Market Share of US Catholic Hospitals and Associated Geographic Network Access to Reproductive Health Services.

IMPORTANCE: Access to reproductive health services is a public health goal. It is unknown how geographic and health plan network availability of Catholic and non-Catholic hospitals may be associated with access to reproductive health services in the United States. OBJECTIVE: To characterize the market share of Catholic hospitals in the United States, both overall and within Marketplace health insurance plans' hospital networks. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of US counties used data on hospitals' Catholic affiliation and discharges, hospital networks in Marketplace health insurance plans, and US Census population data to construct a national, county-level data set. The Catholic hospital market share overall in each county and in Marketplace plans' hospital networks in each county were calculated. The study examined whether the Catholic hospital market share was different within Marketplace networks compared with the counties they served. Data analysis was conducted in May and June 2018. MAIN OUTCOMES AND MEASURES: The overall Catholic hospital market share was calculated on the basis of the share of discharges in Catholic hospitals in a county compared with all hospital discharges. Overall market share was categorized as minimal (≤2%), low (>2% to ≤20%), high (>20% to ≤70%), or dominant (>70%). The Catholic hospital market share in Marketplace networks was calculated as the share of Catholic hospital discharges in each Marketplace network. RESULTS: The sample included 4450 hospitals in 3101 counties. Overall, 26.1% of US counties had minimal Catholic hospital market share, 38.6% had low Catholic hospital market share, and 35.3% had high or dominant Catholic hospital market share; 38.7% of US reproductive-aged women resided in counties with high or dominant Catholic hospital market share. Among counties with Catholic hospital market share greater than 2%, the distribution of the median Marketplace network's Catholic hospital market share (median [interquartile range], 4.6% [0%-24.3%]) was lower than overall Catholic hospital market share (median [interquartile range], 18.5% [8.1%-36.5%]). The median Marketplace hospital network had a lower Catholic hospital market share than the county overall in 68.0% of US counties with Catholic hospital market share greater than 2%. CONCLUSIONS AND RELEVANCE: In this national study, 35.3% of counties had high or dominant Catholic hospital market share serving an estimated 38.7% of US women of reproductive age. Marketplace health insurance plans' hospital networks included a lower share of Catholic hospitals than the counties they serve.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States.

Importance: Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown. Objective: To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties. Design, Setting, and Participants: A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004. Exposures: Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas. Main Outcomes and Measures: Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks' gestation). Results: Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric services, and this was followed by a decreasing trend (-0.19 percentage points per year [95% CI, -0.25 to -0.14]). Conclusions and Relevance: In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

Access To Obstetric Services In Rural Counties Still Declining, With 9 Percent Losing Services, 2004-14.

Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than twenty-eight million women of reproductive age living in rural America. Yet the extent of recent obstetric unit closures has not yet been measured. Using national data, we found that 9 percent of rural counties experienced the loss of all hospital obstetric services in the period 2004-14. In addition, another 45 percent of rural US counties had no hospital obstetric services at all during the study period. That left more than half of all rural US counties without hospital obstetric services. Counties with fewer obstetricians and family physicians per women of reproductive age and per capita, respectively; a higher percentage of non-Hispanic black women of reproductive age; and lower median household incomes and those in states with more restrictive Medicaid income eligibility thresholds for pregnant women had higher odds of lacking hospital obstetric services. The same types of counties were also more likely to experience the loss of obstetric services, which highlights the challenge of providing adequate geographic access to obstetric care in vulnerable and underserved rural communities.

Why Are Obstetric Units in Rural Hospitals Closing Their Doors?

OBJECTIVES: To understand hospital- and county-level factors for rural obstetric unit closures, using mixed methods. DATA SOURCES: Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013-2014 telephone interviews of all 306 rural hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care. STUDY DESIGN: Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014. PRINCIPAL FINDINGS: Exactly 7.2 percent of rural hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care. CONCLUSIONS: Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce. Concerns about continuity of rural maternity care arise for women with local prenatal care but distant intrapartum care.

Babies born before arrival to hospital and maternity unit closures in Queensland and Australia.

BACKGROUND: Evidence suggests the closure of maternity units is associated with an increase in babies born before arrival (BBA). AIM: To explore the association between the number of maternity units in Australia and Queensland by birthing numbers, BBA rate and geographic remoteness of the health district where the mother lives. METHODS: A retrospective study utilised routinely collected perinatal data (1992-2011). Pearson correlation tested the relationship between BBA rate and number of maternity units. Linear regression examined this association over time. FINDINGS: During 1992-2011, the absolute numbers (N=22,814) of women having a BBA each year in Australia increased by 47% (N=836-1233); and 206% (n=140-429) in Queensland. This coincided with a 41% reduction in maternity units in Australia (N=623-368=18 per year) and a 28% reduction in Queensland (n=129-93). BBA rates increased significantly across Australia, r=0.837, n=20 years, p<0.001 and Queensland, r=0.917, n=20 years, p<0.001 and this was negatively correlated with the number of maternity units in Australia, r=-0.804, n=19 years, p<0.001 and Queensland, r=-0.906, n=19 years, p<0.001. CONCLUSIONS: The closure of maternity units over a 20-year period across Australia and Queensland is significantly associated with increased BBA rates. The distribution is not limited to rural and remote areas. Given the high risk of adverse maternal and neonatal outcomes associated with BBA, it is time to revisit the closure of units.

