Taylor, Zweig, Williamson, Lawhorne and Wright 343

Loss of a Rural Hospital Obstetric Unit: A Case Study"

Jane Taylor, Steven Zweig, Harold Williamson, Larry Lawhome and Harley Wright

ABSTRACT As familyandgeneral practitioners whoprovidea substantial portion of the obstetric care in rural areas quit their obstetric practice, small rural hospital obstetric units are at risk of closing. Using a case study design, we examined the impact of the loss of obstetric services at a small rural hospital in Missouri. This unit was the site of delivery for less than one-half of the infants born to women living within its service area. However, it was the most likely source of care for women who were young, undereducated and unmarried ( p < 0.01). Evidence derived from birth certificates showed that women who delivered there had good perinatal outcomes compared with local women who delivered at larger hospitals. A gradual decline in the number of physicians providing obstetric care preceded the closing of the hospital unit. Women from the hospital service area who presented late for prenatal care were twice as likely to have had a low birthweight infant in the year after the local hospital unit closed (1 6.7% versus 7.4%), although this difference and other comparisons of outcomes were not statistically significant.

Family and general practitioners have traditionally provided the bulk of obstetric services in many rural parts of the country. In the state of Wash- ington, for example, family and general practitioners delivered 62 percent of babies born to women from rural or semi-rural areas (Starzyk, 1981). In Missouri during 1984, these doctors represented 74 percent of all physicians in rural areas delivering 20 or more babies per year (Missouri Department of Health, 1988). Most of these births occurred in small hospitals with fewer than 500 deliveries per year.

However, family and general practitioners are quitting obstetric practice at a high rate (American Academy of Family Physicians, 1987; Darnell, 1987; Gordon, Mullen, Weiss & Nichols, 1987; Krall, 1988; Rosenblatt & Wright, 1987; Smucker, 1988; Weiss, 1986). Professional liability issues are fre- quently implicated in this decrease in available physicians. Other reasons mentioned are physician age, personal and professional goals, coverage for time off, availability of consultation, and ease of referral to a larger hospital (American Academy of Family Physicians, 1987; Paxton, 1986; Rosenblatt &

*This study was supported by a grant from the American Academy of Family Physicians, Kansas City, MO. Requests for further information should be sent to: Steven Zweig, MD, MSPH, Department of Family and Community Medicine, School of Medicine, University of Missouri-Columbia, Columbia, MO 65212.

The Journal of Rural Health Volume 5, Number &October 1989

344 The lournal of Rum1 Health

Wright, 1987; Selander, 1983). Because the physicians discontinuing obstet- rics are those who commonly staff rural hospitals, obstetric units at these hospitaIs are particularly vulnerable to closure.

In a previous study of a cohort of pregnant women from a rural Missouri county, we found that women who received care from family physicians and who delivered in the local hospital had fewer years of education and were more likely to have inadequate insurance coverage than women who delivered at regional centers (LeFevre, Zweig & Kruse, 1987). Others have also suggested that rural medically indigent women are most likely to be threatened by a loss of local obstetric services (Rosenblatt & Detering, 1988; US. Department of Health and Human Services, 1987). This is the same group of women for whom prenatal care seems most important in prevent- ing bad outcomes (Gortmaker, 1979; Institute of Medicine, 1988).

There have been no published descriptions of the closing of rural hospital obstetric units or studies of the impact of the loss of these services. This case study of the loss of a rural hospital obstetric unit examines the effects of these forces on a small rural hospital and on the women served by this facility.

Methods

The rural hospital that was studied was the only hospital located in the county seat (population 10,000) of a rural Missouri county. This county was similar to other United States counties outside a metropolitan statistical area (MSA) in the percent of the population that was female (49.9% versus 51.0%), in median age (31.2 versus 30.1 years), in mean household income ($15,281 versus $16,045), and in the educational attainment of its residents (58.4% high school graduates versus 63.7% high school graduates). The study county was different from other rural counties in its racial composi- tion (98.8% white versus 88.1% white).

In 1984, the six general and family practitioners that made up the hospital's obstetric staff each delivered 25 or more babies at the hospital. In 1984 the hospital delivered 235 babies. Due to a loss of physician services, this rural hospital's obstetric unit was closed in late 1986.

