HD56 - Establishment of Professional Guidelines for Obstetrical Care


Executive Summary:
House Joint Resolution 110, passed by the 1996 General Assembly, requested the Commissioner of Health to appoint a task force to establish professional guidelines for obstetrical care. In appointing the task force the Commissioner is directed to include representatives of the Virginia Academy of Family Physicians, the Virginia Obstetrical and Gynecological Society, the Virginia Chapter of the American College of Nurse Midwives, the Virginia Chapter, American Academy of Pediatrics, nurse practitioners, and the State Department of Health. The resolution specifies that such professional guidelines as may be established shall include, but not be limited to, prenatal care, detection of high-risk cases, and obstetrical consultation and referral.

A task force was formed and convened June 12, 1996 and July 31, 1996. In initiating its work relative to HJR 110, the task force examined the issues which prompted the request for this study and concluded that access to obstetrical care in rural areas of Virginia is the critical issue to be addressed. Lack of available consultation and appropriate referral has been identified as the primary barrier to obstetrical care across rural areas, not a lack of professional guidelines.

Perinatal issues examined by the task force included the following: standards of obstetrical care and neonatal care, provider availability and distribution, collaboration among providers including nurse midwifery practice issues and birthing centers. A mail survey of all family practice physicians including senior family practice residents was conducted by the Virginia Academy of Family Physicians in August, 1996 to assess the level of provider participation and interest in providing perinatal services in rural Virginia. Survey findings are provided in Appendix D.

The task force identified availability of providers as a major issue regarding access to obstetrical care in rural Virginia. The vast majority of obstetricians are located in urban areas because rural areas do not provide a sufficient population base necessary to support an obstetrical practice. Research shows that other professionals in rural areas such as family practice physicians, nurse midwives and nurse practitioners could safely and conveniently provide obstetrical services. Family physicians are more widely distributed across rural areas than obstetricians. While family physicians in rural areas outnumber obstetricians, very few family physicians practice obstetrics. Research has demonstrated that certified nurse midwives are capable of providing high quality, cost-effective care within their scope of practice. However, at least one third of the nurse midwives licensed in Virginia are not actively practicing. Those who are practicing, like obstetricians, are strongly concentrated in urban areas. Nurse practitioners are also concentrated in the urban areas, even though nurse practitioners provide a substantial portion of prenatal services in rural health departments and clinics.

The provision of risk-appropriate care for all pregnant women is dependent upon clear communication and cooperation among the professionals and organizations involved in providing perinatal services. The recruitment of an adequate number of professionals to rural areas could alleviate some of the maldistribution problem. The ability of providers to assess prenatal patients for any risk factors that require consultation or referral is basic to providing risk appropriate care. Open communication among providers is critical for referrals to be timely and appropriate.

The development of formal arrangements among providers of obstetrical services is complicated and dependent upon many variables at the local level. One variable is the introduction of managed care systems into communities. So far, the impact on the perinatal health care system is unknown. Standards of obstetric care are being determined by factors not only generated by the providers and their knowledge but by payers of care. For example, level of care may be determined by the source of payment not the standard of care or judgment by the provider. Many of these changes highlight the need for more communication among all the providers of perinatal services. The task force felt that efforts to increase communication among the professionals through collaborative educational experiences and professional groups would improve the quality of obstetric care.

Lack of affordable malpractice insurance and fear of litigation have been widely reported to have decreased the numbers of obstetrical providers. The consensus of the task force is that while increased malpractice risks have dissuaded providers of obstetric care from practice, other issues related to lack of collaboration and acceptance of family physicians, nurse midwives or nurse practitioners as obstetrical providers are important contributing factors. With increased communication and collaboration among all providers of perinatal services, there will be increased adherence to established guidelines and ultimately improve the quality of obstetric care. The recruitment of all types of providers into these rural areas is important.

Recommendations of the task force follow.

• Encourage all providers of obstetrical care to utilize established standards of obstetrical care such as Guidelines for Perinatal Care published by the American College of Obstetricians and Gynecologists and American Academy of Pediatricians in setting individual practice guidelines.

• Request the Board of Directors of the Virginia Birth-Related Neurological Injury Compensation Program to consider markedly reducing the premiums for the first several years for any health care provider who provides obstetrical care in rural Virginia.

• Request that the three medical schools develop memorandums of understanding between their Departments of Family Practice and Obstetrics/Gynecology in providing clinical rotations to assure adequate obstetrical experience for family practice physician residents.

• Request that the Virginia Academy of Family Physicians, in cooperation with the Virginia Department of Health and other appropriate local representatives, explore the development of a financial incentive package that would attract providers of obstetrical services to rural Virginia.

• Request that the Virginia Academy of Family Physicians and the Virginia Section of the American College of Obstetricians and Gynecologists hold a meeting to discuss practice issues and develop solutions to problems related to collaborative practice. Subsequent to that meeting, the Virginia Academy of Family Physicians and the Virginia Section of the American College of Obstetricians and Gynecologists should convene a second meeting and include certified nurse midwives and nurse practitioners.

• Request the Regional Perinatal Coordinating Councils to increase participation of obstetricians, family practice physicians, certified nurse midwives and nurse practitioners on their councils.