hospital birth, Uncategorized

Rising Maternal Mortality in the US: Real or Just Hype?

The statistics are staggering.

The high maternal mortality rate in the US has been a matter of great interest and debate, spurring a reflective look into our healthcare system to determine why our country is on the wrong end of this statistic. The reasons and numbers vary across the country and notably in the state of Maryland, which has had a higher than average maternal mortality rate, the number of maternal deaths continues to increase at a rapid pace.

In a comparison of two study periods (2005–2009) to (2010–2014), while the maternal mortality rate increased by an astounding 32% nationwide, it increased by an even more astounding 51% in Maryland. https://www.acog.org/-/media/Sections/MD/Public/MarylandMMRposter2017.pdf?dmc=1&ts=20170927T1731113112

I must admit, as an obstetrician-gynecologist I was skeptical of the media hype regarding maternal mortality in the US (compared to other countries with less advanced technology and more limited access to medications and high quality medical care).

However, there is no denying the fact that the rate is indeed increasing. As I think about these statistics, it becomes clear to me that there are two major crises in the field of women’s health.

Maternal Mortality

The causes vary, but as discovered in the “Maryland Maternal Mortality Review Program” in 2014, the leading cause of death of pregnant women was substance abuse disorder – unintentional overdose. Meanwhile, the leading cause of death directly associated with pregnancy was hemorrhage.

Death by drug can be experienced by anyone, but death directly associated with pregnancy can only be experienced by the pregnant. This difference is important. 

On news outlets, social media, and magazines you have likely heard stories about the loss of a pregnant mother or postpartum patient under horrible circumstances of medical negligence or some preventable health cause. These stories are heartbreaking and infuriating and should not happen, especially in this country. These types of stories also bring ratings, clicks, followers, etc. and are unfortunately also a contributing cause for the growing distrust of physicians based on a very small minority picture of the problem at hand.

The important piece to consider is that a woman who overdoses while pregnant is also considered in overall pregnancy death statistics. Again, overdose was the #1 cause of pregnancy-associated death. The US is facing an opioid epidemic and pregnant women are not spared from this.

Substance abuse prevention and treatment programs during pregnancy will be paramount in reducing the number of maternal mortalities.

More research is needed to determine the complete impact drug use is having on our maternal mortality statistic.

Hemorrhage treatment is also an area where we can improve, and an effort has been made to have massive transfusion protocols and training in hospitals. This is a start.

Ob-Gyn Shortage

Is our country’s shortage of obstetricians linked to our high maternal mortality rate? I don’t think we have the evidence to support this notion. However, we may start to see concerns in the coming years as this shortage becomes more pressing.

The American Congress of Obstetricians and Gynecologists (ACOG) put together a workforce to assess the situation. https://www.acog.org/-/media/Departments/Government-Relations-and-Outreach/WF2011NV.pdf?dmc=1&ts=20170927T1856198056 Facts that emerged are as follows:

images

In the state of Nevada there are 11 (out of 17) counties without a single practicing ob-gyn. Nevada’s female population is expected to increase by 64% by 2030, while the total US female population is expected to increase by 17%.

There are 2.08 ob-gyns per 10,000 women in this state.

By the year 2030, the US is expected to have an 18% (9000) shortage of ob-gyns.

These numbers are outrageous and it is obviously not limited to the state of Nevada, but a nationwide concern. What is causing this ob-gyn shortage, seen not only in Nevada but across the country? Well, the task force also noted an increase in the population of women in the US of 26% since 1980, but the number of ob-gyns trained has remained stagnant due to limited residency training spots (which are still filling each match day). Medical students still remain eager to enter the field of ob-gyn, although with some trepidation and concerns regarding lifestyle and malpractice premiums/lawsuits. The problem arises after they finish residency.

We are starting to see an aging ob-gyn workforce. In addition, physicians are working decreased hours and are retiring early from obstetrics. More recently, ob-gyn residents are opting to avoid obstetrics altogether and are choosing to sub-specialize at increasing rates in fields such as Minimally Invasive Gyn Surgery, Urogynecology, and Gynecologic Oncology. Work-life balance can be better in these fields and malpractice premiums are also much lower. Maintaining our current ob-gyn workforce should be top priority. This starts with supporting them by finally obtaining meaningful liability reform, sustainable working conditions, a positive PR campaign, and increasing the number of residency spots (especially in states such as Nevada with urgent needs).

If we don’t address the obstetrician shortage, we will burn out the ones still in the field. It is not good for our physicians, or more importantly, our patients to have a limited supply of medical knowledge and expertise. In our efforts to decrease the maternal mortality rate in the US, the ob-gyn shortage must also be addressed.

