No OB
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https://jamanetwork.com/journals/jama/fullarticle/2815499
ore than 200 hospitals in rural areas of the US have closed up shop on labor and delivery services over the past 10 years, according to a recent report. The result: more than half of rural hospitals no longer offer birthing services. And as hospital expenses increase, patients in rural areas may face even greater difficulties accessing maternity care, leading some experts to declare a state of crisis.
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“The data that we have shows that there are more and more hospitals closing rural maternity care units every year,” said Harold Miller, president and chief executive officer of the Center for Healthcare Quality and Payment Reform (CHQPR), a national policy center that produced the new report.“There are both greater workforce challenges and financial issues that are likely to make it accelerate,” Miller said of the closures. “There’s in many cases no ability to support what is unfortunately an optional service.”
In 10 states, more than two-thirds of rural hospitals do not offer labor and delivery services as of January 2024, noted the CHQPR report, which is based on data from the Centers for Medicare & Medicaid Services (CMS) Healthcare Provider Cost Reporting Information System and hospitals. In Florida, the state with the highest percentage of rural hospitals without maternity care, only 3 of 21 facilities outside of urban areas still offer these services.
When I left the university, we were doing about 3500 deliveries a year (I think it's over 10K now). The small place I ended up was doing about 1200 a year. By the time I left, it was down to 750. There were serious discussions about whether to shut down the unit for 2 deliveries a day - especially when our "sister hosptial" was about 7 minutes away. Nevertheless, they kept it open for the sake of "the image" of being a full-service hospital while losing tons of money.
About 2 years after I retired, they closed it down - unsustainable.
And, this is in an affluent suburb of Chicago.
It's a real problem. As the article says, one place has only a single OB on staff. He's on call ALL THE TIME. Who's gonna do that to themselves and their family? You need a gas passer as well, if you're gonna do a c-section or the patient wants an epidural. Oh, three shifts of at least two nurses. At least. Gonna need postpartum care and a nursery.
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Worked at a place where a single doc tried it. It just about killed him. The hospital never made any money on it. And several months down the line, he had a bad delivery. His insurance settled out of court (as usual), but his already high rates went up and his rep got damaged in the community.
He left and joined a group in Shreveport...
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U.S. birth rate declined “between 2007 and 2022, dropping from 14.3 births per 1,000 people to 11.1, or nearly 23%, per new CDC data.”
https://www.axios.com/2023/10/04/birth-rate-fertility-rate-decline-data-statistics-graph-2022
Maybe this is just a reflection of lower aggregate demand?
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U.S. birth rate declined “between 2007 and 2022, dropping from 14.3 births per 1,000 people to 11.1, or nearly 23%, per new CDC data.”
https://www.axios.com/2023/10/04/birth-rate-fertility-rate-decline-data-statistics-graph-2022
Maybe this is just a reflection of lower aggregate demand?
U.S. birth rate declined “between 2007 and 2022, dropping from 14.3 births per 1,000 people to 11.1, or nearly 23%, per new CDC data.”
https://www.axios.com/2023/10/04/birth-rate-fertility-rate-decline-data-statistics-graph-2022
Maybe this is just a reflection of lower aggregate demand?
No.
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U.S. birth rate declined “between 2007 and 2022, dropping from 14.3 births per 1,000 people to 11.1, or nearly 23%, per new CDC data.”
https://www.axios.com/2023/10/04/birth-rate-fertility-rate-decline-data-statistics-graph-2022
Maybe this is just a reflection of lower aggregate demand?
No.
U.S. birth rate declined “between 2007 and 2022, dropping from 14.3 births per 1,000 people to 11.1, or nearly 23%, per new CDC data.”
https://www.axios.com/2023/10/04/birth-rate-fertility-rate-decline-data-statistics-graph-2022
Maybe this is just a reflection of lower aggregate demand?
No.
This is an interesting discussion. You medical people here, what do you think it is the reason for deceasing OB/GYN in rural areas? And second to that, why are rural hospitals in general closing?
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U.S. birth rate declined “between 2007 and 2022, dropping from 14.3 births per 1,000 people to 11.1, or nearly 23%, per new CDC data.”
https://www.axios.com/2023/10/04/birth-rate-fertility-rate-decline-data-statistics-graph-2022
Maybe this is just a reflection of lower aggregate demand?
No.
This is an interesting discussion. You medical people here, what do you think it is the reason for deceasing OB/GYN in rural areas? And second to that, why are rural hospitals in general closing?
@taiwan_girl said in No OB:
why are rural hospitals in general closing?
With regards to OB, a rural hospital simply doesn't have the volume to make it not a money loser.
Think about the requirements:
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At least two nurses, for three shifts. Add vacation, days off and you're looking at a bunch of nurses - 12? 14?
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You need an operating room, ready to go on 15 minutes' notice.
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You need an obstetrician. This guy will be on call 24/7/365. Ain't enough money in the world for that. YOu're going to need at least 3 docs.
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You need a gas passer. See comment above. Oh, and if the gas passer is doing an emergency colon resection/craniotomy in the middle of the night, and OB needs something...you need a backup.
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You need the physical plant - probably in addition to the OR (ideally located in the OB suite, but the main OR might do) - you're going to need at least two labor rooms, unless you want the ladies laboring on a cart in the hall.
