HEALTH CARE * LES SOINS

The obstetric care crisisfacing Ontario's rural hospitals

David E. Walker, MD, CCFP

Obstetric services in smallcommunity hospitals in On-tario are facing increasing

pressure because there is a shortageof primary care personnel and staff

David Walker is chief of obstetrics at Alex-andra Marine and General Hospitalin Goderich, Ont., and serves on the OntarioMedical Association's Committee on

Reproductive Care

with the skills needed to respond toemergencies. In 1987, the TaskForce on the Implementation ofMidwifery in Ontario recognizedthat interest in that type of care was

growing and concluded that imple-mentation of care by midwiveswould increase the birthing choicesavailable to women.

With these two trends in mo-

tion, will obstetric care in smallcommunity hospitals survive, will itbe enhanced, or will the overall stan-dard deteriorate? The experiences atmy small community hospital inrural Ontario may provide some an-

swers.

The Alexandra Marine andGeneral Hospital (AMGH), with 50active-treatment beds, is located inGoderich, about 100 km northwestof London. With a population of ap-

proximately 7500 people, Goderichis considered to be "rural" - thatterm applies to any community withfewer than 10 000 residents. About85% of Ontario is considered rural,although these small communitiesaccount for only 25% of theprovince's population.

In 1992 there were 117 births atAMGH, which is roughly the annualaverage over the past 10 years, butlike many other small communityhospitals in Ontario, AMGH is un-

dergoing stressful changes due to theloss of medical services.

The Committee on Reproduc-tive Care of the Ontario MedicalAssociation (OMA) recently com-

pleted a document, Trends in Re-productive Care: A Medical Per-spective, which examines allfactors affecting the provision ofobstetric care. In their chapter onsmall community hospital obstetricservices, Chance and Stretch' citetwo studies to demonstrate therural crisis that has developed be-cause of a shortage of medical ser-

vices.Rourke'24 surveyed 88 Ontario

hospitals with up to 99 acute care

beds. Eighty, which accounted forabout 10 600 births annually, re-

sponded. Most of the hospitals re-

lied upon family physicians to han-dle deliveries; 45 of the hospitalshad fewer than 50 active beds and35 had between 50 and 99 activebeds. The hospitals with fewer than50 beds served, on average, 10 500people.

Thirty-four percent of the hos-pitals reported a shortage of familyphysicians who provided obstetriccare and 66% predicted a shortagewithin 5 years; 36% reported an on-

going shortage of anesthetists, while49% predicted a shortage within 5years. Thirty percent were copingwith a shortage of general surgeons,

and 61% predicted a shortage within5 years.

CAN MED ASSOC J 1993; 149 (10) 1541

Resume: Utilisant l'exemple duservice d'obstetrique d'un petithopital communautaire, l'auteurtraite de la diminution abruptedes services medicaux offerts parles hopitaux communautaires del'Ontario. Une enquete chez lespatientes a demontre que lesfemmes veulent accoucher dansleur ville. Une enquete chez lesmedecins a revele un refus uni-forme de pratiquer l'obst6triquesans l'appui d'un anesthesiste etd'un chirurgien de releve. L'ar-ticle examine aussi l'incidencedes sages-femmes, mais il con-clut que sans un appui approprie,les sages-femmes n'apporterontpas une solution aux problemesqui se posent dans les hopitauxcommunautaires en milieu ruralpour la prestation des soins ob-stetricaux.

NOVEMBER 15, 1993

Cesarean section was availableat 53 (66%) of the hospitals sur-veyed. It was available at all times at21 hospitals (26%), and most of thetime at 32 hospitals (40%), but 14(30%) were without any generalsurgery services.

A second study, by Chance andCampbell,5 involved a survey of100 acute care hospitals that had750 or fewer births annually; 86 re-sponded. Six of the 14 that did notrespond had already discontinuedobstetrics or were in the process ofdoing so. Four others had discontin-ued obstetrics during the year of thesurvey, and six more anticipated adiscontinuation within 2 years be-cause of the loss of GP obstetri-cians.

