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Maternity Care in the United States ~ o understand the effects of medical professional liability on the delivery of obstetrical care in the United States, some background on maternity care is needed. Most American women receive their prenatal care in the office of a private physician, who also supervises their labor and performs their deliveries in a hospi- tal. Payment for such care is usually through private insurance, often supplemented by savings. Large groups of women, however, especially poor and minority women, have different patterns of care that may make them particularly vulnerable to changes in the availability of obstetri- cal services. The committee devoted considerable time to evaluating the effects of professional liability issues on the delivery of care to these groups of women. The results of its efforts are set forth in Chapter 4. Here the committee presents the background necessary to an under- standing of the implications of professional liability issues in obstetrics. OBSTETRICAL PRACTITIONERS Maternity services in the United States are rendered by three groups of providers: obstetrician-gynecologists, other physicians (primarily family physicians), and other practitioners, including certified nurse- midwives (CNMs) and, in some states, lay midwives. At all times during its deliberations, the committee considered the medical liability issue from the perspectives of each of these provider groups. Data from the Alan Guttmacher Institute reveal that low-income women are more 14

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MATERNITY CARE IN THE UNITED STATES 15 likely to see physicians who are not obstetricians; women with higher incomes are more likely to see obstetricians and CNMs (AG1, 19871. According to the 1980 National Medical Care Utilization and Expendi- tures Study (NMCUES), 61.1 percent of first prenatal visits were with obstetrician-gynecologists, 26.0 percent were with other physicians, and 12.9 percent were with other practitioners (AG1, 19871. Obstetr~cian-Gynecolog~sts According to the American Medical Association's Physician Master File, 31,364 physicians in the United States identified themselves as obstetrics-gynecology specialists in 1986 (AMA, 19871. The American College of Obstetricians and Gynecologists, the specialty society for this discipline, counts 27,219 obstetrician-gynecologists as active fellows, 6,587 as junior fellows (still in training), and 2,746 as life and founding life fellows (usually inactive practitioners) (ACOG, 19881. Like other surgical specialists, most obstetrician-gynecologists work in metropolitan areas.iACOG data show that 17 states, primarily larger states in the southern and western parts of the country, have areas with fewer than 10 obstetrician-gynecologists per 100,000 women age 15 to 44 in the population, 35 states have regions with fewer than 20 per 100,000, and 22 states have areas with no obstetrician-gynecologists at all (affecting close to 400,000 women age 15 to 44) (ACOG, 1988) (Table 2.11. Family and General Practitioners Prior to 1969, there was no separate specialty called "family practice." General practitioners were physicians who had completed medical school and one year of internship, and specialists were physicians who had completed the longer residency program in their specialty. Concern about increasing specialization and the declining number of primary care physicians led to the establishment of family practice as a recog- nized program of training and specialization. By 1980, there were approximately 27,000 family physicians, 18,000 of whom were in o~ce-based practice (AMA, 19871. By 1986, the number in o~ce-based practice had grown by 70 percent, to more than 31,000 iThat is, areas with a center city (or twin cities) of 50,000 or more, together with surrounding, economically related jurisdictions, as defined by the U.S. Bureau of Census. Nonmetropolitan areas are those not defined as metropolitan. The terms "urban" and "rural" are used in a general sense in this report, not as the Census Bureau defines them.

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16 MEDICM PROFESSIONAL CITY: VOICE ~ TABI.E 2.1 Active Nonfederal Physicians and Physician-to Population Ratios for Obstetrician-Gynecologists and Family and General Practitioners, by State, 1985 Obstetrician Gynecologists Family and Gen- eral Practitioners Total Physicians StateNumber RatioaNumber RatioaNumber Ratioa Alabama979 25397 105,769 145 Alaska173 3537 7658 132 Arizona884 29381 125,912 194 Arkansas887 38185 83,274 139 California8,232 323,832 1563,009 246 Colorado969 30376 126,373 201 Connecticut556 18563 188,900 282 Delaware150 2490 151,169 191 District of Columbia170 27245 393,547 570 Florida3,093 281,402 1322,295 203 Georgia1,233 21764 139,614 165 Hawaii241 23165 162,150 207 Idaho335 3373 71,202 120 Illinois3,167 281,464 1323,582 205 Indiana1,855 34433 88,002 146 Iowa1,014 35181 63,999 137 Kansas859 35210 94,001 164 Kentucky1,071 29348 95,640 151 Louisiana1,022 23616 147,936 178 Maine408 35109 91,966 170 Maryland955 22924 2113,680 315 Massachusetts991 17835 1418,079 312 Michigan1,879 211,128 1216,179 178 Minnesota1,783 43372 98,658 208 Mississippi713 27215 83,081 119 Missouri994 20581 129,244 185 Montana257 3163 81,148 139 Nebraska608 38123 82,539 158 Nevada245 27102 111,471 162 New Hampshire246 2598 101,813 186 New Jersey1,464 191,102 1517,112 228 New Mexico366 26162 112,379 167 New York3,519 203,056 1752,971 299 North Carolina1,627 26711 1210,489 170 North Dakota288 4256 81,071 156 Ohio2,776 261,243 1220,005 186 Oklahoma872 26296 94,563 138 Oregon808 30308 125,201 194 Pennsylvania3,407 291,433 1225,903 218 Rhode Island167 17130 142,206 229 South Carolina1,078 33335 104,912 149 South Dakota275 3944 6927 131 Tennessee1,128 24561 128,492 180

