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PubMed1990

Obstetric practice patterns in Washington state after tort reform: has the access problem been solved?

We surveyed all potential obstetric providers in Washington state in the spring of 1989 to determine whether the passage of tort reform in 1986 had improved access to care for rural and medically indigent women. We found that, although the exodus of family physicians from obstetric practice that had been observed between 1985-1986 appears to have slowed, there is still substantial net attrition among family physicians. As a result, rural patients are having increasing difficulty obtaining local access to obstetric care. By contrast, the supply of obstetricians and midwives seems to be stable. All three groups of providers are increasingly reluctant to provide care to the growing number of Medicaid patients. Although tort reform may have slowed the rate at which providers are quitting obstetrics, equilibrium has not yet been achieved. Shortages of rural physicians and inadequate Medicaid reimbursement rates must be addressed to improve obstetric access for underserved groups.

Health Services Accessibility↗

PubMed1989

Obstetrical practices of members of the Kansas Academy of Family Physicians.

Data reported from this survey of the members of the Kansas Academy of Family Physicians indicate that members performing obstetrics are paying significantly higher professional liability premiums than members not providing such services. This difference, as well as the overall escalating costs of professional liability insurance, can be expected to result in loss of family physician-provided obstetrical services. As family physicians are providing the only readily available obstetrical services in a substantial number of rural areas, it seems likely that rural areas will experience a significant loss of access to obstetrical care. Although delivery fees have risen, they have not risen at the same rate as premiums. A net loss of family physicians providing obstetrical services has been noted during the period of 1985-88, and such losses appear to be an accelerating future trend.

Academies and Institutes↗

PubMedDate not supplied

Obstetric care in a rural family practice.

Obstetrical care in the United States is becoming more difficult for rural populations to obtain. Fewer family physicians are providing obstetrical services. This study is a report of one family physician's obstetric experience in a small rural town. In a series of 67 obstetrical patients, 8 percent of the deliveries occurred outside of the hospital. The rate of Cesarean section was 3 percent, significantly less than the greater than 20 percent national average. There was 1 premature delivery, and no infant deaths. These figures compare well with national averages and show the need for family physicians to provide obstetrical care in rural areas.

Adolescent↗

PubMed1988

Obstetric outcomes in a rural family practice: an eight-year experience.

There has been debate in some quarters of whether family physicians should do obstetrics and of whether rural hospitals should provide obstetric services. Forks, Washington, is a remote logging town where family physicians and midlevel practitioners have been the sole providers of labor and delivery services. Forks offers an opportunity to evaluate the quality of an isolated rural family practice obstetric service. A retrospective audit of all labor and delivery patient charts at Forks Community Hospital from 1975 to 1983 was undertaken; 1,052 charts were abstracted with 36 factors of morbidity, mortality, and intervention examined. The results, when compared with similar studies in the literature, provide evidence of good performance. In addition, a relatively high-risk obstetric population was served with favorable outcomes. Family physicians and rural hospitals can provide high-quality obstetrical services.

Adult↗

PubMedDate not supplied

Strategies for overcoming problems in implementing the obstetrics curriculum.

This paper describes several recurring problems in implementing the obstetrics curriculum for residents in family medicine. Four broad remedial goals are proposed: to reduce tension between departments of family medicine and of obstetrics-gynecology; to maintain a curriculum that has a balance between family-centered obstetrics and high-risk obstetrics; to help residents make an informed decision about whether to practice obstetrics; and to train residents to do practice evaluation. Multiple strategies are proposed for accomplishing these goals. The paper concludes with the recommendation that a successful curriculum needs to be promoted by at least one enthusiastic faculty member. This person's role should include evaluating and updating the curriculum as well as anticipating and solving problems that interfere with the implementation of the curriculum.

Curriculum↗

PubMed1986

[Anesthesia in gynecology and obstetrics: a national epidemiologic study].