Characteristics of women and the outcomes of their pregnancies were recorded on birth certificates compiled and made available by the Missouri State Department of Health. We examined all recorded births to women living in the service area of this rural hospital from 1984 to 1987. The hospital's service area was defined as including the four zip codes within a 15-mile radius of the rural hospital. Zip code delineations were chosen over county boundaries because they tend to follow natural boundaries and represent more accurately the patterns of travel and utilization of services of patients (Meade, 1974).

Taylor, Zweig, Williamson, Lawhorne and Wright 345

Variables

Loss of local hospital obstetric services was the primary independent variable. Other independent variables acquired from birth certificates included the following demographic characteristics: age, level of education and marital status of the mother. Women were classified as high risk if they had one or more of three demographic characteristics: under 18 years of age, not a high school graduate, or unmarried. These are characteristics of women who have been previously shown to be at increased risk of obtain- ing inadequate prenatal care (Institute of Medicine, 1988), and who there- fore are at increased risk of delivering a low birthweight baby (Institute of Medicine, 1985).

The obstetric outcome variables, also derived from birth certificates, included: low five-minute Apgar (less than seven), low birthweight (less than 2,500 grams), premature delivery (less than 37 weeks), and fetal death (non-living birth greater than 20 weeks gestation). Time of initiation of prenatal care was also obtained from birth certificates. Late presentation for prenatal care (defined as beginning care after the fourth month of preg- nancy) is a measure of inadequate prenatal care (Institute of Medicine, 19881, and has been associated with an increased risk of premature births, perinatal morbidity, and mortality (Gortmaker, 1979; Institute of Medicine, 1985; Ryan, Swaney & Scola, 1980).

We calculated chi-square statistics to assess statistical differences in the distribution of outcome variables. To compare characteristics and outcomes of women who utilized the local hospital to those of women who used other hospitals, births from 1984 through 1986 were compared. To examine changes in outcomes that occurred after the local hospital closed, births during 1984 through 1986 were compared to births occurring during 1987.

Study Objectives

To characterize the use of the local hospital obstetric unit and to address

1. What proportion of the deliveries to women living in the service area occurred in the local hospital, and where did the other women deliver?

2. How did those patterns change following the closure of the hospital obstetric unit?

3. What were the characteristics of women who used the rural hospital compared with those who sought care elsewhere?

4. How did the obstetric outcomes of women delivering in the rural hospital compare with those in the other hospitals?

the impact of its closure, the following questions were answered.

346 The journal of Rural Health

5. How did women at high risk due to social characteristics or lack of early prenatal care fare at the local hospital compared with other hospitals?

6. How did physician services change in terms of numbers of doctors and numbers of deliveries, preceding the closure of the local obstetric unit?

7. Did the rates of adverse perinatal outcomes in the rural hospital's service area change after the obstetric unit closed?

8. Were high-risk women more likely to suffer adverse outcomes fol- lowing the cIosure of the unit?

Results

Of the 353 babies born to women in the hospital service area in 1984,167 (47%) were born in the local hospital. During the next two years, both the

Table 1. Place of Deliveries of Women from Local Hospital Service Area.

Location Year

1984 1985 1986 1987'

Local hospital 167 (47%) 145 (41%) 79 (24%) 1 (0.01%)

Other hospitals

30 - 50 miles 15 33 53 76

51-100 miles 158 161 183 221

101-200 miles 10 10 15 24

Home 2 3 1 0

Clinic 0 0 0 3

Out of state 0 0 0 0

352 352 331 325

* Obstetrics unit was closed during 1987

Taylor, Zweig, Williamson, Lawkorne and Wright 347

number and proportion of deliveries at that hospital declined sharply until the obstetric unit closed in late 1986 (Table 1). In 1984, more deliveries occurred at this hospital than at any of the other hospitals in the region. By 1986, a hospital 55 miles away had more deliveries of women from the service area than the local hospital (123 compared to 79). The number of deliveries at the state-supported university hospital (one of the hospitals 101 to 200 miles away) increased during the four-year period, but contrib- uted little to the total number of deliveries (eight deliveries in 1984; 23 in 1987). Even following the loss of local physician and hospital services, birth certificates demonstrated few home or clinic-based deliveries. There was only a slight decline in the total number of deliveries to women living in the hospital service area (352 in 1984 versus 325 in 1987).

