Impact of a family physician-staffed maternity center on obstetric services in a rural region

In the past few years rural hospitals have found obstetric care increasingly difficult to provide. A trend toward family physicians abandoning the practice of obstetrics has been a major obstacle for these hospitals. Malpractice cost and pressures, professional isolation, and inadequate training have all been cited as reasons that family physicians in rural areas have stopped delivering babies. Faced with a large number of women giving birth without prenatal care, a hospital in eastern Kentucky began a regional primary care obstetric unit to assure that obstetric care would be available to all patients who needed it. The hospital chose to staff the maternity center with family physicians so it could offer a family-centered obstetric program and newborn care. Since the opening of the maternity center in 1985, hospital deliveries have increased over 30%, while the percentage of patients who give birth without prenatal care has fallen from 3.0% to 0.7%. This report describes the factors behind the creation of the maternity center, its effect on the hospital, and its effect on the family physicians who serve on its staff.     

Midwives as Providers of Prenatal Care in Finland—Past and Present

This study analyzes the role of the midwife in prenatal care by exploring the history of the midwifery profession in Finland and by interviewing midwives. Midwifery education started in Finland in the beginning of the 19th century due to the utilitarian population policy aiming to reduce the high infant mortality rate. Because of a shortage of physicians professional midwives attained an important status in the care of births. With industrialization a state-directed welfare policy with state-subsidized health care developed. After World War II, the midwifery were legally defined as care during pregnancy, delivery, and the postpartum period. In the 1950s, the scope of work of midwifery was further altered because hospital deliveries had become routine. Some midwives provided prenatal care in ambulatory maternity health centers while others worked in hospitals managing normal childbirths. Separate midwifery education ended in 1968 and resumed 1986. Since 1972, public health nurses have increasingly provided prenatal and postnatal care in maternity centers, and specialized nurses have managed normal childbirths. In the future, public health nurses may totally replace midwives in prenatal care, and the role of midwives may return to care of normal deliveries. Midwife interviews revealed the "medicalization" of pregnancy caused both by physicians and midwives' own medical concept of pregnancy and by clients' demands for good care.     

Midwives as providers of prenatal care in Finland--past and present

This study analyzes the role of the midwife in prenatal care by exploring the history of the midwifery profession in Finland and by interviewing midwives. Midwifery education started in Finland in the beginning of the 19th century due to the utilitarian population policy aiming to reduce the high infant mortality rate. Because of a shortage of physicians professional midwives attained an important status in the care of births. With industrialization a state-directed welfare policy with state-subsidized health care developed. After World War II, the midwifery were legally defined as care during pregnancy, delivery, and the postpartum period. In the 1950s, the scope of work of midwifery was further altered because hospital deliveries had become routine. Some midwives provided prenatal care in ambulatory maternity health centers while others worked in hospitals managing normal childbirths. Separate midwifery education ended in 1968 and resumed 1986. Since 1972, public health nurses have increasingly provided prenatal and postnatal care in maternity centers, and specialized nurses have managed normal childbirths. In the future, public health nurses may totally replace midwives in prenatal care, and the role of midwives may return to care of normal deliveries. Midwife interviews revealed the "medicalization" of pregnancy caused both by physicians and midwives' own medical concept of pregnancy and by clients' demands for good care.     

A subsidized perinatal care program in a rural Colorado county.

A large number of medically indigent women in rural areas currently receive little or no prenatal care, raising major concerns regarding perinatal health. In Colorado, subsidized prenatal and labor/delivery programs have been instituted to address this problem. This article describes the implementation of two programs in one rural county. In these rural programs, private physicians, health department personnel, and social work staff at the local hospital collaborate to provide financial assistance, comprehensive health education, and quality medical care for eligible pregnant women. The identified benefits and barriers unique to the provision of quality perinatal care in rural settings are discussed.     

