The Disappearance of Rural Obstetrical Care

The United States infant death rate has always been far higher than that in other developed countries. Now researchers are finding that in the United States, the maternal death rate is on the increase while it is going down in other countries.

There are many possible reasons for these disturbing numbers. The American Congress of Obstetricians and Gynecologists (ACOG) states these rates of maternal death are unacceptable and describes some of its initiatives to address the problem. Unfortunately, adding more “watchers” to the list of collaborators doesn’t fix the problem if the changes in the practice of obstetrics itself promotes an environment which contributes to the increasingly poor outcomes.

The Changing Landscape in Obstetrical Care

The changing obstetrical environment has greatly increased risks to the mother and baby in metropolitan areas, but we seldom hear much discussion about those changes. On the other hand, for rural women, obstetrical care is simply disappearing. There has been little tracking of what happens to pregnant women in rural areas, including frontier areas where women may travel a hundred miles or more—one way—for their obstetrical care.

Rural hospitals, especially since they have become Critical Access Hospitals (CAHs) are shutting down their obstetrical units. The hospital administrators often provide the excuse that the cost of the malpractice insurance is excessive. This is a bean-counter excuse, something out of the CEO’s MBA, playbook, not a hospital where physicians are in charge. These same hospital CEOs claiming they cannot offer obstetrics because the malpractice insurance is so high inevitably fail to provide any actual numbers to support their assertions.

This number may be as low as $55,000 a year, depending upon the rural hospital. Frankly, this is a small sum compared to the number of obstetrical patients who could be seen in a year. When a mother delivers her baby in a rural hospital, she is likely to return to that health care center for the rest of her family’s care. The cost of a rural hospital’s malpractice insurance, then, is minimal compared to income lost when patients who use distant obstetrical services return to the distant facility for their family’s care. In other words, this isn’t a real risk, it’s a PERCEIVED risk.

Hospital’s Obstetrical Risk Transferred to the Mother and Baby

When rural hospitals decide to stop offering obstetrical care to area patients because of this perceived malpractice insurance risk, the risk the hospital is trying to avoid does not go away. All that happens is the risk is pushed onto the patient. Additionally, the risk is multiplied greatly as it is passed on to two patients—the pregnant woman and her baby.

When pregnant women have to travel 100 miles one way to deliver their babies, there are enormous REAL risks to both the women and their babies. Some babies will be born in the car on the way to the distant hospital regardless of careful planning. Others will be born in a rural hospital which has chosen to be unprepared to provide delivery services.

So the rural hospital which does not supply obstetrical services because of the “risk” involved is simply putting the pregnant woman and her baby at great risk. 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.

Traveling Great Distances to Deliver
Radically Changes the Nature of the Delivery

In urban areas, where pregnant women live close to their hospitals, the obstetricians don’t worry about the mother getting to the hospital in time to deliver her baby. But when a metropolitan obstetrician must logistically plan to be sure the rural pregnant woman makes it to the hospital on time, the solution is to not wait for the woman to go into labor, but to get the woman into the hospital somewhere near the delivery date and then try to get her delivered within the three days insurances allow.

This is a recipe for tremendous risk for the mother and baby. A “scheduled” delivery, or induction, usually starts with breaking the amniotic bag, followed by the use of pitocin to force uterine contractions, along with an epidural for pain. That is, once hospitalized, the woman has three days to deliver a baby. If the broken bag and large doses of pitocin do not produce the baby in the allotted time, the diagnosis becomes “failure to progress,” which insurances accept as a valid reason for a C-section.

The unrecognized fact that underlies all birth is that it’s not the mother and it’s not the obstetrician who decides when a baby will be born. The baby decides. And when the baby is allowed to decide when to be born, the mother often does not need anesthesia. That is not to say anesthesia shouldn’t be available. Rather, the pitocin used to induce labor makes the contractions so excruciating that some form of anesthesia is absolutely necessary. No one worries about any pain the artificially produced contractions may cause the baby. Furthermore, without the protection of the amniotic fluid, once the bag is broken, pitocin essentially creates an environment in which the babies head is used as a battering ram. This significantly increases the risk to both the mother and the baby.