Selection and concentration of obstetric facilities in Japan: Longitudinal study based on national census data.

AIM: A shortage of obstetricians with increased workload is a social problem in Japan. In response, the government and professional bodies have accelerated the 'selection and concentration' of obstetric facilities. The aim of this study was to evaluate the recent trend of selection and concentration. METHODS: We used data on the number of deliveries and of obstetricians in each hospital and clinic in Japan, according to the Static Survey of Medical Institutions in 2005, 2008 and 2011. To evaluate the inter-facility equality of distribution of the number of deliveries, number of obstetricians and number of deliveries per obstetrician, Gini coefficients were calculated. RESULTS: The number of obstetric hospitals decreased by 20% and the number of deliveries per hospital increased by 26% between 2005 and 2011. Hospital obstetricians increased by 16% and the average number of obstetricians per hospital increased by 19% between 2008 and 2011. Gini coefficient of deliveries has significantly decreased. In contrast, Gini coefficient of deliveries per obstetrician has significantly increased. The degree of increase in obstetricians and of decrease in deliveries per obstetrician was largest at the hospitals with the highest proportion of cesarean sections. The proportion of obstetric hospitals with the optimal volume of deliveries and obstetricians, as defined by Japan Society of Obstetrics and Gynecology, was 4% in 2008, and it had doubled to 8.1% 3 years later. CONCLUSION: The selection and concentration of obstetric facilities is progressing rapidly and effectively in Japan.

Lessons for providers and hospitals from Philadelphia's obstetric services closures and consolidations, 1997-2012.

The Affordable Care Act is triggering an increase in hospital consolidation and mergers. How other hospitals respond to these disruptions in supply could influence patient outcomes. We examined the experience of Philadelphia County, Pennsylvania (coterminous with the city of Philadelphia), where thirteen of nineteen hospital obstetric units closed between 1997 and 2012. Between October 2011 and January 2012 we interviewed twenty-three key informants from eleven hospitals (six urban and five suburban) whose obstetric units remained open, to understand how the large number of closures affected their operations. Informants reported having confronted numerous challenges as a result of the obstetric unit closures, including sharp surges in delivery volume and an increase in the proportion of patients with public insurance or no insurance. Informants reported adopting a number of strategies, such as innovative staffing models, to cope with the added demand brought about by the closure of nearby obstetric units. Informants emphasized that interhospital communication could mitigate closures' stresses on the health care system. Our study supports the need for policy makers to anticipate reductions in supply and monitor patient outcomes.

The effects of safety net hospital closures and conversions on patient travel distance to hospital services.

OBJECTIVE: To examine the effects of safety net hospital (SNH) closure and for-profit conversion on uninsured, Medicaid, and racial/ethnic minorities. DATA SOURCES/EXTRACTION METHODS: Hospital discharge data for selected states merged with other sources. STUDY DESIGN: We examined travel distance for patients treated in urban hospitals for five diagnosis categories: ambulatory care sensitive conditions, referral sensitive conditions, marker conditions, births, and mental health and substance abuse. We assess how travel was affected for patients after SNH events. Our multivariate models controlled for patient, hospital, health system, and neighborhood characteristics. PRINCIPAL FINDINGS: Our results suggested that certain groups of uninsured and Medicaid patients experienced greater disruption in patterns of care, especially Hispanic uninsured and Medicaid women hospitalized for births. In addition, relative to privately insured individuals in SNH event communities, greater travel for mental health and substance abuse care was present for the uninsured. CONCLUSIONS: Closure or for-profit conversions of SNHs appear to have detrimental access effects on particular subgroups of disadvantaged populations, although our results are somewhat inconclusive due to potential power issues. Policy makers may need to pay special attention to these patient subgroups and also to easing transportation barriers when dealing with disruptions resulting from reductions in SNH resources.

Mapping maternity services in Australia: location, classification and services.

