COMMENTARY

What Happens to Babies When Regional Obstetrical Units Close?

Bouncing Back From an Early Surge in Neonatal Mortality

Scott A. Lorch, MD, MSCE

Disclosures

February 09, 2015

Editorial Collaboration

Medscape &

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My name is Scott Lorch. I am associate professor of pediatrics at The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania. I am here to talk about our study,[1] looking at the lessons learned from the closures of obstetric units in the Philadelphia region from 1997 to 2012. For those who are not familiar with this issue, 13 of the 19 hospitals that were delivering babies in 1997 had closed their obstetric units by 2012, which has led to a change in how women access obstetric care in Philadelphia. As we have shown in previous studies,[2] at least initially, this affected the outcomes of babies, with approximately a 40% increase in neonatal mortality rates in the first 3 years after the closures began.

This is important, because with the passage of the Affordable Care Act, we are starting to see more mergers between hospitals (which reduces geographic access to healthcare) as well as changes to the types of services that patients are receiving at individual hospitals. Because the Philadelphia closures were unprecedented and offered a good example of what can happen with these closures, we interviewed 23 key stakeholders in the remaining units where babies were still being delivered in the Philadelphia region and the suburban counties between 2012 and 2013. These stakeholders included obstetric unit chairs, labor and delivery chairs, nurse managers, and other key obstetricians and nurses.

We asked several questions about how their units responded to the global closures of obstetric units in the Philadelphia region. The participants identified several key facts. They confirmed what we already suspected and had shown about the reasons for such closures, emphasizing the financial issues surrounding the delivery of obstetric care, which includes poor reimbursement and high fixed costs for the delivery of care to pregnant women. They explained that when the units closed, their own units experienced substantial surges in volume that were associated with concerns about how babies were being delivered, the quality of care that pregnant women were receiving, and staff morale, because they were facing almost unprecedented numbers of women who were presenting to deliver at their hospitals.

The closures also changed the case mix of patients who were delivering at these hospitals, because these patients were often coming from further away in the Philadelphia region, or even from outside of the Philadelphia area, to deliver at their hospitals. This fragmentation of care between where the women received prenatal care and where they delivered could cause some difficulties in the delivery of their babies.

The key stakeholders identified two main changes that they were forced to undertake in response to the surge in volume. First, they were required to make a dramatic change in their staffing models, increasing the number of obstetricians and other obstetrical care providers (such as midwives) to deliver the babies, as well as increasing the number of nursing staff members. Secondly—and this is something that was brought up as a long-term issue—was the need for the building of more units, more beds within the units, and the need to anticipate these volume increases in the planning stages in a 3- to 5-year period to increase the number of beds on the labor and delivery floors to help deliver the babies.

Finally, and probably of greatest importance, the key stakeholders identified the importance of communication between the units that were remaining open to absorb these volume surges in order to be able to anticipate surges as well as coordinate the timing of the closures so that the remaining units were able to handle the extra women—and that the women knew that they needed to go to a new place to deliver their babies. Without this communication, the delivery of care could be hampered not only on the provider side, but also on the patient side in terms of patients reaching those hospitals that they may not previously had delivered babies at, or even set foot in, on time.

This project is very important, because it emphasizes the need for good communication between providers, and also between the healthcare system and patients, when such a shock to the system as a merger or a closure of a hospital occurs. Otherwise, we run the risk of having adverse outcomes, such as poor birth outcomes, both short-term and long-term, for the children who are being delivered by these women. This project also emphasizes the importance of communication between providers who may also be competitors in the market, and this communication could be facilitated through governmental bodies or such extragovernmental bodies as health departments or other entities. Thank you.

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