 

hospital birth, retirement

Is your City on the list for the coming Ob-Gyn Shortage Crisis? Find out here…

New research released this week from Doximity looked at how the upcoming Ob-gyn shortage will be affecting certain cities more than others. This really hits home for women who are planning families, currently pregnant, and wish to deliver in a hospital in one of those cities most at risk.

 
OB’s in these cities are likely feeling the pressure from the increased workload. Doximity compared number of deliveries in each city to number of practicing Ob-gyns.

 
Cities with the biggest workload per Ob-gyn:
Riverside, CA
St. Louis, MO
Las Vegas, NV
Oklahoma City, OK
Phoenix, AZ
Houston, TX
San Antonio, TX
Los Angeles, CA
Dallas, TX
San Diego, CA

 

Please note that these are major metropolitan areas and not the rural locations we often think of when mentioning the coming “ob-gyn shortage”

 

Smallest Ob-gyn workload: (lowest birth to OB-GYN ratios)
Hartford, CT
Richmond, VA
Louisville, KY
San Jose, CA
Birmingham, AL
Boston, MA
Portland, OR
San Francisco, CA
New York, NY
Providence, RI

 
If you want concrete numbers, ratio of births to Ob-gyn is 248 in Riverside, CA compared to the low end of 58 births to Ob-gyn in Hartford, CT.

We know the higher workloads mean that those cities are hurting for more Ob-gyns.
Interestingly, the research also looked at percentage of Ob-gyns older than 55 in these cities as that is important when considering when these doctors will be retiring. In Las Vegas, a whopping 39% of Ob-gyns are older than 55. According to ACOG, average age of retirement for Ob-gyns 59-69.

images

What does this mean for cities like Las Vegas? They will be feeling this shortage intensely, and really soon.

 
The reality of the matter is that most Ob-gyns actually drop the OB part of their practice much earlier due to the physically demanding lifestyle an on call Obstetrician’s schedule entails. ACOG has reported the average age to stop doing obstetrics to be 48 years old.  In addition, we are not seeing a big enough influx of younger ob-gyn’s to take their place.

There has been a dramatic increase in residents choosing to sub-specialize in Reproductive Endocrinology, gynecologic oncology, minimally invasive surgery, and pediatric gynecology. Most of these specialists do not deliver babies. In addition, we are even seeing less subspecialists in maternal fetal medicine (MFM) willing to do deliveries anymore.

 
So, here is the crux of the matter: Ob-gyns are aging, retiring early, and choosing sub specialization at increasing rates. However, the number of patients seeking care has exploded due to health care reform and population statistics.

 
Some possible ways to address this include:

 
1. Increase number of Ob-Gyn residency spots (perhaps even consider specifically increasing in areas at greatest risk of shortage). Often Ob-gyns continue to work in the area of their residency where connections are made and their lives have become settled.

 
2. Support currently practicing Ob-gyns and provide the infrastructure necessary to maintain this workforce. This can mean utilizing midwives or nurse practitioners/physician assistants to answer phone calls at night, triage patients in the ER and labor and delivery, and write admission notes and prescriptions. This leaves more time for the obstetrician to focus on the patient and provide the best possible care as needed for complex deliveries, cesarean sections or high risk patients that are increasingly at the doorstep.

 
3. Malpractice reform. Residents are choosing to go into a field where there are told to be prepared to get sued 2-3 times during their career (perhaps even without any negligence or merit to a suit). Are there bad doctors out there? Yes. Are they in the overwhelming minority? Yes. Should all ob-gyns practice medicine in an environment of fear with defensive medicine because of a few bad apples? NO. This current litigious system is not helpful to our patients or our practicing ob-gyns.

 

If you are an Ob-gyn, would you consider practicing in one of these locations? What are your thoughts on the coming Ob-gyn shortage?
Are you a resident who is subspecializing to avoid obstetrics?

Patients- are you feeling the shortage already? Is it hard to get an appointment or see a physician? Are you already seeing midwives or nurse practitioners? Do you live in one of these cities?

If you are interested in this topic, you can read more about it in recent news coverage:

https://www.yahoo.com/news/growing-shortage-ob-gyn-doctors-threatens-womens-health-150842816.html

https://www.statnews.com/2017/07/20/ob-gyn-shortages/

 

birth plan, epidural, episiotomy, hospital birth, Physician Training

10 Things to Know Before You Have a Baby in the Hospital

 

  1. You might get sent home. If you show up pregnant with your first baby and it turns out you aren’t 4 cm dilated yet, you will get sent home because you aren’t in active labor. Please don’t cuss out the charge nurse.   Yes, you are in pain- we aren’t denying that.  However, there are limited numbers of beds on labor suites and we need to keep some open for people who will likely roll in right behind you and will deliver way before you. There are no appointments on L & D (labor and delivery) and you never know what will come in.  Space and open beds are the issue, not laziness of admitting physician.