OBJECTIVE: To describe maternity services available to Australian women and, in particular, the location, classification of services and support services available. DESIGN: A descriptive study was conducted using an online survey that was emailed to eligible hospitals. Inclusion criteria for the study included public and private maternity units with greater than 50 births per year. In total, 278 maternity units were identified. Units were asked to classify their level of acuity (Levels 2-6). RESULTS: A total of 150 (53%) maternity units responded. Those who responded were reasonably similar to those who did not respond, and were representative of Australian maternity units. Almost three-quarters of respondents were from public maternity units and almost 70% defined themselves as being in a rural or remote location. Maternity units with higher birth rates were more likely to classify themselves as providing higher acuity services, that is, Levels 5 and 6. Private maternity units were more likely to have higher acuity classifications. Interventions such as induction of labour, either using an artificial rupture of membranes (ARM) and oxytocin infusion or with prostaglandins, were common across most units. Although electronic fetal monitoring (EFM) was also widely available, access to fetal scalp pH monitoring was low. CONCLUSION: Maternity service provision varies across the country and is defined predominately by location and annual birth rate.

A survey of interventional radiology for the management of obstetric haemorrhage in the United Kingdom.

BACKGROUND: Massive haemorrhage remains a leading cause of maternal death worldwide. Interventional radiology can be used to prevent or treat life-threatening haemorrhage, but evidence for its efficacy is limited to case series predominantly from large tertiary centres. The current availability of interventional radiology for management of obstetric haemorrhage in the UK is unknown. METHODS: A postal questionnaire on the use of interventional radiology was sent to the lead clinician for obstetric anaesthesia in 226 UK maternity units. RESULTS: The response rate was 72%; 74 respondents (46%) had considered and 51 (31%) used interventional radiology for control of obstetric haemorrhage. Its use was primarily confined to large tertiary obstetric units and limited by availability of equipment and staff. CONCLUSIONS: Interventional radiology to assist in the management of obstetric haemorrhage is not uniformly available in the UK and experience remains limited. Access to this resource is subject to striking local variability and influenced by the size and nature of the hospital supporting the delivery unit.

Impact of maternity unit closures on access to obstetrical care: the French experience between 1998 and 2003.

As in many other countries, the number of maternity units has diminished substantially in France, raising concerns about the reduced accessibility of obstetric services. We describe here the impact of closures on distance and mean travel time between pregnant women's homes and maternity units. We used data from the 1998 and 2003 French National Perinatal Surveys and from vital registries to measure indicators of accessibility: straight-line distance to the nearest maternity unit, number of units within a 15-km radius and reported travel time to the unit for delivery. We analyzed these measures for all births, births in rural versus urban areas and according to regional rates of maternity closures. From 1998 to 2003, 20% of maternity units closed (reducing the number from 759 to 621) with regional variations in the rate of closure from 0.0% to 36.0%. Mean distance to the nearest maternity unit increased (6.6-7.2 km, p < 0.001). The proportion of women living more than 30 km from a maternity ward was low; but rose from 1.4% to 1.8%. The number of maternity units with a 15-km radius of the place of residence fell (median, 3 to 2). Differences were more marked in rural areas and in regions highly affected by closures. However, reported travel time did not increase and even declined slightly for women from urban areas and in regions moderately affected by the closures. As such, the closures do not appear to have had a negative impact on the geographic accessibility of maternity units. Pregnant women were faced with a reduction in the number of maternity units near their homes and our results suggest that they more often chose their maternity units based on proximity. A full assessment of the impact of closures on accessibility to obstetric services would require information on how these changes affected available choices for care during pregnancy and delivery.

Impact of discontinued obstetrical services in rural Missouri: 1990-2002.

PURPOSE: This study examines the potential relationship between loss of local obstetrical services and pregnancy outcomes. METHODS: Missouri Hospital Association and Missouri Department of Health birth certificate records were used as sources of information. All member hospitals of the Missouri Hospital Association that were located in cities of 10,000 or less were identified and surveyed by telephone. RESULTS: Frequency of low birth weight babies originating from service areas where hospitals closed services was statistically increased in the first year after service closures. This effect was transient. CONCLUSIONS: Transient increases in the rate of lower birth weights may reveal difficulties in service access after closure. These outcomes merit further investigation into the consequences of disruptions in access to maternity care in rural communities.

Unavailability of essential obstetric care services in a local government area of south-west Nigeria.

This paper reports the findings at baseline in a multi-phase project that aimed at reducing maternal mortality in a local government area (LGA) of South-West Nigeria. The objectives were to determine the availability of essential obstetric care (EOC) services in the LGA and to assess the quality of existing services. The first phase of this interventional study, which is the focus of this paper, consisted of a baseline health facility and needs assessment survey using instruments adapted from the United Nations guidelines. Twenty-one of 26 health facilities surveyed were public facilities, and five were privately owned. None of the facilities met the criteria for a basic EOC facility, while only one private facility met the criteria for a comprehensive EOC facility. Three facilities employed a nurse and/or a midwife, while unskilled health attendants manned 46% of the facilities. No health worker in the LGA had ever been trained in lifesaving skills. There was a widespread lack of basic EOC equipment and supplies. The study concluded that there were major deficiencies in the supply side of obstetric care services in the LGA, and EOC was almost non-existent. This result has implications for interventions for the reduction of maternal mortality in the LGA and in Nigeria.