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MATERNITY CARE IN THE UNITED STATES 17 TABLE 2.1 Active Nonfederal Physicians and Physician-to Population Ratios for Obstetrician-Gynecologists and Family and General Practitioners, by State, 1985 (continued) Family and Gen- Obstetrician eral Practitioners Gynecologists Total Physicians StateNumber RatioaNumber RatioaNumber Ratioa Texas4,119 261,825 1126,683 167 Utah414 25192 122,844 172 Vermont163 3166 121,276 241 Virginia1,601 28723 1311,075 197 Washington1,635 38458 118,773 202 West Virginia549 28188 103,122 160 Wisconsin1,543 32432 98,356 175 Wyoming180 3543 8655 128 Total63,948 2729,685 13463,905 205 aPhysicians per 100,000 women, age 15 to 44 in the population. SOURCE: Bureau of Health Professions, U.S. Department of Health and Human Services. 1987. Area Resource File System: U.S. and State Summaries of Selected Geo- graphic Resources and fiends in Resources. Hyattsville, Md. This edition used 1985 AMA data on physicians and 1984 census data. (AMA, 19871. During the same period, the number of general practi- tioners fell, from approximately 52,000 to 30,000, as older physicians retired and younger ones entered family practice or specialty medicine (AMA, 19871. As a result, the number of family and general practi- tioners in ofh~ce-based practice in 1986 was nearly the same as in 1970- 54,000 physicians-about 30 percent of whom were in nonmetropolitan areas. The AMA estimates that approximately 68,000 physicians desig- nate their specialty as family practice or general practice, but this number includes many who do not engage in off~ce-based practice or who are not in practice at all (AMA, 19871. Although the number of specialists practicing in rural areas has grown in recent years, general and family practitioners continue to be the principal providers of primary and obstetrical care in these areas. Fifty-three percent of all visits to physicians in nonmetropolitan areas were to family physicians, compared with 10 percent to internists and 7 percent to obstetrician-gynecologists (National Ambulatory Medical Care Survey, 19871. If one considers only visits by adults, the proportion for family physicians rises to 70 percent (National Ambulatory Medical Care Survey, 19871. Not all family physicians practice obstetrics, however. The American Academy of Family Physicians (AAFP) reported that 71 percent of its practicing members have offered obstetrical care at some time during their careers (AAFP, 1986) and that 35 percent do so currently (AAFP,

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18 MEDICAL PROFESSIONAL CITY: VOLUME ~ 19871. Most of those who accepted obstetrical patients had served in residency programs (73 percent) and were board certified in family practice (83 percent). Of these, 33 percent did not perform complicated deliveries or cesarean sections; 43 percent performed complicated deliv- eries only; and 23 percent performed both (AAFP, 19871. Those perform- ing complicated deliveries or cesarean sections or both were more likely to have completed residencies and to be board certified. The participation of family and general practitioners in obstetrics varies greatly by region of the country, urban or rural location, and physician age. A survey based on 1977-1978 data found that family and general practitioners in the Northeast saw very few obstetrical patients (only 0.4 percent of diagnoses were prenatal or postpartum care), whereas those in the north central states saw relatively many (4.3 percent of diagnoses) (Rosenblatt et al., 19821. Those in rural areas were twice as likely to see obstetrical patients as those in urban areas (5.2 percent of diagnoses versus 2.3 percent) (Rosenblatt et al., 19821. A study of Michigan family practice residents found that 55 percent of third-year residents planned to practice obstetrics on graduation; plans to practice in rural communities were positively correlated with the decision to include obstetrics, whereas plans to practice in suburban areas were negatively correlated (Smith and Howard, 19871. Because the data make it clear that family physicians are critical to the provision of obstetrical services in rural areas, the committee was interested in determining precisely how extensive their role in these areas is. Accordingly, it commissioned research on this question as part of its fact-finding. The results were striking and are reported at length in Chapter 3. It should be noted at the outset that, according to estimates prepared for the committee, two-thirds of all obstetrical providers of private obstetrical care in rural areas are family physicians. During the early 1980s prior to the dramatic increase in professional liability insurance expenses-there were an estimated 16,700 physicians pro- viding obstetrical care in nonmetropolitan areas, two-thirds of whom were family and general practitioners. By contrast, there were only 5,400 obstetrician-gynecologists practicing in nonmetropolitan areas id. Chapin, director of research, ACOG, personal communication, 19881. Certified Nurse-Midwives Certified nurse-midwives are registered nurses with additional train- ing in midwifery. They are certified by the American College of Nurse- Midwives (ACNM), which states that "nurse-midwifery practice is the independent management of essentially normal newborns and women antepartally, intrapartally and postpartally and/or gynecologically. This occurs within a health care system which provides for medical

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MATERNITY CARE iN THE UNITED STATES 19 consultation, collaborative management and referral" (ACNM, 19841. The ACNM believes that there are approximately 3,500 CNMs in the United States but that only 2,000 to 2,500 practice. ACNM members number 2,100, and between 200 and 250 nurse-midwives are~certified each year. The number of persons entering nurse-midwifery training has remained stable over the past few years; however, schools are experi- encing a decline in the number of applicants (ACNM, 19881. A 1982 ACNM survey found that CNMs, on average, attend 75 births per year (ACNM, 19841. The heaviest concentrations of CNM deliveries were in the Northeast, Southeast, and West (Klerman and Scholle, 19881. According to a 1985 ACNM statement, 75 percent of CNM- attended births occur in hospitals and 15 percent in freestanding birth centers (ACNM, 19881. The 1982 ACNM survey found that approximately 59 percent of CNMs were employed by organized facilities, including hospitals (36 percent), public health agencies (9 percent), health maintenance organi- zations (HMOs) (6 percent), the military (6 percent), and university health services (2 percent). The remainder were in private practices operated by either nurse-midwives or physicians (41 percent). Three- quarters of the CNMs were salaried employees; others received income through fee-for-service payments and direct third-party payment (26 percent). The mean 1981 income of CNMs ranged from $18,544 in the Southwest to $25,245 in the Midwest (ACNM, 19841. The scope of services provided by CNMs varied with their employers. The CNMs working in hospitals and HMOs and those in private practice or maternity services were more likely to work in the largest metro- politan areas. Those working in hospitals, maternity services, and pri- vate nurse-midwifery practices were most likely to provide prenatal, labor, and delivery care. Those in practices run by CNMs were also more likely to supervise well-baby care. Those working in public health agen- cies were less likely to do labor, delivery, and postpartum examinations (ACNM, 1984). Comprehensive data regarding the characteristics of women whose care is provided by nurse-midwives are lacking. Although the 1982 survey found that CNM patients were older, of lower parity, and better educated than all childbearing women, a 1985 survey offactors affecting the success of nurse-midwifery practice found that more than one-third of CNMs worked in practices in which most of the clients were poor (R-ooks and Haas, 19861. Other Practitioners The Nurses' Association of the American College of Obstetricians and Gynecologists (NAACOG) is comprised of more than 20,700 nurses,