A sample of 33,508 anaesthetics taken from a national enquiry between the years 1978 and 1982 and representative of the overall activity in this field in France made it possible to look at anaesthesia in gynaecology and obstetrics in France. This study has made it possible to estimate that the annual number of anaesthetics that are given in this filed in France come to about 600,000 of which 22% are in obstetrics. The means that 2.2% of all women have an anaesthetic for these reasons. The most common operations are induced abortion and curettage of the uterus. Epidural anaesthesia was used in 12% of obstetric manoeuvres and 0.8% of gynaecological procedures. 70% of the women who were anaesthetised were aged between 20 and 40 and 64% had already had an anaesthetic in the past. 91% were in satisfactory health before the operation. One in 4 interventions were emergencies. University departments performed 21% of the cases, non-university hospitals 34% and private clinics 45%. In 30% of the cases, the anaesthetic was given by a nurse or a midwife. The risks of major complications while under anaesthetic or in the 24 hours after the operation were higher in obstetrical manoeuvres (2.4 p. 1,000) than in gynaecological procedures (1.1 p. 1,000). 78% of the complications in gynaecology could be attributed to anaesthesia as compared with 44% in obstetrics.

Abortion, Induced↗

PubMed1985

[Analysis of the attraction of an obstetrical service. Analysis of preferences according to geographic distance, sociocultural level and previous medical experiences].

This study analyses selected characteristics of 13,676 women, all single pregnancies, attending the Department of Obstetrics and Gynaeocology of the A. Béclère Maternity Hospital in Clamart (in the greater Paris region of France). The characteristics analysed for each women were: sociocultural level, occupation, place of residence (i.e. distance from the hospital), frequency and time of prenatal visits, and selected aspects of obstetric history (treatment for infertility, previous preterm birth, perinatal mortality). A comparison was made between the patients living near the institution and the patients living far from the hospital; this revealed four separate groups: Women living near by the hospital followed-up early by the department, and whose social class distribution is similar to that of the parisian population as a whole. Women living near the hospital, followed-up late or not at all by the department, most have a low sociocultural level, and are referred to the hospital by local homes for single mothers. Women living far from the hospital, followed-up early and often having a high socio-cultural level. In this group, a higher level of information about pregnancy, obstetrics, and medical services are observed. However this group also shows a high frequency of previous obstetric incidents: previous contact with a medical institution appears to be an important factor in the choice made by these women, independent of their sociocultural level. Women living far from the hospital and followed-up late by the department. These patients have a high sociocultural level, and show a high frequency of previous obstetric incidents: they tend to present as emergencies requiring the department's technical services.(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗

PubMed1985

High-risk obstetrics. The three-year experience of four subspecialists.

The development of maternal-fetal medicine as a subspecialty in obstetrics and gynecology is fairly new. The specialists involved in this area are usually hospital based and involved in multiple activities, including teaching, administration and research. The role of this subspecialist as a provider of primary care to a high-risk obstetric population is important but has not been reported on previously. In this context high-risk obstetrics refers to intercurrent obstetric problems, previous obstetric problems, previous medical problems, infertility and the supposedly high-risk group of physicians and physicians' wives.

Female↗

PubMed1978

Obstetrics in family practice: a model for residency training.

Family physicians have a unique service to offer families at the time of their reproduction, and have a role to play that cannot be duplicated by an obstetrician-gynecologist or pediatrician. The process of a family integrating a new member is a natural concept to family practice and lends itself to a family-centered model of care seldom seen in medicine. Practicing obstetrics has a positive effect on a family physician's practice for without obstetrics a practice largely of episodic adult internal medicine develops. Obstetrical care provided by a family physician is a natural answer to the currently articulated public need for personalized, sensitive, family-centered, and expert childbirth care. Obstetrical training in the family practice residency needs to include a longitudinal pregnancy care experience in addition to block rotation on hospital services to teach residents skills of good obstetrical practice and to develop an attitude of family-centered health-care advocacy. A detailed program of family-centered patient education classes practical for a private group practice has been developed to extend throughout the entire course of pregnancy and includes classes after delivery.

Curriculum↗

PubMed1982

A prospective analysis of hospital-acquired fever in obstetric and gynecologic patients.

