Healthy Living - April 3, 2018

Last week in the Journal of the American Medical Association (JAMA), researchers published the results of a study(1) that looked at the health implications of a worrisome trend that we have seen here in Maine: the closure of obstetrical services in rural hospitals. The authors collected data on nearly 5 million births between 2004 and 2014 and examined such important parameters such as prenatal care access, location of the delivery, and prematurity. Not surprisingly, they found that women in these rural counties had less prenatal care, more deliveries that occurred in unplanned locations, and more infants that were born prematurely, which is one of the major indicators for overall infant health.

During this time frame, the percentage of rural counties with hospital-based OB services declined from 55% to 46%, with 179 counties nationwide witnessing the closure of these units. Although some patients and families were able to receive these services by driving further to an adjacent county, overall this shift put both mothers and infants at risk of poorer outcomes. In a following editorial(2) in the same edition of JAMA, Neel Shah MD of the Harvard School of Public Health pointed out that in our current health care system US hospitals often lose money when they provide local childbirth services, and this serves as a driver for administrative decisions on the long-term viability of these important programs. Community hospital boards and their leaders try to juggle the financial demands of keeping open a 24-hour emergency room, fully-staffed intensive care beds, and all the other ancillary services that small hospitals provide. Still, as Dr Neel wrote, "it is difficult to imagine a health care service more valuable to society than childbirth".

Well, as a physician who has delivered hundreds of babies over the first 2 decades of my career in Maine I am particularly concerned about this issue. It takes more than paying a heating or an electric bill to keep these essential services available to rural communities. There is an investment in people such as obstetricians, anesthetists, labor and delivery nurses, as well as family and pediatric docs that you cannot turn off and back on like a spigot. Once those with skills and expertise have either moved or adapted to new roles, you cannot recreate these quality services.

So what are possible solutions? Looking at our English-speaking cousins in Great Britain, Canada, and Australia who have consistently shown better obstetric and pediatric outcomes than ours as measured by all standard perinatal statistics, how do they do it? The authors of the JAMA article point out that their centralized systems of public health in a single payer environment can more effectively plan and coordinate care in high-risk settings without having to worry about the local budget. The health care 'system' will make savings by investing to maintain some essential services and preventing bad outcomes, which ultimately have a higher burden of personal and societal costs on everyone.

Do I think this approach will work here in our contentious political climate on the shores of the USA? I wish I believed that we have enough level-headed adults in our current civic leadership to forge a practical solution to this real-world challenge in our patchwork of 50 states. However, for whatever reasons, we have are living in a particularly partisan time. If you are concerned about preserving access to OB care in rural settings, my recommendations are:

1) Get involved: Give voice to your concerns to your local and state leaders that this is an issue that you care about, and want real solutions.

2) Support political leaders with a track record of working cooperatively to solve problems with all stakeholders, including those 'across the aisle'

3) Expect accountability: Vote for representatives that really listen to your concerns, and show that they are willing to support public health needs.

All human life begins with the miracle of birth. All infants deserve to be given the best fighting chance to survive that a society can offer, and we can do better.

References:

1. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the US. JAMA.doi:10.1001/jama.2018.1830

2. Eroding access and quality of childbirth care in rural US counties. N Shah. doi:10.100/jama.2018.1646