Table 2 contains data on the characteristics of the women who used the local hospital obstetric unit before it closed. As expected, women who were under 18 years of age, without a high school education, or unmarried, were much more likely to use the local hospital (p < 0.01). Forty-nine percent of the women who delivered there had one or more of these characteristics, thereby meeting criteria for a potential high-risk pregnancy, compared with only 29.5 percent of the women delivering at other hospitals. Because the next closest hospital was 37 miles away, cost and convenience factors may have played an important role in this utilization pattern.

Table 3 summarizes perinatal outcomes in the local hospital and the other hospitals used by women in the service area for the years 1984 to 1986, the time period when the local hospital was still offering obstetric care. For rates of low five-minute Apgar, fetal death, and premature delivery, there

Table 2. Social Characteristics of Women Deliverying at Local and Other Hospitals (for births in 1984-1986).

Risk Group (%) Deliveries at Local Hospital (N = 391)

Deliveries at Other Hospitals (N = 638)

Under 18 years old 8.4 4.2*

Unmarried 17.5 9.1"

Non-high school graduate 44.4 24.6*

High risk+ 49.2 29.5*

* p < 0.01 + One or more of the following characteristics: under 18 years old, unmarried, non-high school graduate

348 The journal of Rural Health

were no significant differences in outcomes. However, low birthweight infants were significantly less likely to have been born at the local hospital (4.1% versus 7.6%, p < 0.05). This occurred even though women who delivered at the local hospital were more likely to present late for prenatal care (32.7% versus l1.9%, p < 0.001). The incidence of low birthweight (LBW) for women in this county was 6 percent, indicating that some amount of regionalization prior to delivery was taking place before the closure of the local rural hospital. This is confirmed by two other findings. For the high- risk women (by virtue of their demographic characteristics), the incidence of LBWdeliveries was4.6percentat thelocal hospitaland 12.6percentat the other hospitals (p < 0.01). Similarly, for women who presented late for prenatal care, the incidence of LBW was 3.6 percent in the local hospital versus 13.5 percent in the other hospitals (p < 0.05).

Although the hospital obstetric unit did not close until the end of 1986, there was a steady decline in the number of deliveries by individual physicians and the number of physicians doing obstetrics in the three years before the closing. In 1984, six physicians delivered 25 or more babies. All of these were general or family practitioners (five MDs and one DO). The number of physicians delivering at least 25 babies decreased to four in 1985 and one in 1986. As the data in Table 1 indicates, the total number of deliveries to women from the service area at the rural hospital was strongly associated with the number of physicians providing services.

Comparison of the perinatal outcomes occurring before the closing of the obstetrics unit at the local hospital (1984 to 1986 data) with outcomes after

Table 3. Pregnancy Outcomes of Women Living in the Service Area (for the years 1984 through 1986).

Outcome (%) Local

Hospital Other

Hospitals

Low 5-minute Apgar (< 7) 1.3 1.7

Low birthweight (< 2,500 grams) 4.1 7.6*

Fetal death (> 20 weeks) 1 .o 0.9

Premature delivery (< 37 weeks) 7.4 8.8

Late presentation for prenatal care (> 4 months)

32.7 11.9**

* p < 0.05 ** p < 0.001

Taylor, Zweig, Williamson, Lawhorne and Wright 349

the closing (1987) showed no significant difference for any of the outcome variables. There was a small increase in LBW infants (8.6% versus 10.4%) to women in the high-risk group. Women from the service area who presented late for prenatal care were more than twice as likely to have had a LBW infant in 1987compared with 1984 to 1986 (16.7% versus 7.4%), although the difference was not statistically significant at conventional levels (p = 0.1 1).

Discussion

This case study examined the impact of the loss of a rural hospital obstetric unit in a small midwestern community. Even at the beginning of the study period, only 47 percent of pregnant women living within 15 miles of the hospital delivered there. Women under the age of 18, women who were not high school graduates, and women who were not married were more likely to deliver at the local hospital. Older, better educated and married women were more likely to travel to a larger town 55 miles away for prenatal and delivery care by obstetricians at a larger hospital.

The outcomes for the women who delivered at the local hospital were comparable to those at other hospitals in the region. The rate of low birthweight infants was somewhat lower, suggesting that appropriate referrals to specialist care were occurring. The rate of women presenting late for prenatal care was much higher at the local hospital, again confirming that this was a group of women at potentially higher risk for bad outcomes. However, the incidence of low birthweight infants was significantly lower at this hospital in both those at risk due to age, education level, or marital status and in those who presented late for prenatal care.