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20 MEDiCM PROFESSIONAL CITY: VOICE ~ representing approximately 20 percent of those employed in the spe- cialty (NAACOG, 19871. lbvo-thirds of NAACOG members work in a hospital inpatient setting, and labor and delivery is the clinical area in which they practice most frequently. In 1978 the NAACOG Certification Corporation began certifying nurses for special knowledge in specified areas of obstetrical, gynecological, and neonatal nursing. According to a 1987 General Accounting Office study, less than 2 percent of all medical malpractice claims closed in 1984 were against nurses (GAO, 19871. FACILITIES OFFERING PRENATAL CARE Most women receive prenatal care in private physicians' offices, either from obstetrician-gynecologists or from family or general practitioners. Approximately 20 percent, however, receive care from a public provider, such as the outpatient department of a public hospital, a Community Health Center, or a health department (Klerman and Scholle, 19881. Low-income, black or Hispanic, teenage, and unmarried women are more likely to use these facilities (Table 2.21. Hospital clinics are the most commonly used clinics, reported by 9 percent of women as the source of obstetrical care for their first prenatal visit and by 13 percent of women as the source of prenatal care provided by other physicians (AG1, 19871. Family planning clinics served 5 percent; health depart- ment clinics, 4 percent; Community Health Centers, 3 percent; and military clinics, 3 percent. Forty-six percent of low-income women relied on these sources of care, compared with 17 percent of higher income women. Public facilities provide services not only to the uninsured and those ineligible for Medicaid but also to Medicaid recipients who have difficulty finding private physicians who will accept them. Hospitals Despite the large contribution of hospital clinics to prenatal care, especially for poor women, very little is known about the care provided in this setting. There is no source of national data on hospital clinic utilization that separates obstetrics or gynecology visits from other . visits. Local and State Health Departments In 1984 the Public Health Foundation reported that 40 state health agencies provided prenatal clinical services to over 361,300 women (Public Health Foundation, 19871. A 1986 Children's Defense Fund survey of officials representing the 51 agencies (50 states plus the

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MATERNAL CARE IN THE UNITED STATES 21 TABLE 2.2 Source of Care for the First Prenatal Visit, 1982 Source of Care (do) Characteristics Clinica Privateb OthersC Poor 38.7 53.8 5.7 Nonpoor 12.4 82.8 4.7 Hispanic 35.7 54.9 9.4 Black, non-Hispanic 44.9 48.0 7.0 White, non-Hispanic 14.1 81.0 4.9 <20 years 41.5 55.5 3.0 20-29 24.4 69.6 5.9 30 + 10.7 83.6 5.8 Married 13.4 81.1 5.6 Unmarried 47.2 46.5 6.3 Total 21.0 73.3 5.7 aIncludes Community Health Centers, health department clinic, family planning clinic, hospital clinic, abortion clinic, student health services clinic, and other clinics. bIncludes private doctor or private group practice. CIncludes military clinic, not ascertained, and no visit; percentages may be unreliable because of the small number of cases. NOTE: Totals may not add to 100 percent due to rounding. SOURCE: Alan Guttmacher Institute. 1987. The Financing of Maternity Care in the United States. New York. Table 17. District of Columbia) receiving maternal and child health funding un- der Title V ofthe Social Security Act found that 48 offered some prenatal care for indigent women, usually through clinics operated by local health departments (Rosenbaum et al., 1988~. Eligibility requirements and distribution of services varied widely from state to state. Eleven states based eligibility on specific conditions, offering services to high-risk, unmarried, teenage, or unemployed wo- men. Thirty-six states used uniform financial eligibility criteria, usu- ally meaning that services were provided without charge to certain groups, such as those with family incomes below the federal poverty level. Services were often available to other women on the basis of a sliding fee scale. Women who receive prenatal care at clinics subsidized by state Title V agencies are more likely to have incomes below the federal poverty level, to be young, and to be uninsured. An Alan Guttmacher Institute survey of directors of 25 state Title V agencies found that 64 percent of prenatal patients had incomes below the federal poverty level, 34 percent be- tween 100 and 200 percent of that level, and 2 percent at approximately 200 percent of the poverty level. Sixty-four percent were uninsured, 27 percent received Medicaid, and 9 percent were privately insured. Sixty- two percent were between 20 and 34 years old, 34 percent were teen- agers, and 4 percent were 35 years and older (AG1, 19871.

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22 MEDICAL PROFESSIONAL LAITY: VOLUME ~ Community and Migrant Health Centers Community Health Centers and Migrant Health Centers are feder- ally funded institutions providing primary health care services, includ- ing perinatal services, to medically underserved and disadvantaged populations. Located in areas designated by the U.S. Public Health Service as medically underserved, they provide a broad range of pri- mary and specialized medical and support services to individuals and families who otherwise would not have access to such care. In 1987 there were 567 such centers; 58 percent of them were located in cities. Standards for the centers are established by the Department of Health and Human Services and require that the centers either provide or arrange for prenatal care and delivery services and that they develop a referral relationship with at least one hospital. In a 1987 survey of health centers 85 percent of the respondents were found to either pro- vide or pay for prenatal care for an estimated 213,000 women (AGI, 19871. Almost two-thirds (64 percent) ofthese women had incomes below the federal poverty level, and another quarter (24 percent) had incomes between 100 and 200 percent of that level. Approximately 300 health centers have on their staffs obstetrical specialists, many of them National Health Service Corps (NHSC) physi- cians repaying medical education scholarships and loans by working in medically underserved areas. As of June 1988, almost 70 percent of the 1,297 NHSC physicians were health center employees, including 419 family physicians, 104 obstetrician-gynecologists, and 50 general prac- titioners. More than half of NHSC placements are in rural areas. The peak of NHSC placements occurred in 1985-1986, and the last of these scholarships has been awarded. In 1989 approximately 100 placements will be made. The NHSC is attempting to keep physicians in under- served areas after their obligation is met, but the retention rate is currently only between 30 and 40 percent. In addition, the corp is recruiting nonobligated physicians and offering a loan repayment pro gram. There are grossly insufficient numbers of NHSC obstetrical special- ists to meet the needs of the centers, and by 1992 virtually all these specialists are likely to be gone. For this reason, many centers must either provide prenatal care through stab members who are not obste- trician-gynecologists or contract with obstetricians in the community to furnish the care their patients need. Health centers' budgets are quite restricted. In fiscal year 1987 Con- gress appropriated $400 million to health centers' programs, yet centers served approximately 5.5 million patients, two-thirds of whom were children and women of childbearing age. Estimates of the number of