The survey indicated that therewas a shortage of physicians able toperform cesarean sections. Eleven of

why physicians end or consider end-ing their obstetric work. Forty-twopercent of respondents indicated thatinterference with personal and fam-ily life was the main reason.

Historically, family phys-icians who practise obstetrics inrural settings have provided excel-lent care. In his 1988 survey ofsmall hospitals with fewer than100 deliveries per year, Hogg7showed that through careful selec-tion of patients, neonatal mortalityrates are comparable to level 2 andlevel 3 hospitals. In a 1984 study,Black8 surveyed obstetric servicesin small communities in NorthernOntario and determined that peri-natal mortality rates were compa-rable with those of level 2 hospi-tals. Both studies reflected carefulselection and referral of womenwith an identifiable risk of compli-

W\Vill obstetric care in small community hospitalssurvive, will it be enhanced, or will the overall

standard deteriorate?

25 hospitals with fewer than 100births annually had no anestheticservice. Of 209 GP anesthetists, 23at 15 hospitals anticipated ceasingtheir anesthetic practice within 2years of the survey. Of the hospitalswith under 100 annual deliveries, 15did not have the surgical capacity toprovide a cesarean section; amongthe 31 hospitals reporting 100 to 249births annually, four lacked that ca-pability. Those that could not per-form cesarean sections were, on av-erage, 178 km from the nearestsurgical facility; the closest was 58km away.

A 1987 Ontario-wide study byBain et al6 focused on the reasons

cations around the time of birth.Despite these encouraging re-

sults, physicians remain anxious andfeel vulnerable. A 1980 study byWilson and Schifrin9 suggested thatapproximately 15% of women ex-perience complications during preg-nancy and birth, 5% of which are se-rious.

At AMGH, a comparison ofanesthesia and general surgery ser-vices between 1987 and 1992 pro-vided these results:

* In 1987, three GP anesthetistsprovided continuous coverage. InJune 1992, one gave up his anesthe-sia privileges because of lifestylepressures. One of the remaining

anesthetists has since consideredgiving up his privileges because ofthe added work load. Continuousanesthesia coverage is no longeravailable.

* In 1987, there were two gen-eral surgeons living and practising inthe town, and they provided almostcontinuous coverage. The older doc-tor, in his early 60s, informed thehospital board in September 1989 ofhis intention to retire in 1 year. Sincethen the hospital has conducted anexhaustive search for a suitable re-placement, without success. [In Sep-tember the search finally paid off.Ed.] The remaining general surgeon,now nearing age 60, finds it impos-sible to provide coverage more than65% of the time. In his absence, thecommunity attempts to call uponother doctors - two general sur-geons living 30 to 40 minutes awayand an FP in a neighbouring townwho is trained to perform cesareansections. [The FP has since relocatedto the US. - Ed.] The availability ofthe two remaining doctors may de-pend on driving conditions.

* Analysis of all hospital-initi-ated transfers of women in labourbetween 1987 and 1991 showedthat before 1990 there was an aver-age of 13 transfers annually, all forrisk factors that could be handledbetter at a level 3 hospital. In 1990there were 17 transfers, including 4because of lack of surgical cover-age and 1 because an anesthetistwasn't available. In 1991, 5 of the21 transfers were caused by a lackof surgical coverage, including 2for which anesthesia coverage wasalso lacking. Figures are not avail-able for transfers from doctors' of-fices.

The loss of medical serviceshas had a profound effect on myhospital and its staff. Local residentsare also aware of the problem andthe availability of surgical and anes-thesia coverage has become a majorconcern of expectant mothers andtheir families. The physicians feelparticularly vulnerable when on callon a weekend during which cover-age may not be available. They are

v- For prescribing information see page 1564 CAN MED ASSOC J 1993.,149 (10) 1543

reluctant to become involved even inbirths with no identifiable risks be-cause they know that the resourcesneeded to deal with unexpectedcomplications may be 90 minutesaway.