This case study demonstrated that decreasing physician services pre- ceded the loss of hospital services. Discussions with the chief of the medical staff of the case study hospital provided additional information which complements the birth certificate analysis. The four physicians providing most of the obstetric care in 1985 were board-certified family physicians in their 30s and 40s who quit doing obstetrics because they felt they could no longer afford the malpractice insurance. While the hospital wanted to continue to provide obstetrics service, it could not recruit additional physi- cians, and it was not willing to provide financial support to the local physicians. Physicians in the area who quit obstetrics did not continue to provide prenatal care, nor was care provided at the local health department. In addition, there were no practicing midwives in the area. A group of obstetricians from the regional center 55 miles away did begin to see pregnant women one day a week in the office of one group of family practitioners. This intervention would be expected to lessen the impact of the loss of local obstetric delivery services.

This study may have been particularly susceptible to several types of bias. The first is that of misclassification, of either the independent or the

350 The Journal of Rural Health

dependent variables. The loss of local obstetric services is the primary independent variable of interest. This measure could be biased by either an incorrect definition of the hospital's service area or an increased availability of other perinatal services after the hospital closed. We are aware of no published report that describes a valid and reliable method of defining obstetric service areas. We chose to use zip codes within a 15-mile radius of the local hospital in an effort to estimate the hospital's obstetric service area. For women residing in each of these zip codes, the local hospital was most likely to have been the place of delivery in 1984 compared with other hospitals. In addition, the four zip codes comprising the service area contributed most of the total deliveries at that hospital. Another hospital was more likely to have been the place of delivery for women living in other surrounding zip code areas.

In addition, outcomes also could have been misclassified. With regard to place of delivery, there was no substantial increase in the reported number of clinic or home deliveries in 1987. However, because home deliveries are often not registered until there is a need for a birth certificate, it is possible that these have been underestimated. The perinatal outcomes measured, such as the incidence of low birthweight infants, are generally considered reliable as recorded on the birth certificates. The risk of misclassification of this and the other outcome variables is probably small.

A second form of bias may be a confounding of the relationships of the independent variable, i.e. loss of obstetric services, with the perinatal outcomes. This is an ecological study. That is, individual outcomes were examined with respect to a community exerted force, change in the availa- bility of local obstetric care. We cannot determine which specific women would have gone to the local hospital in 1987 had services still been available. However, by using women from the same hospital service area as historical controls in these comparisons, other unmeasured variables are less likely confounders.

With respect to generalizability, the population of the county in which it is located was similar to that of other nonmetropolitan counties in distribution of sex, age, mean household of income, and educational attain- ment. It was not similar in terms of its racial composition, therefore making it inappropriate to generalize the findings to dissimilar regions. The analy- sis included all births to women from the defined service area during the years examined, thus preventing the bias implicit in studying only women who delivered at the hospital of interest. However, as with any case study, generalizations must be made selectively and should be confirmed by other studies.

The closing of the local unit in this study did not appear to have a statistically significant impact on the overall obstetric outcomes of women from the hospital service area. However, those who were at high risk by virtue of demographic characteristics and those who presented late for prenatal care had higher than expected rates of low birthweight infants,

Taylor, Zweig, Williamson, Lawhorne and Wright 351

even though these differences were not statistically significant at conven- tional levels.

The finding that there were no significant differences in the obstetric outcome variables following the closure of the local hospital obstetric unit could have occurred for a variety of reasons. First, it is possible that the loss of local obstetric services was a positive event. Perhaps the services being provided previously were of low quality. However, the comparisons of outcomes at the local hospital versus other regional hospitals in 1984 through 1986 argues against that explanation. Second, perhaps the barriers of cost and convenience did not significantly impair access to other care for the group of women who may have previously used the local hospital. It is also possible that the visiting obstetricians providing prenatal care in the offices of the family practice group may have made up for the loss of local services. Third, the effect of the closure on the obstetric outcomes may have been diluted because less than half of the women in the defined service area delivered at the local hospital in 1984, and even a smaller percentage of the total delivered there in the subsequent two years prior to closing.

This gradual decline in the number of deliveries may reflect both the loss of physician services and a migration of women with financial resources to other sources of care in anticipation of the hospital closing its obstetrics unit. Thus, it is possible that an inadequate sample size was the cause for showing no significant differences in perinatal outcomes for this group of women. A larger study examining the impact of the loss of multiple obstetric units would be needed to resolve this question.

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