 

  1. Limit it to 2 guests during delivery. More than that is just a distraction.  If there is an emergency, the last thing we want to be worried about is having enough room to take care of you appropriately without people being in the way. In a true emergency about 10 medical professionals will come barging in your room within seconds and if someone is standing in the way it prevents us from doing our job.

 

  1. Ask for the epidural early. If you plan to wait and see how it goes, likely you won’t have time to get an epidural before baby makes the big entrance.   Murphy’s law will dictate that every pregnant patient on L & D will need one at the same time and there is usually only one anesthesiologist, who will invariably be back in the OR with a C-section tied up for half an hour.  Don’t miss your chance!

shutterstock_538993768

 

  1. You can have a birth plan, but please have it read as follows: I want to leave the hospital with a healthy baby and Mom.  Anything more than that and we get superstitious.  It’s just like the old wives tale about the full moon and people going into labor- there is no scientific evidence to back it up but we all believe it’s true and witness it happen all the time.  The longer and more detailed your birth plan, the higher the percentage likelihood you are to end up with a C-section. At least it always seems to work out that way.

 

It is true that you can expect to have more interventions and temporary discomforts while having a baby in the hospital as opposed to a home birth.  Expect to not eat when in active labor, have monitors strapped to your stomach and frequent vital sign evaluations.  In my opinion, these are small sacrifices to pay to ensure healthy baby and Mom.

 

 

 

  1. Contrary to popular belief, we love when you bring a Doula to the hospital with you! They help you through your labor, make sure your needs are met, and encourage you through pushing.  They are an OB/GYN’s best friend!

comforting

  1. Prepare to not eat food for a while. We are not doing this to be mean. We are doing this because having a baby is dangerous. At any moment you could become a surgical patient. If you vomit and aspirate, this could be dangerous for your health. Nobody wants to have a newborn baby, aspiration pneumonia and recover from surgery all at the same time.

 

  1. We are going to press on your abdomen/uterus after the placenta delivers. I have seen patients get downright angry about this. The reason behind it is that after the placenta comes out, the uterus can become very floppy and you can quickly lose a liter of blood. Massaging the uterus helps with the tonicity and also helps your doctor assess whether there is a problem or if more medications are needed to avoid a hemorrhage.  Just because the baby AND the placenta are out, there is still a need for assessment. You are almost done!

 

  1. Don’t try to rush the OB who is suturing you after you tear with delivery. Episiotomies aren’t routine anymore and are typically only done when medically necessary.  However, it can be very common to tear on your own with a first baby.  Let your OB take their time and do it right, trust me.  10-20 more minutes of meticulous care will be well worth it in the long run, especially if you were “blessed” with a 10lb baby.

 

 

 

  1. Send your husband to get your ice chips. Let your nurse focus on your vital signs, evaluate the fetal monitoring, and document your progress.  Your husband/support person should be the one getting you the much needed ice.  Besides, it will help your partner feel useful at a time when they are often struggling over lack of control and they want to help you in any way they can.

delivery.jpg

  1. You are in competent hands. A normal labor can turn into an emergency at any moment, even in a low risk patient.   In any given day, L & D will have a woman hemorrhage after delivery.  In the next room, the newly delivered baby may not be breathing. 2 doors down a patient just had a seizure and dangerously high blood pressures as her preeclampsia progressed to Eclampsia.  Down the hall a shoulder dystocia occurred.  This happens when the baby’s head emerges but the shoulders are too wide to deliver and asphyxia of the infant makes seconds feel like hours until skillful maneuvers can safely deliver the baby.  I mention these scary but common scenarios because the best thing about having a baby in the hospital is that you are surrounded by scores of people that are trained to handle these exact situations and do so every single day.

 

 

hospital birth, Parenting, Physician Training, Uncategorized

Mother’s Day on Labor and Delivery

Mother’s Day weekend is a great time to be the ob-gyn on call for deliveries at the hospital.  Of course, we physicians would love to be snuggled up next to our little ones on this special day.  However, the next best place to be is bedside with a woman about to become a first time mom.

The new mom is unaware how her life will change. Sure she has had countless advice from well-meaning friends and family. What diapers, breast pumps, sleep sacs, and toys are essential and how to handle the sleepless nights and messy house are all topics of endless conversations these days.

