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Thursday, February 25, 2016

As Rural Hospitals Struggle, Some Opt To Close Labor And Delivery Units

February 23, 2016--

About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

A few years ago, when a young woman delivered her baby at Alleghany Memorial Hospital in Sparta, North Carolina, it was in the middle of a Valentine’s Day ice storm and the mountain roads out of town were impassable.

The delivery was routine, but the baby girl had trouble breathing because her lungs weren’t fully developed. Dr. Maureen Murphy, the family physician who delivered her that night, stayed in touch with the neonatal intensive care unit at Wake Forest Baptist Medical Center in Winston-Salem, a 90-minute drive away, to consult on treatment for the infant.

“It was kind of scary for a while,” Murphy remembered. But with Murphy and two other family physicians trained in obstetrics as well as experienced nurses staffing the 25-bed hospital’s labor and delivery unit, the situation was manageable, and both mother and baby were fine.

Things are different now. Alleghany hospital — like a growing number of rural hospitals — has shuttered its labor and delivery unit, and pregnant women have to travel either to Winston-Salem or to Galax, Virginia, about 30 minutes away by car, weather permitting.

“It’s a long drive for prenatal care visits, and if they have a fast labor” it could be problematic, said Murphy, who teaches at the Cabarrus Family Medicine Residency Program in Concord, North Carolina. (Although not essential, women typically see the physician they expect will handle their delivery for prenatal care.)

About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

“The fact that closures continue happening — over time that means the nearest hospital gets further and further away,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who coauthored the study published in the January issue of Health Services Research.
There are many factors that contribute to the decline in rural hospital obstetrics services. For one thing, obstetrics units are expensive to operate, and a small rural hospital may deliver fewer than 100 babies a year.

 “A labor and delivery unit is functionally no different than an intensive care unit,” said Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School.

Staffing levels are high in obstetrics, often one nurse for every patient, and the rooms are cluttered with monitors, infusion pumps and other equipment.

It can be difficult to staff the units as well. Small rural hospitals may not have obstetricians on staff and rely instead on local family physicians, but it can be difficult to get enough to fully provide services for a hospital, too. Nurses with obstetrics experience also can be scarce.

Meanwhile, bringing in the revenue needed to cover the costs involved in maintaining the units can be difficult because insurance payments are often low. Medicaid pays for slightly under half of all births in the United States, but in rural areas the proportion is often higher, said Kozhimannil.

Since Medicaid pays about half as much as private insurance for childbirth, “the financial aspect of keeping a labor and delivery unit open is harder in rural areas,” she said.

Advocates say there are a number of initiatives that could help bolster labor and delivery services in rural areas.

Encouraging medical professionals to move to rural areas is key, they say. A bipartisan bill introduced in Congress last year, for example, would require the federal government to designate maternity care health professional shortage areas.

Such designations exist for primary care, mental health and dental care. The National Health Services Corps awards scholarships and provides loan repayment to primary care providers who commit to serving for at least two years in designated shortage area. Once they get to a community and put down some roots, the hope is they’ll stay.

Expanding the use of midwives and birthing centers could be cost effective since they are generally less expensive than physicians and hospital obstetric units. 

Although birthing centers and home births are on the rise, more than 98 percent of the 4 million babies that were born in 2014 made their arrival at a hospital.

“You can deal with lower volume and still be sustainable,” said Shah.

“Finding strength in numbers, small rural hospitals are increasingly banding together to share resources, said Kozhimannil. For example, since it’s difficult to keep rural staff trained in rare complications, small rural hospitals sometimes pool resources to buy a mobile simulation unit to train people on handling postpartum hemorrhage, the leading cause of maternal mortality.

Kozhimannil sees great opportunity in the ongoing national dialogue about health reform but says much of the research to date has focused on reforming health care in urban settings.

“That’s why it’s crucial to have rural people at the table,” she said.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Monday, February 1, 2016

Palliative Approach to Care Especially Fitting for Rural Hospitals

Article in Critical Care Nurse discusses how nurses at critical access hospitals can use palliative approach to care for rural residents and families

Critical Nurses can aid Palliative Care for Rural Americans
Newswise, February 1, 2016 — Nurses at critical access hospitals are well positioned to provide high-quality palliative care close to home for millions of Americans in rural communities, according to an article in the February issue of Critical Care Nurse (CCN).

The United States has 1,332 critical access hospitals located in rural communities, providing mostly acute inpatient services, ambulatory care, labor and delivery services, and general surgery.

With fewer than 25 beds each and a mean daily census of 4.2 patients, these hospitals may frequently have a single registered nurse as the only healthcare professional on duty.

The article “Palliative Care in Critical Access Hospitals” uses a case report to illustrate the role that critical access hospitals play in meeting the need for high-quality palliative care in rural settings.

Palliative care provides psychological, spiritual, goal-setting and decision-making support not only to patients with life-threatening illnesses but to their families as well.
The benefits of such care include early initiation of comfort-focused treatment goals, decreased length of stay, continuity of care and reduced cost of care without an increase in mortality.

Unlike hospice care, palliative care is appropriate early in the course of illness, and patients can be simultaneously treated for their condition, including therapies intended to prolong life.

Millions of patients are living with serious, complex and potentially life-threatening conditions, increasing the need for palliative and end-of-life care.

Co-authors Dorothy “Dale” M. Mayer, RN, PhD, and Charlene A. Winters, PhD, APRN, ACNS-BC, are on the faculty of the College of Nursing, Montana State University, Missoula.

“As expert generalists, rural nurses are well positioned to provide support and promote quality of life close to home for patients of all ages and their families,” Mayer said.

“In sparsely populated areas, nurses are not strangers to their patients, often providing care to their neighbors, friends and relatives.”

The healthcare system is increasingly moving away from the consultative model of palliative care, in which clinicians bring in specialists to advise on individual cases.

The authors advocate for a different model, in which frontline staff, including physicians, nurses, social workers and chaplains, incorporate a palliative approach into patient care, especially with patients who have complex health conditions.

This approach is especially suited for rural area and critical access hospitals, in part because of an inherent sense of community between friends and neighbors.

“With limited personnel and resources, healthcare providers can no longer rely on specialized palliative care teams as the only clinicians to provide palliative care,” Winters said.

 “Working together, rural nurses and their urban nursing colleagues can provide palliative care across all healthcare settings to meet the needs of rural residents and their families.”

The American Association of Critical-Care Nurses, which publishes CCN, offers resources and tools to help nurses care for patients and their families at the most difficult times of their lives, including an e-learning course and a free, online self-assessment tool.

For more information on palliative and end-of-life care, please visit

As AACN’s bimonthly clinical practice journal for high acuity, progressive and critical care nurses, CCN is a trusted source for information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients.

The journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in high acuity, progressive and critical care settings. CCN enjoys a circulation of more than 106,000 and can be accessed at

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than 500,000 acute and critical care nurses and includes more than 225 chapters worldwide.

The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution.;;