When the baby decides when to be born, the labor may progress more slowly than our technophobic health care system considers convenient. After all, the three-day delivery is a great time saver for everyone. Not considered in these protocols is the safety and health of the mother and baby, or the money saved by not winding up with unneeded C-sections. Furthermore, without the time constraints of the three-day labor, the mother will likely be able to deliver the baby with less wear and tear on her own body, and certainly less wear and tear on the baby.

The best thing for the obstetrician to do with his or her hands is to sit on them.
Dr. Hubert Clapp

In labors left to progress naturally, without pitocin, women often have contractions for a while and then the contractions may stop. Perhaps the woman goes home for a day or so, near the hospital, so when the labor begins again, she can quickly get to the hospital as needed. Or perhaps the woman’s water breaks. If near a hospital, the woman can still go home and wait for the labor to begin again.

Obviously, this kind of relaxed labor cannot be extended to women who live 100 miles away. Once checked into the hospital, the designation of metropolitan or rural becomes irrelevant. A baby will be delivered in the 3-day time frame by hook or by crook. This can often lead to prematurely delivered babies, called iatrogenic prematurity. This condition and the environment which produces it receives little attention in and of itself in health care studies of infant and maternal mortality, according to ACOG.

The Wrong Reasons to
Close Obstetrics in Rural Areas

Besides the imagined risk of expensive malpractice insurance, the actual decision to shut down an existing obstetrical program in rural hospitals often hinges on some incident which convinces the hospital and it’s board to no longer offer obstetrical services.

Unfortunately, these incidents usually arise from poorly planned and poorly organized obstetrical programs. Because hospital staff and hospital boards often do not understand what makes an obstetrical program dysfunctional, no effort is put into understanding how to do obstetrics safely.

Simply put, the hospital staff and the hospital board do not understand how to make a high risk obstetrical program low risk. Studies of maternal and infant death should be giving serious attention to what makes high risk obstetrical programs low risk, setting aside any prejudices that good obstetrical programs can only exist in metropolitan areas. Many third world countries manage to provide obstetrical services to rural areas with lower infant and maternal death rates than in the U.S.

Doing Deliveries Badly is Optional

The practice of obstetrics has changed radically over the past 30 years, and not for the benefit of the mother, the baby, or the family. Changes in the practice of obstetrics have been particularly hard on rural women, replacing the local hospital’s ability to provide good-quality obstetrical services with the development of the aggressive three-day delivery in distant metropolitan hospitals.

Tragically, there has been no effort on the part of ACOG or the medical profession to work with rural hospitals to provide assistance and training and to encourage rural hospitals to begin or continue offering obstetrics. As a result, in rural areas, more and more women are choosing to delivery at home with midwives. To make matters worse, most established hospitals make it very difficult for midwives to pass on the care of a delivering woman to an obstetrician in a hospital for reasons little beyond disdain for those who choose a trial of delivery at home.

Medicine has never been a one-size-fits all discipline. Recipe medicine has never worked well and it never will, especially in obstetrics. The one-size fits all, three-day forced delivery in a metropolitan hospital with a “doc on deck” is a terrible environment for birthing.

Countries such as the United Kingdom and the Netherlands, where women have routine access to woman-centered care and where there is better match between medical need and the number of medical interventions performed, have fewer deaths and lower health care costs.
          Francine Coeytaux

Attention to developing low risk obstetrical programs in rural areas might become a model for helping transform the popular three-day delivery into a safer, healthier, birthing environment for all.

Choice—choice without discrimination—for both metropolitan and rural women, desperately needs to be reintroduced into standard prenatal and obstetrical care.


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