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MATERNITY CARE IN THE UNITED STATES 23 prenatal patients served by health centers range from 120,000 to more than 200,000 a year. It is estimated that approximately 62,000 babies are delivered in health centers annually. Of those women who received prenatal care at health centers but whose babies were not delivered there, most were referred to an obstetrician early in the course of their pregnancy and were followed jointly by the center and the obstetrician. This arrangement is frequently necessary, because many centers do not have on-site obstetricians. Births to center patients made up 6.5 percent of all poor and near-poor births (approxiamtely 1.85 million) in the United States in 1987. A cost-based analysis of perinatal services fur- nished by health centers in 1986 and conducted by the Public Health Service has estimated that more than $85 million of the program fund- ing for Community and Migrant Health Centers was devoted to such care. Because the committee was persuaded that Community and Migrant Health Centers are an important source of obstetrical care for low- income women, it commissioned a study on the effects of medical profes- sional liability on the delivery of obstetrical care in Community and Migrant Health Centers. The results are published in the companion volume of this report, and the committee's discussion of them is in Chapter 4. LABOR AND DELIVERY SERVICES Although the number of obstetrical beds in all hospitals increased by approximately 4 percent between 1980 and 1986, the number of such beds in hospitals operated by state and local governments decreased (AMA, 1987) (Table 2.31. The majority of all hospital beds, as well as obstetrical beds, are found in nongovernment, not-for-profit hospitals, and their number has increased slightly. The number of obstetrical beds in investor-owned (for-profit) hospitals, however, increased 40 percent during this period. More births are occurring in hospitals with more than 1,500 births per year and fewer in hospitals with less than 500 births per year (ACOG, 19861. The decrease in public hospital beds is significant because public hospitals serve proportionately more poor patients: approximately 30 percent of all deliveries in government hospitals are paid for by Medicaid, compared with 18 percent in nonprofit, 17 percent in investor-owned, and 16 percent in church-aff~liated hospitals (AG1, 19871. Government hospitals also perform more no-payment deliv- eries. Any decrease in obstetrical beds in government hospitals may affect poor women disproportionately.

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24 MEDICO PROFESSIONAL LAITY: VOLUME ~ TABLE 2.3 Obstetrical Facilities in Community Hospitals Obstetric Hospitals Obstetric Units Overall Change Sponsorship Number BedsNumber Beds in Beds (%) State and local governments 1980 0 0 1,034 13,414 1986 0 0 964 12,365 Nongovernment, not-for- profit 1980 1986 Investor-owned (for-profit) 1980 1986 Total community hospitals 1980 1986 9 4062,260 40,837 5 2622,315 42,671 4 143214 2,847 6 305299 4,570 13 5493,508 57,098 11 5673,578 59,606 7.82 + 4.10 + 63.04 + 4.38 SOURCE: American Hospital Association. 1987. Hospital Statistics. Chicago. FINANCING OF MATERNITY CARE The average bill for having a baby in the United States in 1986 (including physician services and hospital costs) was $4,300; it was approximately $2,900 even if the pregnancy was uncomplicated, the delivery normal, and the infant healthy. The average cost was approx- imately 40 percent higher in urban areas (where approximately 75 percent of all U.S. couples live) than in rural areas. The bill can be much higher when there are complications. Charges for a cesarean birth averaged $4,860 when the newborn had no health problems, and they averaged $6,250 when complications were present. A premature birth with major complications averaged $12,000. In 1985 approximately $16 billion was spent in the United States on maternity care. Of this, an estimated $4.7 billion was spent for physician care and outpatient laboratory procedures and $11.3 billion for hospital charges ($6.3 billion for care of the mother, $5.0 billion for care of the newborn) (AGI, 1987). Maternity care may be paid for out of pocket, by private insurance, or by Medicaid; or it may be received without charge because there was no charge or because the charge was not paid. Seventy-three percent (41 million) of the 56 million U.S. women of reproductive age have some form of private health coverage, but approximately 9 percent of these

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MATERNITY CARE IN THE UNITED STATES 25 policies do not cover maternity care. Others have policies with gaps or loopholes in coverage, including waiting periods before coverage begins (AG1, 19871. According to the 1980 NMCUES-the only source of infor- mation on payments for prenatal care approximately 44 percent of prenatal charges were paid by private insurance, 35 percent out of pocket, and 17 percent by Medicaid and other government programs (AGI, 19871. Women whose care was paid for by Medicaid or other government funds were more likely to be less than 20 years old, black or Hispanic, unmarried, and without a high school diploma (Klerman and Scholle, 19881. In a 1986 survey by the Children's Defense Fund only 23 states reported programs that finance inpatient maternity programs (Rosen- baum et al., 19881. Of these, 16 limited services to women in special programs or to women identified as high-risk prior to labor and delivery. NEED FOR OBSTETRICAL CARE In analyzing the ejects of professional liability concerns on the supply of obstetrical providers, the committee thought it important to examine the "demand" side of the obstetrical equation; that is, how much obstet- rical care is needed under the current system, and how much obstetrical care would be needed if the current system were not underfunded. The committee concluded that forecasting the need for obstetrical services is difficult because of the number of variables involved. However, two notable observations emerged: (1) there is mounting evidence of existing shortages of obstetrical care for certain groups of women and for women living in certain geographic areas; and (2) despite the fact that the birth rate in the United States is not expected to increase dramatically in the next decade, there is good reason to believe that the need for obstetrical services in the United States will increase. The evidence that profes- sional liability concerns are driving physicians and other obstetrical providers from practice and raising barriers to access, presented in Chapters 3 and 4 of this report, must be evaluated in light of these observations. Evidence of Existing Shortages of Obstetrical Services In evaluating the ejects of medical professional liability on access to obstetrical care, the committee was mindful of the larger problem of constrained access to health services for low-income and minority women generally in the United States and of the fact that the American maternity system is seriously underfinanced (IOM, 19881. Seventeen percent of all women have no health insurance coverage, and others

