Since late January, when the story broke about the upcoming closure of the maternity ward at the Grand Marais hospital, I’ve been thinking a lot about pregnant women, clinicians, and hospital administrators in Grand Marais, and in other rural communities in Minnesota and beyond. For pregnant women in rural areas and for all individuals seeking care, both access and patient safety are necessary components of effective health care systems. They are not negotiable. In order to better understand how to ensure both access and safety, we need to start with relevant information for understanding both capacity and need for care in rural communities.
Approximately 20 percent of the U.S. population lives in a rural area, but only about 10 percent of the nation’s physicians are practicing in rural areas. Of the 2,050 rural U.S. counties, 77 percent are designated as health professional shortage areas. A report from the Minnesota Department of Health highlights the workforce challenges and clinician shortages in Greater Minnesota. And this is important, because rural Americans suffer worse health outcomes than those in urban areas, having higher rates of death, disability and chronic disease.
Each year, a half a million babies are born in rural U.S. hospitals, but information on the physicians, nurses, and other clinicians who care for these babies is extremely limited. Very little is known about the obstetric care workforce in rural hospitals beyond broad recognition of limited capacity. I have had the opportunity to work with my colleagues at the University of Minnesota Rural Health Research Center to address this knowledge gap. Our current work asks – Who deliveries babies in rural hospitals?
To learn about how they take care of women during labor and delivery, we surveyed the obstetric unit managers at all 306 rural hospitals that do births in nine US states (Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin). In a study, published recently in the Journal of Rural Health, we report that obstetric care staffing differs significantly across rural hospitals by birth volume. Surveyed rural hospitals with lower birth volumes (fewer than 240 births a year) were more likely to rely on family physicians and general surgeons doing deliveries, while those with a higher birth volume were more likely to have obstetricians and midwives attending deliveries. Lower birth volume hospitals were also more likely to have labor and delivery nurses who were not specialized in obstetrics – that is, who also worked in other areas of the hospital. Reported staffing challenges included scheduling, training, recruitment and retention of clinicians, dealing with census fluctuation, and dealing with intra-hospital relationships.
Efforts to address healthcare workforce and access issues have accelerated with implementation of the Affordable Care Act (ACA). Our analysis highlights the need to tackle the challenges of obstetric care workforce and provision in rural hospitals under the ACA, especially for low-birth-volume hospitals. We recommend utilization and expansion of federal, state, regional, and hospital-systems level approaches to increase access to appropriate training during medical education and in clinical practice through programs including simulation training, telehealth, and interprofessional education.
In addition, medical, nursing, dental, and public health schools can work to recruit future clinicians, care providers and professionals from rural areas to create a “homegrown” workforce to meet the health care needs of rural communities. Also, rural hospitals can band together to address these shared challenges. Our research implies that rural hospitals working in isolation may struggle to address the burden of workforce challenges.
What does this mean for families Grand Marais and other rural communities? I think it means that it’s time to bring research findings and data into compassionate conversation that recognizes the needs and constraints of rural communities and of rural healthcare systems. The suggestions that emerge from such conversations would offer excellent fodder for policy discussion to find solutions that support both access to and quality of care in rural communities.