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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
OCR for page 27
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.
OCR for page 28
28 MEDICAL PROFESSIONAL LIABILITY: VOLUME I
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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.
OCR for page 29
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
OCR for page 30
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 ~-
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, ACE\\] 2 ~
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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.
OCR for page 31
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,
OCR for page 32
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.
OCR for page 33
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.
OCR for page 34
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.
Representative terms from entire chapter:
professional liability