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26 MEDICAL PROFESSIONAL ~lABlLITY: VOLUME ~ have inadequate coverage (AGI, 19871. Below, the committee summa- rizes some of the disturbing trends that point to shortages of obstetrical services for certain groups of women. It is important to bear in mind that the effects of professional liability concerns are being experienced in a system that is already falling far short of meeting the public health goals of this nation. To be sure, the problems associated with the underfinancing of the maternity system in the United States make it difficult to assess the independent effect of professional liability concerns on the delivery of obstetrical care. Moreover, the committee recognizes that, unless these critical finance issues are also addressed, solutions to the problems wrought by professional liability concerns on obstetrics may not be fully realized. Conversely, the committee notes that resolving the profes- sional liability problems will not by itself address all the unmet needs for obstetrical services. However, the committee does believe that profes- sional liability problems are exacerbating the problems faced by the U.S. maternity system. Insufficient Prenatal Care The data available to the committee make it clear that, although the United States has made many strides in improving maternal and child health in the last two decades, access to prenatal care is far less than optimal, and the incidence of low birthweight and of certain preventable complications of pregnancy and delivery remains too high (IOM, 19881. In 1985 approximately one-fourth of all infants in the United States were born to women who did not begin prenatal care in the first three months of pregnancy; almost one-third were born to women who did not obtain the amount of care currently recommended by the ACOG (19851. More than 5 percent were born to women who began care only in the third trimester of pregnancy or who had no care at all. For certain groups, these percentages were higher: for example, only 47 percent of black teenagers began care in the first trimester of preg- nancy, and 14 percent obtained no care or care only in the third trimes- ter (National Center for Health Statistics, 19871. Similar patterns were reflected in a study by the Alan Guttmacher Institute (1987), which found that 34 percent of mothers obtained less than adequate prenatal care. Again, certain groups exhibited even higher percentages of insuff~- cient prenatal care. Fifty-one percent of black women and 47 percent of Hispanic women obtained less than adequate care. Women younger than 20 years were more than twice as likely to have received less than adequate care (55.7 percent), as were women aged 35 years and older (26.4 percent). Women who were unmarried, who had relatively little

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MATERNAL CARE IN THE HATED STATES 27 education, or who were poor also were more likely to have obtained insufficient prenatal care (AG1, 1987) (Figure 2.11. These trends are particularly disturbing in light of the broad consensus that prenatal care is an effective intervention that is clearly associated with improved outcomes of pregnancy. Arrested Decline in Infant Mortality The committee noted with alarm that in 1985, following several years of slowing improvements in infant health, the national rate of decline in infant mortality had been arrested. This lack of improvement masked the first nationwide increase in black and nonwhite neonatal mortality in 20 years, from 11.8 to 12.1 deaths per 1,000 live births. In 1978 the Surgeon General of the United States established a set of objectives for infant health to be met by 1990 (USDHHS, 19861. He determined that the national infant mortality rate (deaths of children younger than 1 year) should be reduced to no more than 9 deaths per 1,000 live births, with no county and no racial or ethnic subgroup having a rate in excess of 12 deaths per 1,000 live births. Recent calculations by the Children's Defense Fund suggest that, although the national goal will be met, the goal for blacks and other nonwhite ethnic subgroups will not (Hughes et al., 19881. In his Midcourse Review, the Surgeon General acknowledged this and specifically mentioned professional liability con- cerns as a contributing factor: In addition, two recent developments, the escalating costs of malpractice insur- ance and changes in methods offinancing hearth care for the medically indigent, must be monitored for their potential to affect efforts to reduce infant mortality. In a 1983 nationwide survey by the American College of Obstetricians and Gynecologists, 17.6 percent ofthe obstetricians reported that they had decreased their level of high-risk obstetrical care, and another 9.1 percent reported they had ceased to practice obstetrics.... Given these and other barriers to progress, it is clear that further reduction of infant mortality rates will require a con- certed national, state, and local effort (USDHHS, 1986, p. 37~. Inability to Pay for Care The Alan Guttmacher Institute found that more than 25 percent of women between the ages of 16 and 24, who account for 40 percent of all births, have no private health care coverage (AG1, 19871. Medicaid covers only 43 percent of these women with family incomes below $5,000 and 30 percent of those with incomes between $5,000 and $10,000. bends suggest that the absence of adequate insurance coverage may be complicated by a decline in charity care.