El renacer de una sala de partos / A labour room is re-born

El Servicio de Urgencias Gineco-Obstétricas, conocido por “Sala de Partos” es un servicio con una actividad asistencial muy marcada por los pacientes obstétricas. También, existe un grupo notable de pacientes ginecológicas, a pesar de que esta última actividad representa un porcentaje mucho menor. El servicio tiene una voluntad universitaria muy acusada, aunque la investigadora se encuentra obstaculizada por la organización actual y por el gran volumen asistencial. La “Sala de Partos” (SP), está muy orientada a la demanda de la puerta de urgencias y a todas las intervenciones que de éstas derivan. La Dirección del Servicio de Obstetricia, se plantea la creación de una SP con mayor autonomía de gestión, orientada a un modelo organizativo basado en el proceso asistencia. En este caso se va analizar la estructura y la actividad e la SP actual y posteriormente se discutirán oportunidades de mejora en la gestión clínica y la eventualidad de la fusión o no con las urgencias ginecológicas (AU)

The obstetrics and gynecology emergency service, Known as the “Labour Ward”, is a service whose nursing care is highly marked by obstetrics patients. The “Labour Ward” is oriented to emergency demands and all the interventions deriving from this. This work analyses the structure and activity of the current Labour Ward and discusses opportunities for improving clinical management and the possibility of its fusion with gynecological emergencies (AU)

The relationship among cost, quality, and competition: an analysis of obstetrics services in Missouri hospitals.

An understanding of the relationship among cost, quality, and competition is vital to ongoing efforts of market-based health care reform. The objectives of this study were to introduce a distance-based operational definition of competition and to examine the relationships among competition, cost, and quality within the singular product and geographic market of obstetrics services at hospitals within the state of Missouri. Correlational results indicate that increased competition is related to both increases in quality of care and costs--the characteristics of a price-insensitive market. This has obvious implications on health policy debates focusing on enhancing market competition as an avenue for health care reform.

Pasantías funciones obstétricas esenciales

Presenta los contenidos a desarrollarse en las pasantías para el manejo de las funciones obstétricas esenciales de emergencia, con las que se pretende proporcionar conocimientos y desarrollar habilidades y destrezas en el personal de salud que atiende a la mujers durante el embarazo y parto en las diferentes urgencias obstétricas.

[Immigrant women and health services. Experience with hospital obstetric-gynecologic department (1992-94)]. / Donne immigrate e servizi sanitari. Esperienza nell'area ostetrico-ginecologica ospedaliera (1992-94).

In order to know more about immigrant women who have applied for obstetrical and gynaecological care and the results of these requests, data on those admitted have been analyzed at the obstetric and gynaecological ward of the general hospital of Perugia during the period from July 1992 to June 1994. The following observations were made: a) African and eastern european women comprised the group that most frequently applied for abortion; b) the percentage of cesarean sections was lower among foreign women than Italians women; c) with respect to average of all immigrant admitted for obstetrical pathologies, the largest group, according to the area of origin, was comprised of women from Africa and it was decided that the quality of obstetrical assistance received by this group should be verified.

Patterns of obstetrical care in single-hospital, rural counties.

This study used logistic regression to identify differences in community-level characteristics of small, rural hospitals that provided obstetrical services compared to those that did not. The hypothesis was that community characteristics, such as demographics, geographic location, and socioeconomic status influence the ability of rural hospitals to sustain obstetrical services locally. The sample included small (fewer than 100 beds) non-federal, general, acute-care hospitals that were the only hospitals in their nonmetropolitan counties with fewer than 50,000 people in 1989 (n = 963). Data came from the Area Resource File and the American Hospital Association 1989 Survey. The results suggest that: 1) hospitals in the South are much less likely to offer obstetrical services; 2) hospitals in counties with higher socioeconomic status, measured by unemployment rate and percentage of the population who are white, have an increased likelihood of providing obstetrics; 3) hospital ownership has a relatively strong association with the provision of obstetrical services; and 4) the same characteristics that predict a hospital has obstetrical services do a poor job at predicting which hospitals do not offer those services. These results encourage researchers to examine areas where hospitals do not provide obstetrical care, and to investigate the dynamic between community characteristics and provider and consumer behavior. This study suggests to policymakers that targeting vulnerable communities and promoting regional and alternative modes of delivering obstetrical services may be effective means to ensuring that rural women have equitable access to obstetrical care.