It is now the practice to transferall women safe to travel to a referralhospital. This causes anxiety forboth expectant mothers and theirfamilies, as well as for the phys-icians and nursing staff. It is also un-fortunate for the referral centre,which has to provide care forwomen who could receive adequatecare in an appropriately staffed level1 facility.

To discover the impact on pa-tients, a questionnaire was distrib-uted by mail to 153 women aged be-tween 18 and 35. Recipientsincluded those who had given birthin the obstetric unit in the past year,members of a young women's groupat a local church, members of a localchapter of Women Today, and thosewho participated in public healthprenatal classes.

Eight-seven percent of respon-dents felt it was important or veryimportant to give birth in theirhometown. Thirty-one surveys werereturned with comments; 20 per-tained to the quality of family-cen-tred care at AMGH, 19 of whichwere very positive. There wereseven comments from respondentswho had given birth at both a cityhospital (in Toronto, London orHamilton) and the local hospital. Inall instances, they extolled the per-sonal care they received inGoderich and provided unequivocalsupport for giving birth in theirhometown.

While 33% of respondents ex-pressed an interest in giving birthwith the assistance of a midwife, lessthan 5% perceived the midwife asthe primary caregiver. The com-ments indicated that this latter groupconsider home birth their preferredchoice.

In September 1992, a question-naire that had been sent to familyphysicians involved with obstetricsat the AMGH in 1987 was recircu-

lated. It was designed to estimate theimportance of factors that influencethe practice of obstetrics in a smallcommunity hospital.

The 1992 survey also includeda three-part question regarding theimplementation of midwifery in On-tario, and physicians were askedhow comfortable they felt aboutmaintaining their obstetric skillswith their present caseload. Thebirth statistics for each physicianpractising during both study periodswere compared to note any trends,such as increased or decreased case-loads.

In 1987, seven local FPs werepractising obstetrics. By 1992 two ofthem had stopped doing this workbut another physician had arrivedand was included in the 1992 survey.

In 1987, three of the seven re-spondents were aged 30 to 34, three

lifestyle, increased anxiety regardinglitigation, and the perceived disin-centive of malpractice insurance pre-miums.

Without an influx of physicianstrained and willing to include obstet-rics in their practice, it appears thatGoderich will lose more GP obstetri-cians over the next 5 years. If phys-icians continue to be the primarycaregivers for birthing mothers, thenfewer physicians will be attendingmore births. Each of the busier phys-icians already reported that the in-creased caseload has had a majorimpact on lifestyle. They will likelybecome less satisfied if caseloadscontinue to grow.

This survey indicated somescepticism concerning the imple-mentation of midwifery in smallcommunities. All physicians felt thepresence of a midwife as a labour

Physicians feel particularly vulnerable when on callon a weekend during which coverage may not be

available. They are reluctant to become involved evenin births with no identifiable risks because they know

that the resources needed to deal with unexpectedcomplications may be 90 minutes away.

were aged 40 to 44, and one wasolder than 50. Of the six physicianssurveyed in 1992, four were aged 35to 39 and the other two were aged 45to 49.

The data suggest that phys-icians aged 30 to 34 are at the peakof their obstetric practice and on thewhole the families they serve areyounger. Families in a practice tendto parallel the age of the attendingphysician, so after age 45 the num-ber of births attended falls. By age50, physicians are either deciding orhave already decided to stop deliver-ing babies; they cite sharply decreas-ing numbers of patients, a decreasedcomfort level, increased effects on

coach would be either unimportantor a neutral factor. Most felt the mid-wife would not make an acceptablebirth attendant. None felt that havingmidwives attending births would bea factor in their decision to discon-tinue obstetrics.

