Rural Obstetrics Workgroup Meeting Minutes

Thursday, September 15, 2011 12-1:30 p.m.

Members Present: Tom Crowley (chair), Roberta Decker, Mary Devany, Jeff Hardwig, Scott Johnson, Sue LaMotte, Frank Lawatsch, Nicole (Manemann) Wilson, Michelle Quale, Millicent Simenson, Kim White, Thomas Witt

MDH Staff Present: Paul Jansen, Jill Myers Kemper, Mark Schoenbaum, Kristen Tharaldson

WELCOME AND INTRODUCTIONS

Jill Myers Kemper reminded the workgroup that the scope of this project includes planning for deliveries, labor and deliveries, c-section coverage, and post-delivery care. Birth rate data in rural regions will help us determine the extent of shortages of OB providers and limits to c-section coverage in some parts of the state.

CURRENT OBSTETRIC WORKFORCE

Paul Jansen presented data on the number of obstetric providers and their location and distribution. Interesting age trends in the obstetric workforce include an increase in young physicians pursuing family practice and a decrease in older physicians still practicing.

Currently there are a lower number of applicants for certified nurse midwifery (CNM) programs. Anecdotal evidence suggests midwife practices are well established by 40- to 50-year-olds who are not ready to retire. Most have years of experience as RNs before they seek CNM specialization. It is likely a pre-requisite to have some obstetric experience to enroll in CNM programs. It may be interesting to check if recent CNM graduates are moving out of state.

A map showing hospitals and their number of deliveries will be updated for this project. There are some discrepancies due to limitations around physician workforce data at the state level. For example, they may list their home or work as the primary address.

Data from 2006-2009 can identify recent trends in deliveries. A snapshot from 2010 (and maybe 2011) can be based on birth record data. Future projections can be based on state demographer data (population projections, age group x county). To recruit obstetric providers, need to ensure there is high demand into the future. Staff will look for sources to capture solo midwife and home deliveries. This data could be very interesting, especially if we compare before and after the 2010 legislation to encourage home births for mothers enrolled in public insurance programs.

Primary obstetric providers include OB/GYNs, family practice physicians, and CNMs. The group believed it is out of the scope of practice for NPs to do births, so they cannot be counted as primary obstetric providers. They are more likely to provide prenatal care.

 

Are there clearly established requirements or policies around staffing for c-sections? For example, is it a requirement that two physicians need to be present during c-sections? The group believed only one physician is required as nursing staff can attend to the newborn. They also believe CRNAs are not required to be present or on call during vaginal births. Staff can check if c-section requirements are outlined in state statutes related to scope of practice or if policies are defined at the local facility level.

A map of Minnesota showing c-section rates is available. It would be interesting to revise the map into two categories: (1) scheduled/planned versus (2) emergency c-sections.

Family practice physicians with c-section capabilities are very important for rural obstetric practices. Birth certificate data can be used to identify family practice doctors doing deliveries. More accurate information may be obtained through a survey of family practice doctors in one or two regions, or all 79 Critical Access Hospitals in rural Minnesota. Staff can look at national literature on trends in this area.

Liability issues are complex for family practice physicians doing c-sections. In one scenario, the family practice doctor was performing a c-section and cut a main artery. A general surgeon was on call and brought in to do the repair. If the general surgeon was not available within 30 minutes, it would have become a more serious scenario. In rural areas, CRNAs often travel to provide care in multiple locations. Staff can look into workforce data on where general surgeons and CRNAs are available for obstetric backup.

Advanced training is crucial for family practice physicians who perform c-sections in rural locations. The volume of deliveries is directly tied to the comfort level to perform obstetric procedures. One young family practice doctor working in a rural area had to travel to get enough experience. There are a certain number of deliveries required to be trained and a certain number of deliveries required to stay comfortable. These numbers vary based on desired level of competency (basic versus advanced), training program requirements, and personal preference of physicians.

Some parts of Minnesota already have limited access to obstetric services. Will things get worse and is this a growing problem? We should consider primary obstetric providers’ plans for retirement in the next five years. The physician workforce is aging and many doctors are already working past retirement age. A new generation of obstetric provides will be needed in rural areas. It will be important to be proactive and find workforce models and solutions that are realistic for rural areas.

DISCUSSION

The workgroup requested more information on obstetric training programs in Minnesota and neighboring states (Iowa, North Dakota, South Dakota and Wisconsin). This includes standard training (all obstetric providers), advanced training (C-section or other high risk births; OB/GYN or family practice with OB emphasis), continuing education (all obstetric providers) and training specifically for rural settings.

What can be done if we know there will not be enough obstetric providers in rural areas? Solutions may include:

  • Focusing on obstetric emergency training (nursing, ER, EMTs)
  • Planning deliveries at regional centers
  • Encouraging return to home community after travel for deliveries
  • Determining the role of telehealth for rural obstetric team
  • Increasing c-section training in family practice residency programs
  • Recruiting medical students in family practice willing to do obstetrics.

The model to cluster obstetric care within regional centers creates problems for many patients (family separation, travel costs) and providers (continuity of care, high-risk pregnancies). A better strategy is to include obstetric training for family practice MDs through a fellowship or a year-long intensive course.

There are high burnout and turnover rates for CNMs. They do many on-call hours and have limited support in their work. They tend to do a lot around community and provider education. They may benefit from a support network for nurse midwives in rural areas.

Midwifery practice is dependent on hospital bylaws. The nature of the supervisory relationship between doctors and CNMs ranges from strict to very independent. The type of supervision is up to each organization and physician supervisor. Those who are strict often have not had a lot of experience working with CNMs and are apprehensive about liability issues. Those who are less strict often create opportunities to share lessons learned and are comfortable with flexible team models of care.

NEXT STEPS

The next workgroup meeting will be via webinar in early November. We will continue to look at obstetric workforce issues including education and residency for primary OB providers. Malpractice, insurance and lifestyle issues may also be covered. Mac Baird, M.D., M.S., chair of Family Practice at the UMN-Twin Cities, will be asked to join us for the meeting.

ADJOURN

The webinar adjourned at 1:40 p.m.

Updated Tuesday, 18-Oct-2011 08:32:59 CDT