Of 2,725 obstetric and 4,090 gynecologic patients admitted to a community hospital during a 12-month period, 131 obstetric patients (4.8%) and 294 gynecologic patients (7.2%) had temperature elevations (rectal) of 38.3 degrees C or higher. All patients with fever were seen and followed up until discharge, and 80 different parameters were recorded for each patient, including sex, age, underlying illness, operative or diagnostic procedures, height and duration of fever, laboratory data, medications received, and ultimate cause of fever. Sixty-three obstetric patients (48%) with temperature elevations were found to have infections and fever, with skin and soft-tissue infections (59%), urinary tract infections (16%), and bacteremias (10%) being most common. Sixty-eight febrile obstetric patients (52%) were not found to have an infection. Eighty-six gynecologic patients (29%) with fever had an infection. Pelvic inflammatory disease (37%), urinary tract infection (18%), and abscess (14%) were the most common infections. Two hundred eight gynecologic patients (71%) had fever, but the exact cause of the fever in these patients remains obscure. While fever can be an early indicator of infection, it may be due to noninfectious causes in almost two thirds of hospitalized obstetric-gynecologic patients.

Bacterial Infections↗

PubMedDate not supplied

Defensive medicine and obstetrics.

OBJECTIVE: To test the hypothesis that physicians with greater malpractice claims exposure, either through personal experience or in their practice environment, will use more prenatal resources and have a higher cesarean delivery rate than physicians with lesser claims exposure. DESIGN: Retrospective cohort study using county malpractice defendant rate data from the Washington State Physicians Insurance and Exchange Association and prenatal care, delivery method, and self-reported obstetric suit experience data from the Content of Obstetrical Care Study database. SETTING: Washington State obstetric practices. PARTICIPANTS: Stratified random samples of obstetrician-gynecologists and family physicians. MAIN OUTCOME MEASURES: The rates of obstetric ultrasound use, referral and consultation, prenatal care resource use, and cesarean delivery. RESULTS: After controlling for patient, physician, and sociodemographic characteristics, we found no difference in prenatal resource use or cesarean delivery rate for low-risk patients between physicians with more and less exposure to malpractice claims. CONCLUSIONS: This study does not support an association between the malpractice experience or exposure of individual physicians and an increase in the use of prenatal resources or ceserean deliveries for the care of low-risk obstetric patients.

Cesarean Section↗

PubMed1995

Pakistan: the Faisalabad Obstetric Flying Squad.

The Faisalabad Obstetric Flying Squad was established in 1988 and provides access to emergency obstetric services for the poor women of Faisalabad. The service is highly appreciated by both women and participating dais. The latter receive training from the Mother and Child Welfare Association of Faisalabad and form an integral part of the obstetric care team. While problems in accessing communication facilities exist, the project has made a lasting impact on the provision of emergency obstetric services in the city. Improved recording and reporting mechanisms would permit a more precise assessment of the impact of the service on the reduction of maternal morbidity and mortality. It would also permit an assessment of the operating costs of the service. One of the reasons the service functions effectively is that it is fully integrated into the general operations of the Allied Hospital. If similar institutional mechanisms can be established there is good reason to think that the Faisalabad Obstetric Flying Squad could be replicated in other developing country settings.

Demography↗

PubMed1995

Family practice obstetrics in a community hospital.

OBJECTIVE: To review obstetric care provided by family physicians and to determine why they transfer patients to obstetricians. DESIGN: Retrospective chart review. SETTING: Obstetrics department of a regional non-academic community hospital PATIENTS: Of 683 women booked with family physicians for obstetrical care, 601 were admitted by family physicians and 82 were transferred to obstetricians before admission. MAIN OUTCOME MEASURES: Risk score, induction, augmentation, consultation, forceps delivery, cesarean section, episiotomy, epidural anaesthesia, narcotic analgesia, neonatal birth weight and Apgar scores, and maternal complications. RESULTS: Family physicians' patients had good maternal and neonatal outcomes; spontaneous delivery rate was 82%; cesarean section rate was 9%. Women transferred from family physicians to obstetricians before admission for delivery had a cesarean section rate of 63%. CONCLUSIONS: Family physicians provided total obstetric care to most women in this community and transferred patients to obstetricians for expected reasons. Community hospitals with family physicians highly involved in providing obstetric care are likely ideal institutions for training future family physicians.

Alberta↗

PubMed1993

[Analysis of the obstetrical situation in swine from the clinical point of view].