The physicians were uni-formly uncomfortable practisingobstetrics in their communityhospital in the absence of anes-thetic or surgical coverage. Forseveral doctors, this absencewould be the determining factorin their decision to give up ob-stetrics. Others would attend onlyemergency births and wouldmake arrangements for all others

LE 15NOVEMBRE 19931544 CAN MED ASSOC J 1993: 149 (10)

to go to the nearest referral cen-tre.

The analysis of anesthesia andsurgical services parallels perfectlythe findings and warnings containedin the studies mentioned earlier. It isconceivable that within 5 years thiscommunity hospital may be withoutany general surgical services andmay have lost one or both of its GPanesthetists.

The shortage of staff with theskills needed to respond to in-evitable obstetric emergencies isbound to be a serious disincentivefor family physicians who had con-sidered including obstetrics in theirpractices.

Women prefer to give birth intheir hometown, and if residents ofOntario's rural communities hadtheir say local obstetrics units wouldsurely survive. But these units areclosing because the skilled personnelrequired are not available.

Family physicians in Goderichexpress a high level of satisfactionabout making obstetrics part of theirpractice. They doubt that the imple-mentation of midwifery will helpthem and their patients.

Most women in rural communi-ties consider the family doctor theirprimary caregiver and the entrypoint for care needed during a preg-nancy. Without the involvement andacceptance of these physicians, mid-wives will not have sufficient case-loads.

Family physicians see them-selves as advocates for safe care fortheir patients, and are unlikely to co-operate in births under conditionsthat make them feel apprehensive. Idoubt that a physician, having givenup delivery privileges because of alack of back-up obstetric services,would ever refer or encourage pa-tients to seek a midwife's care undersimilar conditions. On the otherhand, if safety is not the reason whyphysicians are declining to attendbirths, midwives surely would be abenefit to the community and, in thelong run, would be accepted andbusy.

There will be an overall deteri-

oration in obstetric care in ruralareas if shortages involving anesthe-sia and general surgery are not ad-dressed soon. The integration ofmidwives will not help address thebasic problem of providing safe carein rural communities.

Solutions must be sought byall concerned. The present trend, inwhich family physicians are eitherleaving or refusing to enter obstet-ric practice, must be reversed.Family practice residents should beexposed to and receive at leastsome of their obstetric training inrural settings. Advanced trainingthat allows family physicians toperform cesarean sections shouldbe developed for those wishing topractise in areas that cannot attractgeneral surgeons. Likewise, thesupply of trained GP anesthetistsmust be assured.

Government's first responsibil-ity lies in the provision of basic care.Once that basic standard can be as-sured, then diversification andchoice can only serve to enhancecare.

References1. Trends in Reproductive Care: A Medical

Perspective, Ont Med Assoc, Toronto,1992: 7-15 (ch 2), 16-27 (ch 3)

2. Rourke J: Small hospital medical ser-vices in Ontario: 1. Overview. Can FamPhysician 1991; 37: 1589-1594

3. Idem: Small hospital medical services inOntario: 3. Obstetric service. Ibid:1729-1734

4. Idem: Small hospital medical services inOntario: 4. Anaesthesia service. Ibid:1889-1892

5. Chance GW, Campbell MR: Obstetricstaffing in small hospitals. Can FamPhysician 1992; 38: 524-528

6. Bain ST, Grava-Gubins I, Edney R: Thefamily doctor in obstetrics: who's look-ing after the shop? Can Fam Physician1987; 33: 2693-2701

7. Hogg WE, Calonge N: Topics for familymedicine research in obstetrics: the effectof obstetrics manpower trends on neo-natal mortality rates. Can Fam Physician1988; 34: 1943-1946

8. Black DP, Fyfe IM: The safety of obstet-ric services in small communities inNorthern Ontario. Can Med Assoc J1984; 130: 571-576

9. Wilson RW, Schifrin BS: Is any preg-nancy low risk? Obstet Gynecol 1980;55: 653-656

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NOVEMBER 15, 1993 CAN MED ASSOC J 1993; 149 (10) 1545