Rural Obstetrics Workgroup Meeting Minutes
Wednesday, June 22, 2011 9:30 a.m.-12 p.m.
Members Present: Emily Bakken, Tom Crowley (chair), Roberta Decker, Roxanne Fabian, Ann Gibson, Jen Harvey, Kathryn Houchins, Scott Johnson, Roxy Kjos, Sue LaMotte, Frank Lawatsch, Nicole Manemann, Diane Muckenhirn, Michelle Quale, Millicent Simenson, Suzanne Sudmeier, Kim White
Members Absent: Ray Christensen, Mary Devany, Brenda Freborg, Jeff Hardwig, Mina Spalla, Anthony Stone, Thomas Witt
MDH Staff Present: Paul Jansen, Jill Myers, Mark Schoenbaum, Kristen Tharaldson
WELCOME AND INTRODUCTIONS
Members were asked to share their level of interest and expertise as it relates to this work group.
Ann Gibson (Minnesota Hospital Association) – There is continued interest in how to address workforce challenges in rural areas. Obstetrics is one area where workforce shortages are an ongoing challenge.
Jen Harvey (Women’s Health Consultant, MDH) – There is interest in access to care for women seeking prenatal services in rural areas. Outcomes for maternal and child health are being tracked statewide. We have access to data sets available at a state level including those related to pregnancy and birth.
Mark Schoenbaum (Office of Rural Health & Primary Care, MDH) – ORHPC staff study rural demographics, health care and how these relate to rural community development. There is interest in sustainable health care delivery systems that meet community needs, which also leads to retention of young families and children. There are similar workforce challenges between the rural general surgery and rural obstetric services. The previous workgroup on rural general surgery and this rural obstetrics workgroup will help identify challenges and solutions at the state policy and programs level.
Scott Johnson (OB/GYN, Essentia Health) – Essentia Health in Duluth has close ties to the medical school. It is clear that rural obstetric services are largely provided by family practice doctors. Rural family practice doctors need c-section training to feel competent in this role. A fellowship in rural obstetrics is available to a small number of medical students. Training for rural practice and general surgery available are needed as a backup for rural OB/GYNs and family practice physicians. Essentia is looking into the possibility of developing a rural general surgery residency program.
Nicole Manemann (Medical student, UMN-Duluth) – As a medical student, this is a unique opportunity to get to know the policy behind the medicine. An idea for an aspiring medical student’s roundtable discussion on obstetrics is in the works. This can help identify current medical students’ opinions and perceptions of rural obstetrics. Medical students at the Duluth campus have an option to take an obstetrics longitudinal course to follow one patient through their pregnancy and birth.
Michelle Quale (Midwife, Glencoe Regional Health Services) – I have worked in Bemidji in obstetrics and currently work as a midwife in Hutchinson. It is important to have women health practitioners in rural areas and support them to remain in rural communities as their place of practice. Are there currently enough choices for obstetric services in rural areas? OB/GYNs are difficult to recruit. Some family practice physicians in rural areas do c-sections or are involved in a few deliveries a year. Mid-level practitioners stay in rural, but compete with metropolitan areas.
Diane Muckenhirn (Advanced Practice Registered Nurse, Hutchinson Medical Center) – There needs to be an emphasis on nurse practitioners working at the top of their license as primary care and physician extenders. Collaborative practice can fill gaps in expertise and workforce that are common in rural areas.
Tom Crowley (CEO, St. Elizabeth’s Medical Center) – St. Elizabeth’s hospital in Wabasha has about 85 births each year. Midlevel and primary care practice is integrated. Historically, it’s been difficult to recruit OB/GYNs due to lifestyle expectations. With flexible staffing models, rural communities can have viable obstetric programs.
Frank Lawatsch (CEO, Swift County-Benson Hospital) – Benson hospital had 109 births last year. We would like options for maintaining a successful obstetrics program. Two years ago we discontinued deliveries. With no c-section coverage, patients were transferred by ambulance to Willmar. Medical staff was not happy when the hospital board discontinued obstetric services. We are currently trying to recruit physicians with an interest and willingness to do obstetrics. We want to ensure staff competencies (physicians and nursing staff) in a low volume environment.
