?
Consider the 11-bed Providence Valdez Medical Center. According to Dr. John Cullen, one of several family doctors who delivered babies at Valdez Hospital in Alaska, the center brings 40 to 60 new students to the world every year Son. He said that if snow and ice do not make the road dangerous, the next nearest obstetric unit will take six to seven hours by car.
Karen said the hospital conducts cross-training of nurses so that they can take care of trauma and general internal medicine patients and women in childbirth, and invest in simulation training to improve their skills. He usually stays at the scene and checks regularly as the childbirth progresses. If there is a problem, it is just a few steps away.
If the metric is the number of deliveries, “I do think that obviously the number is too small, and we may be at the limit of low deliveries,” Karen said. “I don’t think we really have a choice. So, we just need to be very good at what we do.”
Based on their findings, some researchers have raised concerns that hospitals with fewer deliveries are more likely to experience delivery problems. At the same time, “maternity deserts” are becoming more and more common. According to statistics, from 2004 to 2014, 9% of rural counties in the United States lost all hospital obstetric services, and slightly more than half of rural counties did not have any obstetric services. A study Published in the journal Health Affairs in 2017. However, closing the obstetrics department does not prevent the baby from arriving, either in the emergency room or on the way to the next nearest hospital. In addition, if there is no obstetrics and gynecology department in the local area, women may need to go further afield for prenatal check-ups.
Dr. Nancy Dickey, family physician and executive director of Texas A&M, said that if there is not enough practice, the skills and confidence of clinicians will be affected. [University] University Town Rural and Community Health Research Institute. So, what is the minimum threshold for childbirth? “I don’t have your number,” she said.
Dickey and Cullen are not the only ones who are unwilling to set indicators.For example, the American College of Obstetricians and Gynecologists published a Position statement Measures that can be taken in rural and other low-volume facilities to maintain clinician skills and patient safety, including frequent exercises and regular rotation of medical service providers to high-volume facilities to gain experience. But when asked to define “low volume”, a spokesperson wrote in an email: “We deliberately did not define a specific number for low volume because we did not want to cause an inaccurate misunderstanding, that is, more Less volume equals lower quality.”
The American Academy of Family Physicians also did not provide guidance on what constitutes a safe delivery for too few deliveries. According to a written comment by the president of the organization, Dr. Sterling, the college “due to the uniqueness and versatility of each case in each community, there is no minimum number of deliveries required to maintain high-quality obstetric care in rural and underserved communities.” .Xiaolan Song
Katy Kozhimannil, a professor in the School of Public Health at the University of Minnesota, said that one challenge in clarifying any link between the number of deliveries and safety is that researchers use different cut-off values ??for hospitals that meet low birth numbers. Research on the health of pregnant women in rural areas. In addition, this data-driven analysis cannot reflect local conditions, she said. The income level of local women, their health risk factors, the distance to the nearest hospital with a maternity ward, the hospital’s ability to retain trained doctors and nurses-hospital leaders must consider these and other factors because they see The number of her own births has declined due to the following reasons. She said that the local population has declined or pregnant women choose to give birth in more urban high-tech hospitals.
Studies on birthrates and outcomes are mixed, but the “more consistent” finding is that hospitals with fewer deliveries are more likely to have complications, mainly because of the lack of dedicated obstetricians and nurses, and resources that may be used in emergencies Fewer, like blood banks, according to one author 2019 Federal Report On improving maternal health in rural areas.A sort of Research cited in the reportA study published in the American Journal of Obstetrics and Gynecology in 2015 found that in rural hospitals with the fewest births (defined as 50 to 599 per year), women are more likely to bleed after delivery 1,700 or more Women’s triple.
According to a survey, only 7.4% of American babies are born in hospitals that handle 10 to 500 newborns each year. Geographic analysis Published on JAMA Network Open last month. But these hospitals described by researchers as low-volume hospitals account for 37% of all hospitals for delivering babies in the United States.
Finances will also influence these decisions, because half of rural births are paid for by Medicaid, which is usually less than private insurance. Kozhimannil said that the obstetrics department was “known as a loss leader by hospital administrators”. She said that as the number of births decreases, paying clinicians and other resources to support a service that must be available 24/7 can be daunting. “The obstetrics department of most hospitals will be at a loss for a long time, but at some point it may become very difficult.”
Dickie said that if a hospital closes its ward, it is likely to reduce the chances of local women’s access to prenatal care and miss the mother’s severe anemia or baby’s breech position. “Not receiving prenatal care increases the risk, no matter where the patient gave birth.”
Dickie said a Texas A&M program will enable its family medicine residency program to use telemedicine and regular face-to-face visits to provide more prenatal care for pregnant women in rural Texas. “What we really want is healthy mothers and healthy babies,” she said.
The Rural Research Institute led by Dickey also plans to use mobile devices to provide maternal simulation training for emergency room clinicians in 11 rural hospitals in Texas, of which only 3 provide obstetrics. “But all of them catch babies in the emergency room from time to time,” Dickie said.
Karen said that in Valdez, Alaska, keeping the hospital department open has paid off for residents in other ways. Since the hospital delivers babies including C-sections, it is necessary to support an anesthesia nurse in a community of slightly more than 4,000 people. He said this allows the hospital to handle trauma calls and the complexities of treating covid-19 patients recently.
In her ongoing research, Kozhimannil is still working to determine a range where deliveries are reduced enough to indicate that the hospital needs “more resources or more training because safety may be at risk.” She emphasized that do not close the obstetrics department. Instead, she said, the hospital will automatically qualify for more support, including additional funding through state and federal programs, because it is the taxpayer who pays for complications.
Because women will continue to get pregnant, Kozhimannil said, even if the hospital or doctor decides to stop providing obstetric services. “This risk will not go away,” she said. “It stays in the community. It stays with people, especially those who are too poor to go elsewhere.”
Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.This story provides