The Ob-Gyn Shortage
"I am not having my baby in this car," thought Mattelyn Lee, a mother of two, as she tried to breathe through another contraction. Giving birth on the side of a road had been her biggest fear ever since her local hospital, Rappahannock General, in Kilmarnock, Virginia, closed its obstetrics ward earlier that year -- forcing women to drive more than 80 miles to Richmond for prenatal care and deliveries. In fact, she had been so worried that she'd convinced her new obstetrician to induce her before her due date. But as fate would have it, Lee went into labor on Christmas Eve, a week before her scheduled induction -- and she delivered her daughter, Dekoda, a few hours after she arrived at the hospital. Another local mother, Melissa Hudnall, wasn't as fortunate: Two months earlier, she had given birth to her baby girl in the front seat of a Chevy.
Cars haven't always been labor-and-delivery units in Virginia's Northern Neck, an 85-mile strip of land on the Chesapeake Bay. Approximately 300 babies were born each year at Rappahannock General, and its two dedicated ob-gyns had been there for more than 20 years. But with the escalating costs of medical-malpractice insurance, obstetrics became such a financial drain that the ward was forced to close in 2004. Scenarios like this are playing out across the country as more and more ob-gyns and hospitals bail out of the birthing business. A survey by the American College of Obstetricians and Gynecologists (ACOG) found that one in seven ob-gyns has stopped delivering babies, and more than 20 percent have cut back on high-risk obstetrics.
Physicians say that outrageous liability-insurance premiums are the result of exorbitant medical-malpractice lawsuits and jury awards. (Family-practice physicians, often the only doctors providing obstetrical care in rural communities, are equally affected.) According to ACOG, almost half the country -- 22 states including Illinois, Maryland, Missouri, Washington, and New Jersey -- is now in "Red Alert" crisis mode, meaning that the number of ob-gyns is not sufficient to meet patients' needs.
Ever since the one ob-gyn and two family physicians in Macon, Missouri, stopped delivering babies in 2003, many expectant moms have had to drive to a hospital 60 miles away in Columbia. "Going for prenatal checkups was incredibly inconvenient," says resident Janet Ancell, whose third child was born in Columbia. "I had to miss hours of work, arrange for childcare for my other kids, and travel alone most of the time because my husband lost half a day of work if he came with me."
The situation is even worse in neighboring Kentucky, where 25 percent of the state's obstetricians have moved away or stopped practicing since 2001, leaving 71 out of 120 counties without one. Every year, at least 3,000 pregnant women in the state scramble to find new doctors or midwives. Last year, Rashelle Perryman had her third child at a hospital 45 miles away from her home. Ironically, she'd been the obstetrics-ward nurse supervisor at Crittenden County Hospital, in Marion, Kentucky, until the ward closed in 2005. "There are doctors here who want to deliver babies, but they can't afford to," says Perryman. "The sad part is that pregnant women are the ones left bearing the burden."
It's this burden that keeps David Doty, DO, chair of ACOG's Kentucky chapter and an ob-gyn in Maysville, in the delivery room. "My partners and I are the only obstetricians within a 60-mile radius. I can't, in good conscience, leave these women without medical care," says Dr. Doty, who at age 56, admits that he'd like to stop doing deliveries. Unfortunately, finding candidates to fill his shoes is becoming increasingly difficult.
Midwives could help fill the gaps, but their ranks are shrinking too. "Liability-insurance costs have also skyrocketed for certified nurse-midwives, despite low lawsuit rates," says Parents advisor Katherine Camacho Carr, CNM, PhD, president of the American College of Nurse-Midwives. In 10 states, including Virginia, Indiana, North Carolina, and Florida, midwives must be directly supervised by physicians, and 30 other states require a "collaborative partnership." Although midwives handle 10 percent of all vaginal births today, they can't perform cesarean sections unassisted. "If there's no obstetrician in a community, it's very difficult for a certified nurse-midwife to practice," says Dr. Camacho Carr.
Obstetricians pay the second highest liability-insurance premiums of any medical specialty (only neurosurgeons pay more) and are each sued an average of three times during their careers. Although nearly half of the claims against ob-gyns are found to be without merit -- and ob-gyns win 80 percent of the cases that do go to court -- insurance companies often decide to settle cases without giving a doctor the chance to defend himself. "Even if there's no payout to a plaintiff, companies pay an average of $25,000 per case for a physician's legal defense," says Leona Egeland Siadek, vice president of government relations for The Doctors Company, a physician-owned medical-malpractice provider.
And when plaintiffs win, they often win big. The median award in cases related to childbirth is $2.5 million, according to Jury Verdict Research. While large verdicts like this are rare, insurers say they must charge higher premiums because of the risk of huge awards. Although rates vary dramatically across the country, insurance premiums for ob-gyns in Richmond, Virginia, for example, jumped nearly $47,000 in four years -- from $19,500 in 2001 to $66,400 in 2005 -- while rates for doctors practicing internal medicine there increased only $8,600, from $3,200 in 2001 to almost $12,000 in 2005.
