Relationship of infant mortality to the availability of obstetrical care in Indiana

Journal of Family Practice, Dec, 1991 by Deborah I. Allen, Jeffrey M. Kamradt

Indiana has an alarmingly high infant mortality rate; the most current statistic is 10.99 deaths per 1000 live births in 1989. [1] For mothers who obtained the necessary and adequate prenatal care, however, infant mortality rates are very low. [1] An important determinant of adequate participation in prenatal care by expectant mothers is whether they have eay access to that care. In a recent study, McDonald and Coburn [2] demonstrated that when a long travel time is required to visit a povider, the likelihood of a pregnant woman receiving adequate prenatal care decreases. Nesbitt et al [3] found taht in counties with proportionately smaller numbers of providers, there were greater proportions of complicated deliveries, higher rates of prematurity, and higher costs for neonatal care.

There has been little discussion about access to physicians' services by Indiana's rural communities; to date, the emphasis has been placed on economic barriers and access to care in urban areas. [1] This study was undertaken to determine whether the current supply of family physicians, general practitioners, and obstetricians in Indiana is sufficient to provide adequate prenatal and obstetrical care in nonmetropolitan counties.

Indiana is primarily a rural state, with 62 of its 92 counties considered nonmetropolitan. The other 30 counties are within a standard metropolitan statistical area (SMSA) and are considered metropolitan. An SMSA is a county or group of counties within which there is at least once city with a population of 50,000 or more. Traditionally, nonmetropolitan obstetrical care has been provided by family physicians and general practitioners. Many of these physicians, however, are no longer providing obstetrical care because of increasing malpractice premiums and heightned fear of litigation. [4-12] In the period from 1987 to 1990, the percentage of American Academy of Family Physicians members who included obstetrics in their practice decreased from 41% to 29%. [13,14] Studies done in other states confirm this decrease in family physicians' participation in obstetrics. Smucker [15] documented a decrease in obstetrical practice by Ohio family physicians from 54% in 1975 to 16% in 1989. Similar trends have been demonstrated in Alabama, Arizona, Missouri, Mississippi, Oklahoma, and Oregon. [16-21] Rosenblatt et al [22] found that during a 6-year period (1982 to 1988), 10% of the obstetricians and 32% of family physicians had discontinued obstetrical care but remained in practice in the state of Washington. The decreasing number of family physicians participating in obstetrics as well as the rural character of Indiana may impair a woman's opportunity to receive adequate prenatal care.

Methods

A list of family physicians, general practitioners, and obstetricians currently providing obstetrical care in Indiana was accumulated. The list was assembled through two sources: a "physician profile" created in 1990by the Indiana Academy of Family Physicians (IAFP), and a survey of Indiana hospitals.

For the IAFP profile, a 1-page questionnaire was mailed to all physicians licensed to practice medicine in Indiana requesting demographic, educational, specialty, and professional practice information. At the time of our study, 84% of Indiana physicians had returned the questionnaire. The nonresponders were similar to the respondents when compared by age and specialty.

Information concerning physicians who responded yes to the question "Do you accept obstetrical patients?" was acquired from the IAFP profile, and an original list of 1288 physicians was compiled. From this information, the physician's county of practice and self-designated specialty were determined. This group was na4rowed by removing physicians who did not deliver babies but provided other care for obstetrical patients (eg, radiologists, neurologists, and anesthesiologists). Only physicians in the specialties of family practice, general practice, and obstetrics were counted. The resulting list included 944 physicians.

The second source of physicians was a 1988 list f physicians having obstetricla privileges in Indian hospitals. This list, provided by Dr David Marrero of the Regnestrief Insitute at the Indiana University School of Medicine, was generated by contacting each hospital in Indiana and requesting a list of physicians with obstetrical privileges. This list consisted of 957 physicians.

The two lists of physicians were compared, and physicians whose names appeared on both lists were considered to be currently providing obstetrical care. The office of each physician whose name appeared on only one of the lists was contacted by telephone to determine whether the physician was still providing obstetrical care; the names of those who were not were removed from the list. An additional 104 physicians were removed from the list because they had retired, their telephone lines had been disconnected, or they had moved out of state. The final list of physicians providing obstetrical care in the state of Indiana consisted of 996 names.