Medicaid expenditures for maternity and newborn care in America

An Alan Guttmacher Institute (AGI) survey of the Medicaid programs in each state and the District of Columbia found that some 542,000 low-income women have a Medicaid-subsidized delivery each year--about 15 percent of all women who give birth. The proportion ranges from three percent in Alaska to 25 percent in Michigan. The federal and state governments spend almost $1.2 billion annually for maternity care (including prenatal, postpartum and newborn care); the average expenditure per patient is $2,200. Tennessee reports the highest expenditure per patient ($3,500) and Louisiana the lowest ($1,300). Only the highest payments under Medicaid are close to charges for maternity care in the open market, a fact that results in a significant disincentive for physicians and hospitals to accept Medicaid patients. The $1.2 billion spent for Medicaid-subsidized maternity care compares with an estimated $11.5 billion spent for such care nationwide. Thus, Medicaid pays for about 10 percent of the nation's maternity care bill, although Medicaid subsidizes deliveries for 15 percent of all women who give birth. The figures for maternity care do not include Medicaid expenditures for neonatal intensive care, which, for the 17 states reporting data, average about $11,800 per infant. Although only about six percent of all newborns whose deliveries are subsidized by Medicaid require neonatal intensive care, such care is so expensive that it adds about 30 percent to all Medicaid expenditures for maternity care. Increased Medicaid payments for maternity care, including prenatal care, could have a positive impact on health outcomes for low-income mothers and their babies, and could reduce the necessity for massive and expensive medical treatment for newborns.     

Midwifery care, social and medical risk factors, and birth outcomes in the USA

STUDY OBJECTIVE: To determine if there are significant differences in birth outcomes and survival for infants delivered by certified nurse midwives compared with those delivered by physicians, and whether these differences, if they exist, remain after controlling for sociodemographic and medical risk factors. DESIGN: Logistic regression models were used to examine differences between certified nurse midwife and physician delivered births in infant, neonatal, and postneonatal mortality, and risk of low birthweight after controlling for a variety of social and medical risk factors. Ordinary least squares regression models were used to examine differences in mean birthweight after controlling for the same risk factors. STUDY SETTING: United States. PATIENTS: The study included all singleton, vaginal births at 35-43 weeks gestation delivered either by physicians or certified nurse midwives in the United States in 1991. MAIN RESULTS: After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower. Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for physician attended births. CONCLUSIONS: National data support the findings of previous local studies that certified nurse midwives have excellent birth outcomes. These findings are discussed in light of differences between certified nurse midwives and physicians in prenatal care and labour and delivery care practices. Certified nurse midwives provide a safe and viable alternative to maternity care in the United States, particularly for low to moderate risk women.     

Prenatal HIV testing in Ontario: knowledge,attitudes and practices of prenatal care providers in a province with low testing rates

OBJECTIVE: To describe the knowledge, attitudes and practices of prenatal care providers in relation to prenatal HIV testing. METHODS: A stratified random sample of 784 family physicians, 200 obstetricians and 103 midwives providing prenatal care in 3 health planning regions in Ontario received a questionnaire. RESULTS: Response was 622/1087 (57%). Almost half of participants (43%) were not aware of Ontario's prenatal HIV testing policy. Eighty-five percent of participants reported that they offered or ordered HIV testing for all pregnant women. Sixty-six percent agreed that women should have a choice about whether to test or not, and midwives were more supportive of having an informed consent process than were physicians. CONCLUSION: Knowledge about the risks and benefits of prenatal HIV testing needs to be improved, and standards for informed consent should be re-evaluated to achieve the most ethical process with the least complexity.     

Availability of Rural Minnesota Obstetric Services: Is It a Problem?

In the late 1980s several published articles predicted a crisis in the availability of obstetric care due to declining numbers of rural obstetrical providers. Several state and national studies documented the adverse impact of malpractice and time demands on both urban and rural physicians. But only limited information is available to document current trends in rural obstetrical practice and assess whether or not the predicted crisis occurred. This study sought to provide that updated information for rural Minnesota. A telephone survey of all rural Minnesota obstetrical providers was used to document the number, location, and specialty of rural obstetrical providers, their practice limitations, and plans for future practice. This data was combined with state perinatal statistics for each county to further assess obstetrical care availability and perinatal outcomes. All rural Minnesota obstetricians and certified nurse midwives provide obstetrical care as did 69 percent of all rural family physicians. Only 27 percent of rural obstetrical providers put any type of restrictions on their obstetrical practices. During the past year, 67 currently practicing rural physicians have stopped providing obstetrical care while 55 new obstetrical providers have begun rural practice. Two to 3 percent of current rural providers plan to retire or discontinue obstetrical services during the next five years. The provider demographics from the survey identified eight counties with no prenatal providers, and 12 additional communities of decreased provider availability. However, only two of the counties with no prenatal providers and five of the counties with areas of limited providers had increased percentages of adverse prenatal outcomes such as low birthweight or late prenatal care. This study concluded that Minnesota does not have a serious statewide problem with availability of rural obstetrical providers. However, a few isolated regions of the state have limited provider availability, including limited availability of local high-risk services and consultants.     

