Yesterday the U.S. population reportedly reached the 300,000,000 mark. It is probably more than that if one considers all of the ‘illegal aliens’ that call this home as well. You know, those people who live here, work here, spend money here, have babies here, raise children here, pay (some) taxes here, but sometimes have to share Social Security cards to get medical care and, so we are told, really aren’t citizens(?), Americans(?). Forgive my sarcasm. In our own area we have seen the Hispanic population increase from 4% of our deliveries to more than 30% over the past 5 years. Many of these are young, hard-working women, who show a genuine interest in the health of their babies, want to make the most of their lives in the ‘land of opportunity,’ and have no funding, except for the willingness to pay what they can out of pocket, but an ethic that also tells them that that is the right thing to do.
Anyway, I have digressed from the original topic_ 300,000,000 Americans and, I had the thought as I was falling asleep the other night, someone had to deliver all those babies! The scary thing from my perspective is that I have been around long enough to remember when there were just 200,000,000! In the U.S., most of those deliveries over the past 50 years have been by physicians. Today, even though the overall “birth rate” is reportedly down, we are still having to care for more pregnant women than ever before because of the population growth (and that influx of young reproductive age women who barely speak English). Business is great! So, why am I worried? Well the bottom line is that we do not have enough OB providers.
Many factors have contributed to this crisis. Fewer medical students are choosing OB as a profession (too many long hours and hungry, but never greedy, attorneys). Reimbursement for the many hours spent in total care during pregnancy is very poor compared to other specialties. (My dermatologist makes more money doing a few cases of ‘acne surgery’ than we get for an entire pregnancy, labor, delivery, and postpartum care). We face a growing percentage of Medicaid patients and never know when the next ‘check will be in the mail’ and reimbursement certainly hasn’t kept up with inflation or the liability insurance premiums over the years.
A greater percentage of medical students entering OB/GYN are women. That is great on the surface but, unfortunately, an unexpectedly high percentage of these women are choosing not to include obstetrics in their practices (or give it up after only a few years) so, there has actually been a relative dilution in the OB work force. And, as insurance premiums rise, well-established practitioners, who already have a large and loyal patient base, find it easy to give up obstetrics to stay solvent and sane rather than face the constant fear of capricious litigation. Furthermore, providers in rural areas, often family practitioners, are being driven to give up OB because they cannot cover the added expense of the liability insurance with the volume of their practices and current levels of reimbursement. The net effect of this is a worsening of the maldistribution of OB providers that is already present in the U.S. Pregnant women in rural areas will have to travel longer distances to get prenatal care, which will reduce their incentive to do so, and will inevitably result in an increase in maternal and fetal morbidity.
It is also my impression that the pregnant patients are getting sicker! When I began in Maternal-Fetal Medicine, most MFMs had fairly large practices with patients they followed for the duration of their pregnancies. There were even many ‘low risk’ patients thrown into the mix. As such, we often antagonized the general providers, and it took us years of coming to our senses to overcome that stigma of ‘competitiveness.’ Now, most of us have dropped longitudinal care, except for the highest risk women, and we still find it hard to keep up with even the ‘consultative’ side of our practices. There are more women waiting until they are older to get pregnant. There is an epidemic of obesity, diabetes, and hypertension. Preterm labor rates, primary cesarean section rates, and repeat cesareans (with greater risks of placenta previa, placenta accreta, uterine rupture, and difficult operative procedures) are all rising. As a result, we are not only short on general providers, but also short in the area of subspecialty care as well.
Anyway, argue with me if you want to, but something has to give. We have fewer OB providers (not to mention, residents finishing residencies with less OB experience due to multiple factors), a maldistribution of providers (exodus from rural obstetrics), more patients, a higher percentage of ‘at risk’ patients, lower reimbursement, and rising insurance premiums. Seems to me that we have the recipe for real disaster here. In fact, I went to a meeting today and had some of my concerns justified by one of the speakers who reported that there was evidence that there has actually been a slight rise in maternal and perinatal mortality rates in the last few years. Unless we can come up with some well-thought out solutions, the quality of obstetrical care will eventually suffer and the next 100,000,000 deliveries may not go quite as smoothly as the last, even if we end up having a cesarean section rate of 100% sometime in the next 50 years!!!!!!