Statewide Survey in the Nation Shows Many Who Deliver Babies Are Stopping or Are Intending to Stop
03/03/03 Portland, Ore.
OHSU School of Medicine survey reveals access to obstetric care in serious danger due to falling provider ranks
Robbie Law, M.D., of Reedsport reports his practice of five family physicians lost back up for cesarean sections when a local general surgeon relocated. Now, secondary to liability issues, it's extremely difficult to find another surgeon to back-up high risk deliveries. Meanwhile Law's group was barely breaking even on normal deliveries, and has had to stop caring for pregnant women altogether. "We wanted to continue deliveries as a community service," Law said. "It's important for our patients and it impacts the health and economic viability of Reedsport as well. New businesses come in trying to recruit employees, but what young family will move here if they can't count on obstetric care?"
Previously, patients walked to appointments at Law's office. Now they have to travel all the way to Florence or Coos Bay -- often in labor. Law expects his group won't be able to care for pregnant women beyond the first trimester. "It's such a demoralizing experience," he added. "It tends to make you awfully cynical."
Tammi Dunlap, due the first of April with her fourth child, used to be one of Law's obstetric patients. Now she travels 45 minutes on windy, often wet roads for prenatal care. "It's horrible," she stated. "Dr. Law has been my doctor with all my children. Now I have to take all three kids with me to every appointment and leave home early just to arrive in time. I get there, get my stomach measured, hear the heartbeat and then have to turn around and come home. It's exhausting." As to labor? "That's my biggest worry," she said. "Hopefully, we'll make it."
According to the American Medical Association, murmurings of a crisis in obstetrics have hit at least a dozen states including New York and Texas, yet until now no hard data existed on the extent of the problem. Inspired by personal experience in Enterprise, Ore. and a passion for public health, Ariel Smits-Neis, M.D., a family practice physician in the School of Medicine determined to tackle the issue. With assistance from John Saultz, M.D., assistant dean in the School of Medicine for primary care education and chairman of the Department of Family Medicine, Smits-Neis developed a ground-breaking survey of all licensed providers in the state to quantify current -- and future -- obstetrical practice. Smits-Neis's survey of every obstetrician, family practitioner, certified nurse-midwife and general practitioner in Oregon draws a portrait of a state in the grips of a crisis as formidable as the nursing shortage, and as far-reaching in national implications.
Almost 60 percent of current Oregon obstetric providers responded to the survey, and one-third said they plan to stop delivering babies in the next five years. The most common reason offered was the rising cost of malpractice insurance, with family or lifestyle issues as secondary concerns.
Implications for residents of rural Oregon are perhaps most frightening. A total of 125 clinicians who used to do deliveries dropped out of obstetrics in the last four years alone -- fully 22 percent of all those delivering babies. Of providers who quit since 1999, 74 percent practice outside the Portland metropolitan area, where more than half the state's women give birth. Additionally 10 percent of current obstetric clinicians -- 80 percent of who practice outside Portland -- say they intend to quit doing deliveries in the next year or two.
Aside from the stark implications of women being forced to travel long distances for prenatal care and delivery, survey results portend longer wait times before women receive prenatal care, more women receiving insufficient or no care at all, and concomitant maternal and infant complications -- all with grave impacts on quality of care and health care costs. And significantly, once physicians or nurse-midwives stop delivering newborns, they very rarely return to obstetrics, instead focusing on other health care fields.
"This is a survey of attitudes and opinions," Saultz said. "But it suggests several things we need to be quite concerned about. People are dispirited and planning to quit, and the number of those who quit last year speaks to the veracity of those who will quit in the future. If these providers do stop practicing obstetrics, we need to learn very quickly how this will affect access to care for pregnant women, particularly in rural Oregon.
"The real question is, what will happen to the quality of care?"