Sue LaMotte (Midwife, Minnesota Board of Nursing) - Advanced Practice Registered Nurses (APRNs) are currently divided into four categories. There is a national effort to standardize certification and licensing. The scope of practice for nurse midwives is different in each state. There is a need to address regulatory barriers to practicing at the top of a license and attain written prescribing privileges. The Institute of Medicine report “Future of Nursing” describes opportunities for APRNs who practice in rural settings.
Jill Myers Kemper (Office of Rural Health & Primary Care, MDH) – ORHPC’s interested in helping articulate and uncover challenges to rural obstetric services. The group needs to stay focused on unique challenges of providing this service in rural areas.
Paul Jansen (Office of Rural Health & Primary Care, MDH) – Staff will facilitate a conversation and shed light on data specific to rural obstetric services in Minnesota.
Emily Bakken (Home Visiting Coordinator, White Earth Home Health Agency) – Public health and tribal health obstetric services are set up differently. Pregnant moms often obtain prenatal care at an IHS facility or local clinics. For delivery they are sent to larger hospitals in the area. Doulas are important to bridge the gap between prenatal care services and delivery services. Patients are mobile and often switch providers, so doulas help them get the services they need while helping providers understand the transitions of their patients. This workgroup could help larger hospitals better understand the process and referrals back to rural clinics and IHS.
Roberta Decker (Doula, Leech Lake Health Division) – Doulas help with transitions. A strength of care doulas provide is their emphasis on prenatal care. They explain the importance of prenatal and postpartum care and help follow up when there are changes in providers. They explain available options about where and how babies can be delivered.
Roxy Kjos (Inpatient Manager, LifeCare Medical Center, Roseau) – Continuing education issues are important for obstetric labor and delivery staff. More information is needed about training opportunities, especially those available remotely.
Kathryn Houchins (Medical Social Work, Sanford Hospital, Bemidji) – Bemidji has a unique population that requires obstetric services. There is high poverty, high rates of substance abuse, and many mothers who are or will be single parents. Access to prenatal care services as well as wrap around social services is essential. Even with availability of services, there are still many barriers to accessing prenatal care.
Suzanne Sudmeier (Midwife, Specialty Clinic-Avera Health, Worthington) – It is important to explore and promote connections between certified nurse midwives and physicians (family practice and OB/GYN).
Kim White (Physician Recruiter, Mayo Health System) – It is difficult to attract family practice physicians with OB specialty because they are in short supply in the U.S. workforce. New medical school graduates do not wish to take call, so it is difficult to compete in the new environment of work/life balance. The willingness of current family practice physicians to do obstetrics is on the decline. Training may be inadequate or there are malpractice hesitancy or fears.
WORKGROUP PROJECT PLAN
The workgroup project plan was presented for discussion and feedback. The project scope will include the pipeline for new obstetric providers and alternate care models. It is important to identify all the providers of rural obstetric services as well as those who provide support services such as doulas and general surgeons.
It will be important to distinguish between traditional midwives, certified professional midwives (CPM) and certified nurse midwives (CNM). A scope of practice document will be created to identify statutes related to obstetric services providers.
Home births are another topic of interest. When a woman undergoing a home birth experiences complications, this can be a difficult situation for the hospital and health care providers upon admission. Emergency room and on-call physicians may or may not have c-section training. ORHPC staff will look for data on the number of home births and their outcomes. There are two licensed birth centers in Minnesota, both in the metro area.
Most rural patients want care close to home. Health care systems are shifting their thinking to address workforce challenges with a “train your own” workforce mentality. The data shows the majority of providers who do a fellowship or advanced training in rural areas are more likely to stay in rural areas.
What is an adequate ratio of obstetric providers to women of child bearing age? A composite FTE/OB services configuration should be identified. This could inform accountable care organization discussions and be a part of benchmarks for primary care. The ratio should consider FTEs because they provide a more accurate assessment of the available obstetric workforce.