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I have no idea what the insurance premiums for the hospital are if OB service is provided, but I know of at least 3 docs who stopped doing OB and restricted their practice to gyne, saving buckets of dollars.
As I mentioned, our place stopped doing OB just after I retired. They were losing money at 750 deliveries a year. At least 200 of those were c-sections.
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@taiwan_girl said in No OB:
why are rural hospitals in general closing?
With regards to OB, a rural hospital simply doesn't have the volume to make it not a money loser.
Think about the requirements:
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At least two nurses, for three shifts. Add vacation, days off and you're looking at a bunch of nurses - 12? 14?
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You need an operating room, ready to go on 15 minutes' notice.
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You need an obstetrician. This guy will be on call 24/7/365. Ain't enough money in the world for that. YOu're going to need at least 3 docs.
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You need a gas passer. See comment above. Oh, and if the gas passer is doing an emergency colon resection/craniotomy in the middle of the night, and OB needs something...you need a backup.
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You need the physical plant - probably in addition to the OR (ideally located in the OB suite, but the main OR might do) - you're going to need at least two labor rooms, unless you want the ladies laboring on a cart in the hall.
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I have no idea what the insurance premiums for the hospital are if OB service is provided, but I know of at least 3 docs who stopped doing OB and restricted their practice to gyne, saving buckets of dollars.
As I mentioned, our place stopped doing OB just after I retired. They were losing money at 750 deliveries a year. At least 200 of those were c-sections.
@George-K Thanks.
It seems as though there is no way to reverse it.
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It seems like it’s only financially feasible at scale, and surely declining birth rates affect that.
Maybe fit-for-purpose birthing centers with doulas and midwives doing the most, with OR available in situ for problem cases could be a viable business at scale.
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It seems like it’s only financially feasible at scale, and surely declining birth rates affect that.
Maybe fit-for-purpose birthing centers with doulas and midwives doing the most, with OR available in situ for problem cases could be a viable business at scale.
with OR available in situ
Staff it.
ACOG guidelines say that for a c-section. You gotta move fast.
"15 minutes from decision (to operate) to incision" is the standard.
When I worked in a small place in rural illinois (we were there for only about 8 years), when I got called for an epidural, or a section, the nurse told me that she's noting the time of the call in the patient's chart.
Half-hour delay? Gonna have a bunch of bad babies.
This is why, even on 2nd or 3rd call at our "bigger" place, I had to be within 15 minutes of the hospital. Got to be a drag when you're on 2nd call 5 times a month, and 3rd call 5 times a month.
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Seems like there is no choice. People in rural areas are going to have to travel far to have a baby.
(Unless there is some rich guy willing to pay a bunch of doctors to do nothing most of the day.)
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Pinedale’s residents have good reason to be excited. New full-service hospitals with inpatient beds are rare in rural America, where declining populations have spurred decades of downsizing and closures. Yet a few communities in Wyoming and others in Kansas and Georgia are defying the trend.
“To be honest with you, it even seems strange to me,” said Wyoming Hospital Association President Eric Boley. Small rural hospitals "are really struggling all across the country,” he said.
There is no official tally of new hospitals being built in rural America, but industry experts such as Boley said they’re rare. Typically, health-related construction projects in rural areas are for smaller urgent care centers or stand-alone emergency facilities or are replacements for old hospitals.
About half of rural hospitals lost money in the prior year, according to Chartis, a health analytics and consulting firm. And nearly 150 rural hospitals have closed or converted to smaller operations since 2010, according to data collected by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research.
To stem the tide of closures, Congress created a new rural emergency hospital designation that allowed struggling hospitals to close their inpatient units and provide only outpatient and emergency services. Since January 2023, when the program took effect, 32 of the more than 1,700 eligible rural hospitals − from Georgia to New Mexico − have joined the program, according to data from the Centers for Medicare & Medicaid Services.
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Problem is how do you staff an ER in a rural setting? Years ago, I've worked 25-30 bed rural hospitals with one "trauma room" and a couple of exam rooms. Local docs (all three of them) would take call, often sleeping in the hospital. You'd have one nurse assigned to the ER at night, with the ability to pull another nurse and an aide from the floor if things got really hairy.
Doctors won't work like that anymore. I'm not sure nurses will. And you've got to have enough ancillary staff to support an ER, so I guess those guys would pull call. I guess you can cross-train a lab guy to do xray ( doesn't work well the other way, high complexity testing can get way beyond a xray guy) and the physician can do the basic respiratory stuff.
If you hire your ER doc, rather than having a local doc pull call, it's $200/hr (more on holidays, I've seen $500/hr on Christmas) if you can get one.
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So then how did this used to be done and these places stay open? The small hospital in my town, had a birthing center for decades. Over a 12 year span, all 5 of our kids were born there. A couple births, a day, was the norm there since...forever.
Did something change to make the couple births a day model unsustainable?
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Doctors and reimbursement.
Surprisingly, even Medicaid reimbursement for a vaginal delivery is pretty good. I'm not sure about a C-section.
Problem is the today's OB docs will simply not live the job. They want a life outside the practice.
And at the risk of being PC incorrect, I think it's because we have a lot more female OB/GYN docs. More women than men, won't live the job.