In a study including 477 parturitions in sows the obstetrical situation of this species is analyzed from the clinical point of view. Obstetrical interventions before consulting the veterinary clinics led to partly severe lesions of soft tissues of the genital tract in 35.5% of all primiparous and in 12.6% of all pluriparous sows. So 3.1% of all obstetrical patients had to be slaughtered due to the enormous perforating lesions in vestibular-vaginal-cervical parts of the genital tract. In 71 cases parturition could not be completed because of stress, insufficiency of the cardiovascular system or economic reasons. In general, 76% of parturitions came to an end conservatively and 24% by caesarean section. In older sows the relation was 88% vs. 13%. During the recent years the loosing-rate by completed parturition could be reduced to 3.4% after conservative obstetrical intervention and to 20.6% after caesarean section in preinjured sows by compensation of the respiratory and metabolic acidosis, stabilizing of the cardiovascular system and the supply of warmth. Possibilities to diminish total losses are discusses, concerning the large number of animals with injuries due to inappropriate conservative obstetrics as well as the intensification of intra- and postoperative supportive therapy.

Animals↗

PubMed1993

Access to obstetric care.

Initially, this article examines the relationship between access to components of obstetric care and birth outcomes. It goes on to describe the significant decline in physician participation in obstetrics and its possible relationship to increasing rates of late or no prenatal care in the United States. The limitations of obstetric capacity and future access to providers of obstetric care in the United States versus Canada are explored. The article concludes with a discussion of strategies for improving access to obstetric care.

Female↗

PubMed1995

U.S. Air Force aeromedical evacuation of obstetric patients in Europe.

U.S. Air Force (USAF) regulations do not recommend the routine movement of obstetrical patients greater than 34 weeks gestation. However, U.S. Department of Defense and embassy physicians throughout Europe continually request aeromedical movement of obstetrical patients greater than 34 weeks gestation. Therefore, a year-long prospective review of obstetric patient movement within the military aeromedical system in Europe was undertaken to evaluate the need for and safety of transporting pregnant women over 34 weeks gestation. Civilian studies demonstrate the safety of transporting these patients, but these studies generally address short-range transport by helicopter. By contrast, the USAF operates a high-volume, long-range aeromedical evacuation system with large fixed-wing aircraft. Of the 13,095 patients reported for military aeromedical movement within the study time frame, 329 patients were uneventfully airlifted for obstetrical reasons. This study suggests that long distance movement by fixed-wing aircraft of obstetric patients at any gestational age can be done safely in the USAF military aeromedical system.

Air Ambulances↗

PubMed1997

The effects of the ALSO course as an educational intervention for residents. Advanced Life Support in Obstetrics.

BACKGROUND AND OBJECTIVES: Previous descriptions of the Advanced Life Support in Obstetrics (ALSO) course have indicated increases in physician comfort in managing obstetric emergencies and in their intentions to continue offering maternity care after taking the course. No previous studies have been done about the educational outcomes of the ALSO course on family practice residents. This study compared residents' pre- and post-ALSO course confidence to manage obstetrical emergencies and their intention to provide maternity care when they enter practice. METHODS: A self-selected group of 55 family practice residents completed questionnaires before and after ALSO training. The questionnaire was designed to measure confidence, using Bandura's model of self efficacy, and future intention, using Ajzen's Theory of Planned Behavior. RESULTS: Residents' confidence in their abilities to manage obstetrical emergencies increased significantly after the ALSO course. Residents' intent to provide maternity care when the residents enter practice did not change. CONCLUSIONS: The ALSO course is a valuable teaching intervention that can improve family practice residents' perceived self-confidence in managing obstetric emergencies. The study had sufficient power to detect a moderate effect size of the ALSO course on resident intention to provide maternity care but did not do so.

Analysis of Variance↗

PubMed1997

The malpractice premium costs of obstetrics.

This study examined, in 1992, the variation in the level of malpractice premiums, and the incremental malpractice premium costs associated with the practice of obstetrics for family practitioners and obstetricians. On average, in 1992 obstetricians and family practitioners providing obstetric services paid malpractice premiums of roughly $44,000 and $16,000, respectively. The incremental increase in malpractice premium costs represented roughly 70% of the premium the physicians would have paid had they not provided obstetric services. These results suggest that for both family practitioners and obstetricians, there is a considerable premium penalty associated with providing obstetric services which may have implications for women's access to obstetric services. Moreover, the results make it clear that physicians practicing in different states, and different specialists within a state, may face very different malpractice premium costs.

Costs and Cost Analysis↗