How far can they go? Rural hospitals weigh obstetric maintenance units when births decline

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As rural hospitals struggle to remain financially stable, their leaders see other small facilities shutting down obstetric units to cut costs. They are faced with a no-win dilemma: can we continue to operate safe delivery units if there are few births? But if we close, are we risking the health and lives of babies and mothers?

The other question on which this debate is based: how few births is too few?

Consider the 11-bed Providence Valdez Medical Center, which delivers 40 to 60 newborns each year, according to Dr. John Cullen, one of the many family doctors who give birth at hospital in Valdez, Alaska. The next nearest obstetrics unit is a six to seven hour drive away, if the ice and snow don’t make the roads unsafe, he said.

The hospital trains its nurses to care for trauma and general medicine patients as well as working women, and it is investing in simulation training to maintain their skills, Cullen said. He usually stays put, regularly checking the progress of the work, a short walk away if any problems arise.

Dr John Cullen is a family physician who gives birth at the 11-bed Providence Valdez Medical Center in Alaska. Since the nearest obstetrics unit is at least a six to seven hour drive away, the hospital works hard to keep their unit well prepared and ready to handle labor and delivery. Nurses are cross-trained to be able to care for trauma and general medicine patients as well as working women, and the hospital spends money on simulation training to maintain skills, he says.(Michelle Cullen)

If the metric is the number of deliveries, “I think it’s obviously too small and we’re probably at that low volume limit,” Cullen said. “I don’t think we really have a choice. So we just have to be really good at what we do.

Some researchers have expressed concerns based on their findings that hospitals with few deliveries are more likely to have problems with these births. Meanwhile, “maternity deserts” are more and more common. From 2004 to 2014, 9% of rural counties in the United States lost all inpatient obstetric services, leaving just over half of rural counties without any, according to a study published in 2017 in the journal Health Affairs. However, the closure of the obstetrics unit does not prevent the arrival of babies, whether in the emergency room or on their way to the nearest hospital. Additionally, women may have to travel further afield for antenatal care if there is no local maternity hospital..

Clinicians’ skills and confidence suffer without sufficient practice, said Dr Nancy Dickey, family physician and executive director of Texas A&M [University] Institute of Rural and Community Health at College Station. So what is this minimum threshold for baby deliveries? – I don’t have a number for you, she said.

Dickey and Cullen aren’t the only ones hesitant to define a metric. For example, the American College of Obstetricians and Gynecologists published a position statement on steps rural and other low-volume facilities can take to maintain clinician skills and patient safety, including conducting frequent exercises and periodically rotating health providers to higher-volume facilities to gain experience. But when asked to define ‘low volume’, a spokesperson wrote in an email: ‘We intentionally don’t set a specific number for low volume because we don’t want to create a false perception that is inaccurate. that less volume equals less quality ”.

The American Academy of Family Physicians also does not provide advice on what constitutes an insufficient number of deliveries for safe function. The academy “did not specify the minimum deliveries required to maintain high quality obstetric care in rural and underserved communities due to the unique and multifaceted nature of each case in each community,” according to a written commentary. from the group’s chairman, Dr Sterling. Ransone Jr.

One of the challenges in making any link between number of deliveries and safety is that researchers use different cutoffs for what is considered a hospital with a low number of births, said Katy Kozhimannil, professor at the University of Minnesota School of Public Health that studies rural maternal health. Moreover, such data-driven analyzes do not reflect local circumstances, she said. The income level of local women, their health risk factors, the distance to the nearest hospital with an obstetrics unit, the capacity of hospitals to keep qualified doctors and nurses – the heads of The facility must take these and other factors into account when they see their birth numbers plummet due to the declining local population or pregnant women choosing to give birth in more urban high-tech hospitals, he said. she declared.

Research on birth volumes and outcomes has been mixed, but the “more consistent” finding is that hospitals with fewer deliveries are more likely to have complications, largely due to a lack of doctors. and dedicated midwifery nurses, as well as potentially fewer resources for emergencies. , like blood banks, according to the authors of a Federal report 2019 on improving maternity care in rural areas. A study cited in report, published in 2015 in the American Journal of Obstetrics & Gynecology, found that women are three times more likely to have postpartum hemorrhage in rural hospitals with the lowest number of deliveries – defined between 50 and 599 per year – than among those with 1,700 or more. .

Only 7.4% of American babies are born in hospitals that treat 10 to 500 births per year, according to a geographic analysis published last month in JAMA Network Open. But these hospitals, which the researchers described as low-volume, account for 37% of all U.S. hospitals that deliver.

Finances also influence these decisions, as half of all rural births are paid for by Medicaid, which typically reimburses providers less than private insurance. Obstetrics are “seen as a bargaining chip by hospital administrators,” Kozhimannil said. As births decline, it can become intimidating to pay for clinicians and other resources to support a service that needs to be available 24/7, she said. “Most hospitals will be operating in the red in their obstetrics for a very long time, but at some point it can get really tough. “

If a hospital closes its unit, it is highly likely that fewer local women will benefit from antenatal care and that conditions such as severe anemia in the mother or a baby’s seat position will not be taken into account, a said Dickey. “Not having antenatal care increases the risk no matter where this patient gives birth. “

An initiative by Texas A&M will allow its family medicine residency program to use telemedicine and periodic in-person visits to provide more prenatal care to pregnant women in rural Texas, Dickey said. “What we really want are healthy moms and healthy babies,” she said.

Rural Dickey Institute is also leading plans to use a mobile unit to provide maternal simulation training to emergency room clinicians at 11 rural Texas hospitals, only three of which offer obstetrics services. “But all of them catch babies every now and then in their emergency,” Dickey said.

In Valdez, Alaska, keeping the hospital unit open has paid off for residents in other ways, Cullen said. Since the hospital gives birth, including by Caesarean, there is work to support a nurse anesthetist in the community of just over 4,000 people. This allows the hospital to handle trauma calls and, more recently, the complexities of treating Covid-19 patients, he said.

In her ongoing research, Kozhimannil remains committed to determining a range in which deliveries have fallen low enough to signal that a hospital needs “more resources or more training because safety could be threatened.” Do not close the obstetrics unit, she stressed. But rather to automatically qualify this hospital for more support, including additional funding through state and federal programs since taxpayers are footing the bill for complications in childbirth, she said.

Because women will continue to get pregnant, Kozhimannil said, even if a hospital or doctor decides to stop providing obstetric services. “This risk does not go away,” she said. “It stays in the community. It stays with the people, especially those who are too poor to go elsewhere. “

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