Labor stories abound and she has heard 50 different versions of what could happen during the process and how it didn’t always go the way it was expected.  Everyone has their own struggles and triumphs to share but most of the stories end with a healthy baby and a physically exhausted mom who may be hurting from delivery or surgical wounds but exhilarated in the way only a new mom can understand.

puppyhat

Little does she know, she will never be the same person.  Her body will never be the same.  Her heart learns to expand to be able to love exponentially more with each child she has. Her needs now become secondary to those of another, and she will gladly have it this way.  She experiences life with a different view and understanding of others and thinks of random strangers as “someone’s son or daughter”.  She finally has a better appreciation for her own mother and understands her love in a much deeper way.  To help deliver her baby and be a very small part of this transformation is a unique gift.  Watching it unfold as her newborn is placed in her arms for the first time is one of the most gratifying experiences as an ob-gyn, and for a moment everything is blissful.

But there is also a different group of women that are sometimes forgotten on mother’s day.

040

On Mother’s Day, many other patients are also on my mind.  The patients who have struggled with infertility for years. The patients who have suffered miscarriage, possibly multiple times. The patients who have lost an infant shortly after birth, or many years down the road. This day weighs especially heavy on them.  It forces them to deal with their hurt.  It resurfaces pain and brings memories to the front of their mind that are always lurking in the background. I have been on this journey with many of them.

While celebrating the wonderful women in my own life and the people who are getting to experience the world of motherhood for the first time, I stop to remember and include the women who are forever changed by the short life of a child, pregnancy that ended too soon, or the indescribable desire to become a mother.

 

hospital birth, Maternity Leave, Parenting, Physician Training

Open Letter to a Child of a Doctor: To My Daughter on Her 9th Birthday

It was the end of my 3rd year in ob-gyn residency.  I was 39 weeks pregnant with you and doing a hysterectomy, my gravid abdomen being utilized as an “extra hand” to displace the large clamp nicely to the side as I pressed my belly gently against the table. I was doing surgery all day and loved operating and feeling your occasional gentle movements when in the quiet operating room as I was working. I knew my days were limited with us being one. 

It was sometimes hard to breathe with the mask covering my face from the natural air hunger that can sometimes accompany pregnancy. I would have the OR nurse gently loosen my mask and take a deep breath.  Worried about you, I wanted to make sure you were getting enough oxygen.  After my last case was finished, it felt so good to drive home and rest sitting down after standing all day.  This was my favorite time of day as you moved the most on my way to and from work while I was still and I could concentrate on just you.

Later that same day I went into labor and your Dad drove us back to the same hospital where I was operating earlier that afternoon.  He was nervous but I knew you were safe and we had a long journey ahead of us.

When you finally made it into my arms 19 hours later I was exhausted and exhilarated all at the same time.  Looking at you, I finally understood what it meant to feel like your own heart was outside of your body. You were perfection and I didn’t know how I could make something so beautiful. I still feel that way.

I spent a precious 6 weeks at home with you but had to return to work and help other women bring their own miracles into the world.  I hoped you would grow to understand that I of course always wanted to be with you, but also felt a pull to continue my path as a doctor.

That first year was tough.  I was working 80 hours a week and there were some days when I only got to see you an hour a day, or when on call not at all. Those days were torture. You were often asleep for the night before I got home. There may have been more than one occasion when I sneakily scooped you out of your crib while you were still asleep and rocked you in the middle of the night so that I could have that precious time with you.  I knew you were well cared for during the day, and it was me who needed this snuggling more than you.  I missed you so much during those times.

It got better over the years as my work load became manageable and I got to feed you breakfast in the morning and dinner at night. We would play before bedtime and I could see that you were thriving and my guilt for leaving you during the day lessened.  Your pictures covered my desk at work and your smiling face was plastered all over my bulletin board along with the babies I have delivered.

After you were born, I was also changed as a doctor.  Delivering a baby wasn’t the same.  I empathized more with my patient in pain, begging for an epidural. I understood the fear before a C-section.  The first cry from a baby I delivered brought me back to hearing your first cry every time.  Unfortunately, the losses my patient’s experienced also hit me 5x harder as I felt their pain as only a parent could.  I think you made me a better doctor.

 I’m sorry I missed your field trips at school.  I so wanted to be there but work requires 6 month notice for a day off and schools don’t often understand this.  I’m sorry I would forget to send you in with crazy hair on “crazy hair day” or miss a deadline for a book fair.  I was doing the best I could juggling surgeries, being up all night at the hospital delivering babies, and seeing patients in the office all day. Despite all that, you were always in my thoughts.