Neurological disorders like cerebral palsy in babies are the number-one reason why ob-gyns are sued, and yet fewer than 10 percent of all cerebral palsy cases are due to delivery complications, according to ACOG. "Parents expect a perfect baby, but sometimes a child has problems. It's very unfortunate, but you can't always blame the doctor," says Paul Gluck, MD, a gynecologist in Miami and chairman of the National Patient Safety Foundation. His state has seen a 600 percent rise in verdict awards over the last 15 years. As a result, there are now only a handful of insurers in Florida (down from 66 companies in 1999), and annual malpractice-insurance premiums for ob-gyns in South Florida -- $300,000 in 2005 -- are the highest in the nation. "With so little competition, premiums have soared," says Dr. Gluck, who dropped obstetrics five years ago.
Amazingly, nearly 20 percent of all Miami-Dade County doctors now work without insurance, a risky practice known as self-insuring or "going bare." Self-insured doctors in Florida must show they can post bond or pay a judgment of up to $250,000 if they're sued. Only a handful of states allow this practice.
No New Blood
These economic pressures are also a major reason why fewer and fewer medical students are choosing to go into obstetrics -- which makes the doctor shortage even worse. "You have to work long, erratic hours for fixed pay -- thanks to Medicaid and managed care dictating reimbursements -- with astronomical expenses and a constant fear of being sued. Young people are saying 'No thanks,' and who can blame them?" says John Nelson, MD, past president of the American Medical Association and a Salt Lake City gynecologist who dropped obstetrics in 2003 after his premiums doubled.
But even walking away from the delivery room won't automatically ensure that a doctor will have affordable premiums. Many gynecologists perform surgical procedures and are often the first to diagnose gynecological and breast cancers, so they're still vulnerable to lawsuits. Lori Abrams, DO, a gynecologist in Sarasota, Florida, says that her premiums have been lower since she gave up obstetrics, but they still exert terrible pressures on her practice. "My premiums would have hit the six digits if I'd stayed in obstetrics -- but if they increase again, I'll have to self-insure," she says. "I loved delivering babies, and I miss it. There has to be a better answer than abandoning your life's calling."
Searching for a Solution
Insurance companies say that changes to federal or state laws (known as tort reform) could provide relief. California's lawsuit legislation is a model that many lawmakers would like to see duplicated across the country. In 1975, the state placed a $250,000 limit on noneconomic damages awarded for intangibles like pain and suffering or emotional distress. It also restricts the amount that attorneys receive in such cases. As a result, malpractice-premium increases in California have averaged less than 3 percent per year.
For almost 10 years, medical groups like ACOG have lobbied for similar legislation on the federal level. In his 2006 State of the Union address, President Bush urged Congress to pass medical-liability reform for the "women in nearly 1,500 American counties without a single ob-gyn." The House of Representatives has passed such measures for four consecutive years, but Democrats in the Senate have kept them from being voted on. With federal help unlikely, doctors must convince their state legislators to take action.
One innovative remedy: A handful of hospitals now employ on-site, hospital-insured obstetricians called "laborists" who handle deliveries, emergency situations, and high-risk patients. Available 24-7, laborists help both the patient and her regular ob-gyn by providing an extra level of care. "We believe this will reduce medical complications and associated lawsuits," says Duncan Neilson, MD, chief of women's services for Oregon-based Legacy Health System, which has employed laborists at its Vancouver, Washington, hospital since it opened in 2005.
Kristine Galloway, of Washougal, Washington, admits that she wasn't thrilled about the idea of having her baby delivered by a stranger when she learned that her family physician didn't yet have hospital privileges at the newly opened Vancouver Legacy facility. "I was worried that it would be awkward, but when it came time to deliver, I was grateful to have a skilled doctor, and it was a wonderful experience," says Galloway.
But laborists aren't a cure-all. Ob-gyns in private practice still provide prenatal care and perform most of the deliveries at hospitals where laborists work, so they remain at risk for lawsuits and high insurance premiums. And smaller, rural hospitals -- often the ones that are most desperate for obstetricians -- don't have enough pregnancy-related admissions to justify the cost of hiring around-the-clock staff ob-gyns.
While the medical community scrambles to find a remedy, the growing shortage continues to take a toll on mothers and their children. The infant-mortality rate in Virginia, for instance, has increased as the number of obstetricians has decreased. In 2003, 766 infants died during childbirth -- the state's highest number in nine years. "The situation is dire," says John Partridge, MD, chairman emeritus of ACOG's Virginia chapter. "This state -- and the other states in crisis -- can't afford to lose any more good doctors."
Copyright ? 2007. Reprinted with permission from the January 2007 issue of Parents magazine.