Extent of utilisation of maternal care services of P.H.C. by the families of a rural area

The utilization of the maternal health care services offered by an upgraded primary health care (PHC) facility in a rural area of West Bengal, India was assessed. Information on the use of the maternal services by pregnant women over a 5-year period was collected from a house-to-house sample of 100 families living less than 1 hour away from the health facility and having at least 1 child born into the family in the previous 5-year period. Women in 58% of the families used the prenatal services of the facility, 6% received prenatal care from private practitioners, and 36% received no prenatal care. Reasons given for not using the facility were 1) using the clinic was too time consuming, 2) the staff was unfriendly, 3) a lack of interest in the services provided. There was no significant differences between prenatal service utililizers and nonuser in regard to caste differences. Utilizers were somewhat more likely to live in households with a literate household head than nonusers. The number of visits made by the utilizers ranged from 1-5, but many respondents had difficulty recalling the exact number. Utilizers were no more likely than nonusers to use the delivery services of the PHC. Among the 58 women who used either the prenatal services of the PHC or of private practitioners, 34 had their deliveries at the PHC, 23 at home and 1 in the hospital. Among the 42 women who received no prenatal care, 15 gave birth at the PHC center, 20 at home, and 4 at nursing homes. Home deliveries were conducted either by untrained midwives or by family members. 3 cases of neonatal tetanus and 1 case of maternal tetanus were reported in the community during the 5 year period. All of these births occurred at home. Only 6% of the 100 mothers used the postnatal services of the PHC center. The findings indicate that the provision of upgraded services by itself is insufficient to overcome the lack of health care motivation on the part of the target population.     

Shortage of midwives -- the effect on family planning

The Safe Motherhood Initiative calls for improved maternity care for all women, essential obstetric services at the nearest place possible, and access to and acceptance of family planning services adapted to the needs of individual couples. Central to this effort is the midwife, who can serve as a link between community health workers and physicians. However, an International Planned Parenthood (IPPF) review of 29 countries that utilize midwives in their health systems found that half had a shortage and that a collective total of 61,000 additional midwives is needed to create a midwife:live birth ratio of 1:200. The regions with the worst ratios are generally those with lowest prenatal coverage and contraceptive prevalence rates and the highest incidence of maternal mortality. This situation could be remedied, in part, by greater utilization of auxiliary nurse midwives or specially trained traditional birth attendants. In countries where trained community health workers are permitted to distribute condoms, barrier methods, and the pill, an intermediate-level health worker should be authorized to provide injectables and IUDs. In many countries, even midwives are not permitted to provide family planning services, and their education does not include family planning content. Experiments in Indonesia, Turkey, Thailand, and the Philippines have demonstrated that midwives can be trained to insert Norplant and IUDs, and even perform sterilizations, as effectively as physicians. In Chile, a core of 300 physicians and midwives were selected for training in family planning methods and education and went on to train others. It is important that midwives themselves take the lead in restructuring and upgrading their profession and form strong partnerships with women's organizations at the grass-roots and policy-making levels.     

经济欠发达地区农村产前保健项目中间结果评价

目的:对经济欠发达地区农村开展的产前保健项目的中间结果进行评价.方法:由县卫生局组织有关产前保健专家对乡镇卫生院产科医务人员进行业务培训;由县卫生局和乡镇领导协调卫生与计划生育部门开展农村社区产前保健的健康教育;由乡镇卫生院产科助产士负责开展产前检查.应用整群随机分组的设计及做干预前后测量的方法进行评价.评价的指标包括初次产前检查孕周、产前检查次数和产前检查率.结果:干预使孕妇初次产前检查的时间提前.干预提高了产前检查率.干预提高了高危妊娠妇女的产前检查次数.结论:卫生与计划生育部门合作开展产前保健是促进经济欠发过地区农村母婴保健工作可行与有效的途径.     