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28 MEDICAL PROFESSIONAL LIABILITY: VOLUME I 60 56 52 48 44 40 36 c - 8 32 28- 24- 20- 16- 8 12- 4- O - 34.1 s. .... ...... - ::::::2 ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ........ ....... ::::::: '_ ,7.9 ~ = 28.7 _ _ 3.5 ;-;-;-; ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: .2... ::-:: ::.:: :::: :::: :::: :::: .'.','.' ::::::: ......... ~.^ 57.8 8.3 :-.::' .....2'. :::: ::: ::: :::: :::: :::: :::: :::: :::: :-: : ....... ::::::- ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ::::::: ...-.. .:-:.: ':.':.:,:.' :::::: :::::: 9. l 29.5 123.5 1-;-:-;-:4 1::::::::' 1::::::::' I::::, I::::::::, i:::::::: t::::::::l t::::::::l t::::::::l t::::::::l t::::::::l t::::::::l 1.'~ I::-::::; I:::::::; I:::::::; F:::::::; F:::::::; F:::::::1 F: :-:-:3 t:.:::::i t:-:::::d rem Sol so.e F_ 136eq A....... 1 1::::-:: 1::::-.:-- 1::::::-: 1:: :-: 1::::::-.: 1:::::::e, 1::::::::, 1.2' If-:-:-: Fig :-' FF..... F:::::::1 F:::::::l F:::::::1 F:::::::1 F-::::::1 F:::::::1 F:::::::1 F:::::::1 F:::::::l F:::::::l F:::::::l F:::::::1 F:::::::l F:::::::l F:::::::l F:::::::l F:::::::l F:::::::l C-:-:-:-l h4. 46.8 32.41 . .-.-. .i :::::::::3 :::::::::3 .--:-::3 ::::::::-1 ::::::::.3 :::--- :-1 :::::::::3 :::::::::3 :::::::::3 ::] ,~ 43 | L F::::::::l F::::::::43 | L F::::::::l F::::::::'3 F::::::::'3 1:::::::::'3 1:::::::::'3 F.::::::::' F:::::::: F:::::::: F:::::::: 1::::::::: 1::::::::: 1::::::::: F.~ E:-:-:-:. ..... , . . . 139.3 1.... ~ 1::::::::] 1::::::::] 1::::::::] 1::::::::] 1::::::::. 1::::::::1 1::::::::1 1::::::::1 1....1 1::::::::1 1 1 1::::::::1 ~....1 ~:-:-:-:-1 ~1 t:::-::::l t:::::::13 t:::::::i t:::::::i ,:::::::i i:::::::i :::::::i :::::::i :::::::i ,:::::::i :::::::i :::::::i :::::::i :::::::i ] '-:-:-:-i 1 ::::::-1 :: ::] ;~ 1 6.41 ~ 35.8 :~ 27.4 '::::::::] ;::: :] :::::] :::: :] :::: :] :::::] :::: :' :::::::::3 ::::::::43 ,-.:: :' ;::: :] '...2..'2] ,, d :::::-:-1 ::::::::1 ::::::::1 ::::::::1 ~::::::::1 ::::::::3 ::::::::3 ; ~133 . . . 8.4,.3 1 28.4 21.4 1-:-:-:-:' 1...1 t:-::::::l t:::::-::l t:::::-::l t::::::::l t::::::::l t::::::::l t:::::::i t:::::::-. t:::::-:i t:::::-:i t:::::::i t:::::::i t:::::::i t:::::::i t:::::::i t:::::::i t:::::::i ~.-.-..1 ;:::::::' ~: ,, ;5.0 ~3 Loss-than t::::'adequatecars s2.6 ~3 Poor or no cars ~;;~*Married women only 1-.-.-.-. It:-:::::: It:.:::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t-:-:-:-: t~ [-:-::: F . F:::::::: F::::::: F:::::::: F:::::::: E::::::: F.:::::::; E::::::: F.~ E:::: I..... t:::::-:: [~ t:::::.:: t:::::-:: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: ~;] r~ 115.5 L 33.0 r~ 326.0t 1:-:-:-:- 1:::::::: }:::::::: 1:::::::: 1:::::::: 1:::::::: 1:::::::: 1:::::::: 1 l:.:-:.:~. F::::::: F:::::::; F:::::::' F::::::: F::::::: F::::::: F::::::: F:::::::: F:::::::: F:::::::: [---2~ t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: .-.-.-.-. r~ t7.0 22.7 18.9 ;;;;;d :::::::::i :::::d :::::d :::::] :: . . :4 ..~ :::::::::] :::::::::] :::::::::] :::::::::] :::::::::1 :::::::::1 :::::::::1 :::::::::1 :::::::::1 :::::::::1 :::::::::1 3.8 47.0 pB.01 [:::;:;:;] I::::::::, I::::::::] E::::::::] [:::::::: I:::::::: I:::::::: [:::::::: [:::::::: [:::::::: E:: :.:: t:::::.:: t::::: :: t::::::: t~ t::::::: t... t::::::: t::::::: t::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t:::::::: t ::: ::: t....... [::::::::: :::: 11.0 ~. 30.0 .... 25.0 '-:-:-:-:-1 :::::::::1 :::::::::1 :::::::::1 :::::::::1 :::::::::1 :::::! :::::! :::::! :::: :] :::: :] :::::] .~...~...~ :-: :-:-1 :::::::::1 :::::::::1 :::::::::1 :::::::::1 :::::::::1 :::::::::1 ::::::::d ::::::::i ::::::::1 :::::-:-i :.:.::::3 ~3 501 24.0 ko.O i....3 I::::3 t::: :d I:::::::i [:::::::i t:::::::i t:::::::i 1::::::::1 1::::::::1 1::::::::1 1.:.:.:.:1 1:::::::1 1::::::::1 k:::::::l t:::::::1 t:::::::1 t:::::::1 t:::::::1 .:.:-:.1 E:::::::] r . ~. 14.ol ~ ~.`9 ~ .o ~ ~ ~ ~ ~8 ~ ~ _ ~ at a, V c~ /\ V A ~ ~s ~'; m Q ~I V g cI - Total Marital Race Age- Years of Income % of Federal Status Group Education Povedy Level* FIGURE 2.1 Percentage of women who had obtained insuff~cient prenatal care, by selected characteristics, 1980. Source: Alan Guttmacher Institute. 1987. The Financing of Maternity Care in the United States. New York.

