Medical Professional Liability and the Delivery of Obstetrical Care Volume I (1989) / Chapter Skim
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2 Maternity Care in the United States
2 Maternity Care in the United States
Pages 14-34
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From page 14... ...
Here the committee presents the background necessary to an understanding 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)
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From page 15... ...
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 recognized program of training and specialization.
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From page 16... ...
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 General 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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From page 17... ...
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.
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From page 18... ...
During the early 1980s prior to the dramatic increase in professional liability insurance expenses-there were an estimated 16,700 physicians providing 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.
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From page 19... ...
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)
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From page 20... ...
Family planning clinics served 5 percent; health department 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.
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From page 21... ...
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 between 100 and 200 percent of that level, and 2 percent at approximately 200 percent of the poverty level.
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From page 22... ...
physicians 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 practitioners.
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From page 23... ...
A cost-based analysis of perinatal services furnished by health centers in 1986 and conducted by the Public Health Service has estimated that more than $85 million of the program funding 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 lowincome women, it commissioned a study on the effects of medical professional liability on the delivery of obstetrical care in Community and Migrant Health Centers.
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From page 24... ...
Chicago. FINANCING OF MATERNITY CARE The average bill for having a baby in the United States in 1986 (including physician services and hospital costs)
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From page 25... ...
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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From page 26... ...
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.
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From page 27... ...
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 concerns as a contributing factor: In addition, two recent developments, the escalating costs of malpractice insurance and changes in methods offinancing hearth care for the medically indigent, must be monitored for their potential to affect efforts to reduce infant mortality.
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From page 28... ...
FIGURE 2.1 Percentage of women who had obtained insuff~cient prenatal care, by selected characteristics, 1980. Source: Alan Guttmacher Institute.
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From page 29... ...
. A 1986 Robert Wood Johnson Foundation survey reported that residents of metropolitan and nonmetropolitan areas experienced approximately equal access to health care but that larger proportions of rural Americans are in poor health (Robert Wood 'Johnson Foundation, 19871.
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From page 30... ...
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 actually expected to be available. If such standards existed, present and future deviations could be examined and their relationship to the "malpractice crisis" at least surmised.
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From page 31... ...
The committee concluded that neither 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 services 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 continuation of the trend toward more complex perinatal procedures.
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From page 32... ...
The increased tendency to test prenatally, the rise in "defensive" procedures discussed in Chapter 5, and widespread consumer acceptance of hightechnology obstetrics are likely to contribute to an increase in the need for obstetrical services. REFERENCES Alan Guttmacher Institute (AGI)
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From page 33... ...
1988. The actual and potential impact of medical liability issues on access to maternity care.
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From page 34... ...
1988. Maternal and child health services for medically indigent children and pregnant women.
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