Family Physicians in the Maternity Care Workforce: Factors Influencing Declining Trends

Family physicians provide access to maternity care for a disproportionate share of rural and urban underserved communities. This paper aims to determine trends in maternity care provision by family physicians and the characteristics of family physicians that provide maternity care. We used American Board of Family Medicine survey data collected from every family physician during application for the Maintenance of Certification Examination to determine the percentage of family physicians that provided maternity care from 2000 to 2010. Using a cross-sectional study design, logistic regression analysis was performed to examine association between maternity care provision and various physician demographic and practice characteristics. Maternity care provision by family physicians declined from 23.3 % in 2000 to 9.7 % in 2010 (p < 0.0001). Family physicians who were female, younger and US medical graduates were more likely to practice maternity care. Practicing in a rural setting (OR = 2.2; 95 % CL 2.1–2.4), an educational setting (OR = 6.4; 95 % CL 5.7–7.1) and in either the Midwest (OR = 2.6; 95 % CL 2.3–2.9) or West (OR = 2.3; 95 % CL 2.1–2.6) were the strongest predictors of higher likelihood of providing maternity care. While family physicians continue to play an important role in providing maternity care in many parts of the United States, the steep decline in the percentage of family physicians providing maternity care is concerning. Formal collaborations with midwives and obstetrician-gynecologists, malpractice reform, payment changes and graduate medical education innovations are potential avenues to explore to ensure access to maternity care.     

Obstetric care in family practice residencies: a 5-year follow-up survey

BACKGROUND: The percentage of family physicians delivering babies decreased from 46% in 1978 to 32% in 1992. Some family practice leaders predicted that, by the turn of the century, training for family practice obstetrics would focus primarily on those planning to work in remote or rural settings. A 1993 study found three primary factors associated with an increased incidence of future maternity care. In 1997 the Residency Review Commission (RRC) stipulated that all family practice residencies have at least 1 family physician serve as an intrapartum attending physician for family practice resident deliveries. METHODS: Using an instrument similar to that used in 1993, we surveyed the directors of 462 family practice residencies in the United States. Sixty-four percent (295) of the program directors responded to one of two mailings. RESULTS: Compared with the survey published in 1993, program directors estimated a 16% increase in the number of residents who included obstetrics in their first practice after residency. Factors associated with increased obstetric participation included having only family physician faculty supervise uncomplicated deliveries and having family physician faculty who could perform other perinatal procedures. Programs that had 4 or more family physician faculty doing obstetrics and those that had more than 10 deliveries per month also produced more physicians who provided maternity care. Fifty-three percent of residencies that did not have family physician faculty attending deliveries before 1997 now meet this RRC requirement. CONCLUSIONS: This study shows that, according to their program directors' estimates, more family practice residents are including obstetrics in their first practice after residency compared with 5 years ago. The new RRC regulation was associated with more than 50% of previously noncompliant programs adding or retraining faculty who could attend resident deliveries within 12 months of the inception of the new policy.     

Comparison Between an Independent Midwifery Program and a District Hospital in Rural Tanzania: Observations Regarding the Treatment of Female Patients

Tanzania faces a significant shortage of physicians. In light of this, nurse–midwives have been critical in reducing maternal mortality in Tanzania in recent years. Despite the importance of both entities in providing health care to women in Tanzania, there have been few studies addressing the cultural competency of each entity. We shadowed and assisted both an independent nurse–midwife as well as physicians and nurse–midwives at a large district hospital in rural Tanzania. In this article we describe our observations regarding the treatment of female patients within the culture of an independent midwifery practice and at a large district hospital.     

The future supply of family physicians: implications for rural America

Throughout the past century rural health care has been dependent upon general practitioners (GPs) and their successors, family physicians (FPs). Only FPs and GPs have practiced in rural areas in proportion to the population, then and now. As specialization occurred, numbers of GPs declined and physician shortages developed in rural areas. The creation of family practice residencies in the 1970s halted this decline, but rural shortages persist today. During the 1990s the number of allopathic and osteopathic FP residency graduates rose 54 percent. At the same time, the percentage of women enrolled in these residencies increased to 46 percent, and women have been less likely than men to select rural practice. We project that if current numbers of graduates continue, the nonmetropolitan FP/GP-to-population ratio will increase 17 percent by the year 2020. However, today, medical students' interest in primary care residencies (including family practice) is declining precipitously. If numbers of FP graduates return to 1993 levels, the density of FPs in rural America and in the nation as a whole will decline after 2010.     

Obstetric care in a rural family practice

Obstetrical care in the United States is becoming more difficult for rural populations to obtain. Fewer family physicians are providing obstetrical services. This study is a report of one family physician's obstetric experience in a small rural town. In a series of 67 obstetrical patients, 8 percent of the deliveries occurred outside of the hospital. The rate of Cesarean section was 3 percent, significantly less than the greater than 20 percent national average. There was 1 premature delivery, and no infant deaths. These figures compare well with national averages and show the need for family physicians to provide obstetrical care in rural areas.     