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MATERNITY CARE IN THE UNITED STATES 29 The disturbing phenomenon of"dumping" women in labor was also brought to the attention of the committee. In 1986 the Children's De- fense Fund asked state Title V officials if they knew of people being denied services or turned away from hospitals because of inability to pay. Fifteen state agencies reported that hospitals were denying admis- sion to women about to deliver, and another 13 reported that hospitals were denying admission to women not yet in "active" labor. The Chil- dren's Defense Fund quoted officials in two states as saying: "tUn- insured] pregnant women sit on the steps of the hospital when they go into labor." In addition, 23 agencies reported that one or more hospitals in the state required preadmission cash deposits from pregnant women; only 4 agencies said no deposits were required. Where preadmission deposits are required, uninsured and indigent women may avoid regis- tering early or may wait until they are in advanced labor to seek care (Rosenbaum et al., 19881. Physician Shortage In Rural Areas The 1970s saw a major upsurge in physician availability in rural areas. Growth was particularly prevalent among specialists, who in- creased to almost two-thirds of all physicians in nonmetropolitan off~ce- based practice. The experience of the 1980s indicates that this growth was a short-lived phenomenon fueled principally by the general rise in physician supply. Although the percentage of fourth-year medical stu- dents selecting family practice has not varied much in the 1980s (see Table 3.1, Chapter 3), fewer physicians have entered medical practice, and thus growth rates in both metropolitan and nonmetropolitan areas have declined (AMA, 19871. The most recent data suggest that, as a result, nonmetropolitan areas may be losing again in the competition for physicians. Between 1983 and 1986, the absolute number of physicians in nonmetropolitan, off~ce-based practice declined by 2 percent (AMA, 19871. Between 1985 ant! 1986 alone, nonmetropolitan areas lost more than 4,000 physicians, whereas the number of physicians in metropolitan areas remained stable. In that one year the number of specialists in nonmetropolitan areas declined by 10 percent; family and general prac- titioners fell by almost 6 percent (Figure 2.2). A 1986 Robert Wood Johnson Foundation survey reported that resi- dents of metropolitan and nonmetropolitan areas experienced approx- imately equal access to health care but that larger proportions of rural Americans are in poor health (Robert Wood 'Johnson Foundation, 19871. This national finding, which did not specifically examine obstetrical care, must be considered with other data which suggest that there is considerable variation in access from region to region and specialty to

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30 MEDICAL PROFESSIONAL LIABILITY: VOLUME 0.4 0.3 0.2 - a) ' 0.1 s UGLY _, -0.1 -0.2 1 970 1975 Year 1 980 , ~ _ <5 ~- Ge~e~' , ACE\\] 2 ~ 1 985 FIGURE 2.2 Physicians in office practice, nonmetropolitan areas, 1970-1986. Source: Lewis-Idema, D. 1988. Professional liability issues affecting family practitioners and delivery of obstetrical services in rural areas. Paper prepared for the Institute of Medicine, Washington, D.C. specialty, however. In 1986 the AMA reported that 126 U.S. counties in 25 states had no practicing physician (AMA, 19871; these counties had 466,800 residents (0.2 percent of the U.S. population). All were rural and all had very Tow population density, an average of 4 persons per square mile; the most densely populated county among these had 60 persons per square mile. The committee's findings relating to the availability of obstetrical providers in rural areas are discussed in detail in Chapter 3. The implications of the data presented there must be considered against this background of emerging shortages in rural areas. Projected Increase in Need for Obstetrical Services Determining the impact of liability issues on maternity care would be easier if there were accepted standards for the number of providers needed to care for pregnant women and projections of the number actu- ally expected to be available. If such standards existed, present and future deviations could be examined and their relationship to the "mal- practice crisis" at least surmised.

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MATERNITY CARE IN THE HATED STATES 31 Several attempts have been made to project manpower needs in medi- cine, although very few have been specialty specific. The 1980 report of the Graduate Medical Education National Advisory Committee (GMENAC) is the best known effort in this regard (GMENAC, 19811. GMENAC projected that this country would have an excess of 70,000 physicians by 1990, including over 10,000 more obstetrician-gynecolo- gists than would be needed. GMENAC procedures for modeling physi- cian requirements and supply have received harsh criticism from orga- nized medicine, particularly the ACOG, primarily because of their dependence on expert opinions and imperfect data sources. The Bureau of Health Professions (BHP) in the Department of Health and Human Services has used a "demand" model based on health services utilization data and economic and demographic trends to estimate the number of physicians needed (BHP, 19821. These data, which were originally not disaggregated by specialty, do not take into account the chronic short- ages of care for low-income women. The committee concluded that nei- ther the GMENAC nor the BHP projections offered a reliable benchmark for evaluating the current situation in obstetrics. Although it is impossible to project overall need for obstetrical ser- vices with any certainty, the committee believes that available data suggest an increase in need in the near future, for three reasons: a rise in the number of births among women who may need additional prenatal visits or prenatal and delivery care from specialists, an increase in the mean number of prenatal visits per pregnant woman, and a continua- tion of the trend toward more complex perinatal procedures. The birthrate has risen slowly but steadily since the mid-1970s. Preliminary data indicate that approximately 3.83 million infants were born in 1987, a 2 percent increase over 1986 (Klerman and Scholle, 19881. This increase over the last decade is related to the increase in the number of women of childbearing age and the increasing tendency of women in their twenties and thirties to delay birth. The birthrate to women aged 30 years and older is expected to increase from 25 percent of live births in 1985 to 30 percent in 1995 (AMA, 19871. However, the Census Bureau projects that the birthrate will peak by the late 1980s and then decline through the 1990s as the female population of child- bearing age declines (Bureau of the Census, 19841. The birthrate among women at higher than normal risk of having a complicated pregnancy or deliver~namely older, unmarried, and mi- nority women is rising and will continue to rise. Seven percent of births were to women age 35 years and older in 1986, compared with 4.6 percent in 1980; 23.4 percent of births were to unmarried women in 1986, compared to 17.8 percent in 1980; 20.9 percent of births were to nonwhite women in 1985, compared with 19.7 percent in 1980 (AG1,