I hope when you are older you will understand the sacrifices and more importantly how much I love you.  You will know a different mother than your much younger brother and sister.  You will remember me coming home in scrubs exhausted after a 30 hour call.  You will remember me leaving your soccer game early to go to the hospital to deliver a baby.

However, I also hope this will help you to see that you can do it too.  Maybe not a career in medicine, but whatever you want to do.  I could see you as an artist, singer, scientist, entrepreneur… the list goes on.  Knowing what a fantastic person you are turning out to be lets me know that it is possible to be a good doctor and also raise a wonderful child. To have a career and also give your children the love they need.  I am fortunate that I will have more time with you moving forward, and I am so happy for that, but I don’t regret our past.  It has made us both who we are today and I couldn’t be more proud.

hospital birth, Physician Training

Who Will be Delivering Babies in the United States in Coming Years?

The American College of Obstetrics and Gynecology (ACOG) estimates that the U.S. will have between 6,000 and 8,800 fewer ob-gyns than needed by the year 2020.  Additionally, there is a possible shortage of 22,000 by the year 2050. 

What is being done about this problem?  Well, there are currently efforts to attempt to increase the number of residency positions.  There is also talk of having nurse midwives take a greater role.  While those are valid interventions, let’s take the issue much deeper, as that is certainly not doing enough to mitigate the problem.  Perhaps of equal or greater importance in the consideration should be retaining practicing ob-gyns and malpractice reform.

 The current work force in Obstetrics and Gynecology is aging, retiring early, and going part time at an increasing pace, all while the number of patients seeking care is exploding due to health care reform and population statistics.  While access to maternity care and women’s health services is vitally important, we need to have infrastructure to support the numbers or these women will have no ob-gyn to turn to despite having insurance. Even if the number of residency spots increases, the attrition of those already in the field must be addressed.

 Today, over 80% of physicians entering the field of ob-gyn are women.  Shockingly, if you look at hospital department chairs, academic medical institutions, and leadership positions in the field it is overwhelmingly male despite the preponderance of women who are practicing and are the future of ob-gyn. In order to appropriately assess the changes and adjustments that need to be made to the field, including what will draw in and retain candidates, we should be asking that very demographic that is accounting for the majority of ob-gyns. This means that women need to be “at the table” for discussions and interventions impacting our field. Women want to be invited to be a part of the change and are willing to step up to the challenge.

 As for malpractice reform, this is vital not only to obstetrics and gynecology, but the entire medical system.  Defensive medicine is valuable to no one and a waste of precious health care dollars.  In addition, increasing numbers of midwives to assist with a shortage will only be helpful if ob-gyns are willing to provide a supportive role.  As it is now, ob-gyns can named in a lawsuit by malpractice attorneys who seek damages for birth injury cases where a labor occurred at home.  These patients often arrive at the nearest hospital’s doorstep seeking help after a failed home birth or bleeding concerns. The attending ob-gyn physician must (and should) accept care for anyone arriving seeking help.  However, if there is a bad outcome, it must be somehow proven when damage occurred.  Was it during the unmonitored 30+ hour home birth or the 30 minutes from when the patient arrived to the hospital prior to an emergent cesarean?  Obviously, no one wants a poor outcome for the patient and blaming each other is not a solution.

 A solution is malpractice reform where a physician does not need to worry that if they are called to help in a complicated case that they will now be liable for whatever happened prior to their involvement with care. Certified nurse midwives, especially those working in a hospital or birthing center, will likely have a huge role moving forward in our field. There are many fantastic midwives who bring valuable assets to the table.  Ob-gyns should be willing and ready to work as a team for improved patient outcomes. 

 Lastly, malpractice reform is important because rising malpractice premiums are a huge part of why private practice ob-gyn is becoming a thing of the past. Understandably, it is hard for a practice to survive while paying $80,000 for yearly malpractice premiums, then staff, then rent for office space.  Somewhere the ob-gyn is expected to make a living, but the private practice ob-gyn is struggling. This is why new residents accepting jobs are looking for employed positions which will provide tail coverage and protection from this concern. While employed positions certainly have their benefits, one of the major drawbacks we are seeing is loss of physician autonomy and control over our field.

 Moving forward, physicians need to have a larger voice in reforms that are taking place in health care. Especially in the field of ob-gyn, female physicians need to be an integral and valuable asset to improving the field by working alongside the people currently contributing to the changes.  While the voices from our government, lawyers and insurance companies are important and necessary, they should not be muting the voices of the physicians who are the ones providing care for our patients and have the patient’s best interest most at heart.  This communication will be vital in continuing to have a robust ob-gyn work force ready to handle an increasingly complex and high risk patient population in the United States.