Patient Population of a Referral Medical Center

An analysis has been made of the patient population attending North Carolina Memorial Hospital (NCMH), primarily a referral center, in a nine-week period, with particular attention paid to county of residence of patients and to the type of care being obtained (consultative or continuing). Patients' use of NCMH, in relation to the population of their county of residence, showed a variability that could not be explained completely by distance from NCMH. Evidence is presented suggesting that the extent of other medical care personnel and facilities in the home county had little influence on utilization rates for this referral center. One significant determinant of increased utilization of NCMH appeared to be lack of county welfare funds for payment for medical care of its indigent population. In a review of the medical records of a five percent random sample of the total patient population, it was found that approximately 16 percent of the patients were probably receiving primary, continuing care at NCMH, i.e., care usually provided by family or personal physicians. Among Orange county residents approximately 35 percent were in the primary care group. Such patients had an average 6.3 visits per year to NCMH clinics and emergency room, compared to 2.3 visits per year for patients receiving consultative care. It is suggested that continuing tabulation of hospital utilization data, in addition to the usual statistics on visits and admissions, would be of value in recognizing changing patterns of utilization and in determining the type of service best suited to each individual patient.     

Delivery Complications Associated With Prenatal Care Access for Medicaid-Insured Mothers in Rural and Urban Hospitals

CONTEXT: Pregnancy complications affect many women. It is likely that some complications can be avoided through routine primary and prenatal care of reasonable quality. PURPOSE: The authors examined access to health care during pregnancy for mothers insured by Medicaid. The access indicator is potentially avoidable maternity complications (PAMCs). Potentially avoidable maternity complications are often preventable through routine prenatal care, such as infection screening and treatment. The authors examined the risks of potentially avoidable maternity complications among rural and urban hospital deliveries for groups of mothers defined by race or ethnicity. METHODS: Data are from the year 2000 Nationwide Inpatient Sample (NIS). The stratified sample represents all discharges from 20.5% of community hospitals in the United States. The Nationwide Inpatient Sample identifies hospital locations, but not patients' areas of residence. Analyses, which accounted for the sample design, included calculation of potentially avoidable maternity complication rates by race or ethnicity, chi2, t tests, and multivariate logistic regression. FINDINGS: Within groups defined by race or ethnicity, unadjusted rates for potentially avoidable maternity complications did not differ significantly by hospital location. Holding other factors constant, potentially avoidable maternity complications were less common in rural hospitals than in urban hospitals (odds ratio, 0.78; CI, 0.62 to 0.99). In rural hospitals, African Americans had notably higher risk for potentially avoidable maternity complications than did non-Hispanic whites (odds ratio, 1.72; CI, 1.26 to 2.36). In urban hospitals, risk of potentially avoidable maternity complications was not significantly higher for African Americans. Hispanics and Asians had notably lower risks of potentially avoidable maternity complications in urban hospitals than did non-Hispanic whites. CONCLUSIONS: Providers and policymakers should work to reduce the risks of potentially avoidable maternity complications for African American women in rural areas who are insured by Medicaid.     

Rural and urban differences in physician resource use for low-risk obstetrics.

OBJECTIVE: To explore the hypothesis that rural obstetricians (OBs) and family physicians (FPs) utilized fewer resources during the care of the low-risk women who initially booked with them than did their urban counterparts of the same specialties. DATA SOURCES/STUDY DESIGN: A stratified random sample of Washington state rural and urban OBs and FPs was selected during 1989. A participation rate of 89 percent yielded 209 participating physicians. The prenatal and intrapartum medical records of a random sample of the low-risk patients who initiated care with the sampled providers during a one-year period were abstracted in detail and analyzed with the physician as the unit of analysis. Complete data for 1,683 patients were collected. Resource use elements (e.g., urine culture) were combined by standardizing them with average charge data so that aggregate resource use could be analyzed. Intraspecialty comparisons for resource use by category and overall were performed. FINDINGS/CONCLUSIONS: Results show that rural physicians use fewer overall resources in caring for nonreferred low-risk-booking obstetric patients than do their urban colleagues. Resource use unit expenditures showed the hypothesized pattern for both specialties for total, intrapartum, and prenatal care with the exception of FPs for prenatal care. Approximately 80 percent of the resource units used by each physician type were related to hospital care. No differences were shown in patterns of care for most clinically important aspects of care (e.g., cesarean delivery rates), and no evidence suggested that outcomes differed. The overall differences were due to specific components of care (e.g., fewer intrapartum hospital days and less epidural anesthesia).