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32 MEDICAL PROFESSIONAL LIABILITY: VOLUME I TABLE 2.4 Births to Minority, Unmarried, and Older Women, 1970 and 198~1986 Women (% of U.S. Population) - Year Minority Unmarried Aged 35 and Over 1986 20.9 23.4 7.0 1985 20.5 22.0 6.5 1984 20.3 21.0 6.1 1983 20.2 20.3 5.7 1982 20.1 19.4 5.3 1981 19.9 18.9 4.7 1980 19.7 17.8 4.6 1970 17.1 10.7 6.3 SOURCES: Alan Guttmacher Institute.1987. The Financing of Maternity Care in the United States. New York. Table 1; National Center for Health Statistics. 1988. Advance report of final nasality statistics, 1986. Monthly Vital Statistics Rep., Vol.37, No.3 (Supp.) Hyattsville, Md. 1987) (see Table 2.41. Minority births are expected to constitute 22 percent of all births by the turn of the century (AMA, 19871. This increase among women who are likely to need additional prenatal visits or care from specialists, many of whom are poor and who are already underserved, should increase the need for maternity services. The discrepancy between the accepted standard of prenatal care and the actual receipt of such care in the United States has been well documented, as noted above. If the multiple campaigns and outreach efforts to increase the number of women who receive adequate prenatal care are successful, the need for services should increase. Finally, the range and number of diagnostic procedures routinely used in obstetrical services continue to increase. These currently in- clude ultrasonography, amniocentesis, chorionic villi sampling, stress testing, electronic fetal monitoring, and cesarean sections. The in- creased tendency to test prenatally, the rise in "defensive" procedures discussed in Chapter 5, and widespread consumer acceptance of high- technology obstetrics are likely to contribute to an increase in the need for obstetrical services. REFERENCES Alan Guttmacher Institute (AGI). 1987. The Financing of Maternity Care in the United States. New York. American Academy of Family Physicians (AAFP). 1986. The Family Physician and Obstetrics: A Professional Liability Study. Kansas City, Mo. American Academy of Family Physicians (AAFP). 1987. Family Physicians and Obstet rics: A Professional Liability Study. Kansas City, Mo.

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MATERNI~ Cal ~ ]~ TED STATES 33 American College of Nurse-Midwives (ACNM). 1984. Nurse-Midwifery in the United States, 1982. Washington, D.C. American College of Nurse-Midwives (ACNM). 1988. The scarcity and high cost of insur- ance. Testimony before the U.S. Congress Committee on Energy and Commerce, Sub- committee on Commerce, Transportation, and Tourism. September 19. American College of Obstetricians and Gynecologists (ACOG).1985. Standards for Obstet- ric-Gynecologic Services, 6th ed. Washington, D.C. American College of Obstetricians and Gynecologists (ACOG). 1986. Consolidation of Hospital Obstetric Services, Obstetrics and Gynecology Manpower Planning Study. Washington, D.C. American College of Obstetricians and Gynecologists (ACOG).1988. Obstetrics and Gyne- cology Manpower Planning Study. Washington, D.C. American Hospital Association (AHA). 1987. Hospital Statistics. Chicago. American Medical Association (AMA). 1987. Physician Characteristics and Distribution in the U.S. Chicago. Bureau of the Census, U.S. Department of Commerce.1984. Projections of the population of the U.S. by age, sex and race 1983-2080. Current Population Rep. Series P-25, No. 952. Washington, D.C.: Government Printing Office. Bureau of Health Professions (BHP), U.S. Department of Health and Human Services. 1982. Third Report to the President and Congress on the Status of Health Professional Personnel in the United States. DHHS Pub. No. HRA-82-2. Hyattsville, MD. General Accounting Office (GAO), U.S. Congress. 1987. Medical Malpractice: Charac- teristics of Claims Closed in 1984. GAO-HRD-87-55. Gaithersburg, Md. Graduate Medical Education National Advisory Committee (GMENAC).1981. Su~n~nary Report to the Secretary, Department of Health and Human Services. Vol.1. DHHS Pub. No. (HRA) 81-651. Washington, D.C.: Government Printing Office. Hughes, D., K. Johnson, S. Rosenbaum, E. Butler, and J. Simons. 1988. The Health of America's Children: Maternal and Child Health Data Book. Washington, D.C.: Chil- dren's Defense Fund. Institute of Medicine (IOM). 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, D.C.: National Academy Press. Klerman, L. V., and S. H. Scholle. 1988. The actual and potential impact of medical liability issues on access to maternity care. Paper prepared for the Institute of Medicine. Washington, D.C. National Ambulatory Medical Care Survey. 1987. Unpublished tabulations in rural health research agenda conference background tables. Prepared by Catherine Norton and Margaret McManus for the National Rural Health Association and the Foundation for Health Services Research. Washington, D.C. National Center for Health Statistics. 1987. Advance report of final nasality statistics, 1985. Monthly Vital Statistics Rep., Vol. 36, No. 4 (Supp). DHHS Pub. No. (PHS) 87-1120. Hyattsville, Md. Nurses' Association of the American College of Obstetricians and Gynecologists (NAACOG). 1987. Obstetrics and Gynecology Manpower Planning Study. Washington, D.C.: American College of Obstetricians and Gynecologists. Public Health Foundation. 1987. Public Health Agencies 1987: An Inventory of Programs and Block Grant Expenditures. Washington, D.C. Robert Wood Johnson Foundation. 1987. Access to Health Care in the United States: Results of a 1986 Survey. Princeton, N.J. Rooks, J., and J. E. Haas. 1986. Nurse-Midwifery in America. Washington, D.C.: Ameri- can College of Nurse-Midwives Foundation.

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34 MEDiC~ PROFESSIONAL CITY: VOLUME ~ Rosenbaum, S., D. C. Hughes, and K. Johnson. 1988. Maternal and child health services for medically indigent children and pregnant women. Med. Care 26:315-332. Rosenblatt, R. A., D. C. Cherkin, R. Scheeweiss, L. G. Hart, H. Greenwald, C. R. Kirkwood, and G. T. Perkoff. 1982. The structure and content of family practice: Current status and future trends. J. Fam. Prac. 15:681-722. Smith, M. A., and K. P. Howard. 1987. Choosing to do obstetrics in practice: Factors affecting the decisions of third-year family practice residents. Fam. Med. 19(3): 191-194. U.S. Department of Health and Human Servicer (USDHHS). 1986. The 1990 Health Objectives for the Nation: A Midcourse Review. Washington, D.C.: Government Print- ing Office.