Which additional providers are needed to support rural obstetrics programs? General surgeons, emergency room physicians and certified registered nurse anesthetists need to be considered.
The workgroup would like to gather data on the number of rural Minnesota children being born in neighboring states (Iowa, North Dakota, South Dakota and Wisconsin). This can be accomplished through birth certificate records. The Minnesota Hospital Association has some data on providers and a 2010 summary is now available.
Workgroup members want to learn more about the role of doulas, especially for tribal reservation communities in northern Minnesota (Red Lake and Leech Lake). They play an important role as educators and connectors to health care and human services. Many doulas serve women at high risk without access to OB/GYNs on the reservation. The typical role of the doula is to work with women for the 30-36 weeks leading up to delivery. They have an initial prenatal meeting and one to two additional prenatal visits. They clarify questions about the baby’s development and birthing process and encourage conversations between women and their health care providers. Following the birth, they help with breastfeeding, maternal education and infant massage. There are eight active doulas in Leech Lake and one in Red Lake.
Sanford Bemidji Medical Center (previously known as North Country Regional Hospital) does about 1000 deliveries per year. The Leech Lake and Red Lake IHS facilities do not perform deliveries and their patients often come to Sanford to deliver. Cass Lake is 17 miles and Red Lake is 35 miles from Bemidji.
Barriers to practice exist for doulas working with the northern reservation communities. Transportation is expensive and sometimes a barrier for the doula and/or patient. The referral process from clinics and WIC to doula services could be more streamlined. For example, it should be easy to identify if a woman is already working with a doula and collaboration with other health providers should be routine. Also, when babies are born into native communities, often there are several family members who would like to attend the birth. Sometimes there are limits to the number of people in the birthing room and mothers struggle to choose between family members.
OBSTETRIC SERVICES IN RURAL MINNESOTA
A high level data and policy preview was presented to the group for discussion and feedback. This included published scientific literature, obstetric workforce information and related state and federal legislation. Workgroup members are welcome to submit any articles or data they have for use in the draft report.
It will be important to look at other states to see if obstetric access issues are pervasive. Another state-to-state comparison should be uniformity of practice for midwives.
With Medicare, there have been increases in payment for rural areas. With rural obstetrics, the payment system is not favorable. Medicaid payments will increase in 2014.
Surveys have found that rural OB/GYNs experience a lower volume of patients while doing more on-call hours. A positive trend is 50 percent of new medical graduates are going into family practice. Is there anything we can build on with this trend? New female physicians tend to work fewer hours or drop their practice earlier in their career. New male physicians also seek a better work/life balance. Because of these trends, hospitals are recruiting 1.5 FTEs to replace 1 FTE. The Minnesota Hospital Association has data on gender and practice hours. It may be necessary to increase Graduate Medical Education (GME) funding or change restrictions on residency slots to address these workforce challenges.
Staff identified three potential areas for case studies: (1) hospitals discontinuing obstetric services (2) hospitals starting obstetric services (3) continuity of care for American Indian women in northern Minnesota. Workgroup members are encouraged to submit ideas for case studies or promising models.
There are patient safety issues to consider around obstetric services. One concern is safety of transport for women in labor. Another consideration is the balance between patient choice and practitioner liability. Tort reform will address costs for call coverage and insurance. Currently, insurance for family practice doctors is $8,000 compared to $40,000 for obstetrics. In this case, an OB/GYN or family practice doctor providing obstetric services would need to do a certain number of deliveries just to recoup the insurance costs. The Minnesota Medical Group Management Association (MMGMA) may have data on this issue.
Upcoming workgroup meetings will be held via webinar or teleconference with phone-in options. Members are asked to attend when interested or when topics converge with their area of expertise. The next meeting will address workforce issues: number and location of providers, practice settings, obstetric workforce pipeline, education and residency, malpractice, insurance and lifestyle issues.
The meeting adjourned at 12 p.m.