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 But she has adjusted her approach since arriving last year at the
70-bed North Baldwin Infirmary in rural, southern Alabama.
Low patient admissions and high costs mean the hospital does not
have doctors on site around-the-clock to administer anesthesia in
the case of an unexpected emergency Cesarean.
As a result, Dr. Arthur performs the surgery if there are any signs
of complication, rather than waiting and running the risk that comes
with the 20 to 30 minutes it takes for an anesthesiologist to arrive
in the middle of the night.
"It's better for me to do a C-section when I suspect that something
may happen," she said of her new strategy. “Getting the baby out
healthy and happy outweighs some of the risk.”
Physicians in rural communities across America are facing the same
tough choices as Dr. Arthur. Hospitals are scaling back services,
shutting their maternity wards or closing altogether, according to
data from hospitals, state health departments, the federal
government and rural health organizations.
Nationally, 119 rural hospitals that have shut since 2005, with 80
of those closures having occurred since 2010, according to the most
recent data from the North Carolina Rural Health Research Program.
To save on insurance and staffing costs, maternity departments are
often among the first to get shuttered inside financially stressed
rural hospitals, according medical professionals and healthcare
experts.
“It’s been a slow and steady decline,” said Michael Topchik, the
National Leader for the Chartis Center for Rural Health, about
maternity ward closings. “It’s very expensive care to offer,
especially when it’s lower volume.”
More than 200 maternity wards closed between 2004 and 2014 because
of higher costs, fewer births and staffing shortages, leaving 54
percent of rural counties across the United States without
hospital-based obstetrics, data from the University of Minnesota’s
Rural Health Research Center show.
The trend has escalated recently even though the national healthcare
law, known as Obamacare, was designed in part to help rural
hospitals thrive. But unpaid patient debt has risen among rural
hospitals by 50 percent since the Affordable Care Act was passed,
according to the National Rural Health Association, especially in
states that decided not to expand Medicaid – the state and federal
insurance program for the poor.
The outlook for these hospitals was not poised to improve had
Congress approved legislation to replace Obamacare. Senate
Republicans’ proposed cuts to Medicaid would have pushed about 150
more rural hospitals into the red, according to the Chartis Center
for Rural Health, mainly in states that voted Republican in the last
election.
But late on Monday, Senate Majority Leader Mitch McConnell said the
Republican effort to repeal and immediately replace Obamacare will
not be successful, after two of McConnell's Senate conservatives
announced that they would not support the bill.
PAIN FELT BEYOND THE BELTWAY
The consequences go beyond politics.
When local doctors and midwives leave town, rural women lose access
to essential services. Many skip or delay prenatal care that could
prevent complications, premature birth or even death. The U.S.
infant mortality rate is among the highest in developing countries
at 5.8 deaths per 1,000 births.
Pregnant woman in rural areas are more likely to have their
deliveries induced or by Cesarean section that, while potentially
life-saving, are more expensive and risky than a normal vaginal
birth, according to patients, medical professionals and researchers.
Almost a year after her second son’s birth, Courtney Cross is still
repaying money she borrowed because of the smaller paychecks and
larger gas bills she had from driving 60 minutes each way to a
specialist in Mobile, Alabama.
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“There were some days I had to reschedule because of the money
factor,” said Cross, a medical technician and mother of two, who
some months made the trip multiple times. “I had to make money.”
Cross is not alone. The most common reasons for the hospital
closures are people and money. More and more people are moving to
urban areas in pursuit of work and a better paycheck. And in most
states, lower revenue from insurance and U.S. government payments
are pushing these hospitals into financial stress, particularly in
states that did not build out their Medicaid programs as Obamacare
allowed.
“The majority of births in rural America are paid for by Medicaid,
and Medicaid is not the most generous payer,” said Diane Calmus,
government affairs and policy manager for the National Rural Health
Association. “For most hospitals it is a money losing proposition.”
This is the main reason why Connie Trujillo shuttered her midwife
practice this spring in Las Vegas, New Mexico. The local hospital
had closed its maternity ward, and the closest hospital to deliver
babies was at least 60 miles away. She sees more elective inductions
because the patients live far away and can't afford to go back and
forth.
“Some of them just don’t have the resources,” she said. A year after
shuttering, the hospital is trying to hire additional staff to
reopen the ward.
MORE SCHEDULED DELIVERIES
The number of induced U.S. deliveries nationally has doubled since
1990 to about 23.3 percent, but rates are significantly higher in
rural areas, where it is routinely offered to women traveling long
distances, especially if the weather is bad.
Induced labor and surgery come at a high cost. Commercial insurance
and Medicaid paid about 50 percent more for Cesarean than vaginal
births, according to a 2013 Truven Health Analytics report. The
report said Medicaid payments for maternal and newborn care for a
vaginal birth was $9,131 versus $13,590 for a C-section.
In largely rural West Virginia - where the Summersville Regional
Medical Center became the latest hospital to stop delivering
newborns earlier this year - elected inductions for first time
mothers rose to 28.7 percent in 2015 from 24.1 percent in 2011,
according to data provided to Reuters by the West Virginia Perinatal
Partnership, a statewide effort to improve care.
"Inductions allow the physicians to manage their case loads and
timing of deliveries,” said Amy Tolliver, director of the Perinatal
Partnership. “We know that inductions are happening in small
hospitals that have difficulty with staffing."
To address staffing issues at Dr Arthur’s hospital in Alabama, the
facility paid temporary doctors for a year to keep the department
open when one of its two maternity doctors stopped doing deliveries.
“It’s important to have access (to obstetrics),” said hospital
president Benjamin Hansert, who also organized a group of doctors
from Mobile about 40 minutes away to cover some of the shifts so
that staff doctors would not always be on call. “Where the mother
goes for care, the rest of the family will follow.”
For the full graphic on hospital closures, click http://tmsnrt.rs/2us7qDM
(Editing by Caroline Humer and Edward Tobin)
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