Study: Rural hospitals work hard to provide maternity care but face significant staffing and training challenges

Monday, March 23, 2015

A new study from the University of Minnesota School of Public Health finds rural hospitals may struggle to address staffing and training challenges in obstetric care.

Rural hospitals with fewer than 240 births per year were more likely to rely on family physicians and general surgeons to perform deliveries, while those with a higher birth volume were more likely to have obstetricians and midwives attending deliveries. Lower birth volume hospitals were also more likely to have labor and delivery nurses who were not specialized in obstetrics – that is, nurses who also worked in other areas of the hospital.  

The study findings were published online today in the Journal of Rural Health.

Approximately half a million babies are born each year in rural U.S. hospitals.  The study systematically investigates who provides the care for these births by documenting the types of obstetric care clinicians who are delivering babies in rural hospitals, their employment status, the relationship between hospital birth volume and clinician types, and the obstetric staffing challenges faced by rural hospitals. 

“The rural hospitals we surveyed were eager to talk with us about their work taking care of pregnant women in their communities. They were clearly committed to providing high-quality obstetric care, and reported a range of different models for doing so,” said Katy Kozhimannil, Ph.D., lead author of the study and assistant professor in the in the School of Public Health at the University of Minnesota.  

Kozhimannil and her colleagues surveyed obstetric unit managers at all 306 rural hospitals that do births in nine states (Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin). The analysis found five main challenges in staffing that rural hospital obstetric units face including scheduling, training, recruitment and retention of clinicians, variability in timing and number of births, and relationships between different units within the hospital. 

Key findings:

  • 77 percent of surveyed rural hospitals have obstetricians attending deliveries.
  • 55.3 percent of hospitals have family physicians doing deliveries.
  • In 32 percent of hospitals, midwives attend deliveries.
  • General surgeons perform cesarean deliveries in 58.1 percent of lowest-volume (<110) hospitals, but in none of the high-volume (>460) hospitals surveyed.
  • 55.7 percent of surveyed hospitals reported obstetric workforce changes over the last three years.
  • 36.2 percent of respondents said scheduling obstetric nurse staff was the most common challenge.

“Our analysis highlights the need to tackle the challenges of obstetric care workforce and provision in rural hospitals under the Affordable Care Act, especially for low-birth-volume hospitals,” said Kozhimannil. “We would recommend utilization and expansion of federal, state, regional, and hospital-systems level approaches to increase access to appropriate training during medical education and in clinical practice through programs including simulation training, telehealth, and interprofessional education.”