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

The comparison between physician availability and infant mortality is displayed in Figure 2. A Pearson's correlation coefficient of -.38 (P > .02) was obtained for this graph. An R [2] of 14.44 was determined from thios graph. This implies that 14.44% of Indiana's infant mortality in nonmetropolitan counties is explained by a lack of physician availability. The analysis indicated that this relationship was statistically significantly using a two-tailed t test (P < .02).

Overall, the state does not have a shortage of physicians providing obstetrical service; rather, there is a serious maldistribution of physicians. Populous metropolitan counties have a substantial excess of physician services, while many nonmetropolitan counties are grossly underserved. This particular example rof maldistribution is representative of the situation for all physicians in Indiana. Eighty-two percent of Indiana's physicians practice in metropolitan areas, [24] whereas, only 68% of the residents live in metropolitan areas.

There is a significant shortage of physicians providing obstetrical care in over 45% (42/82) of Indiana counties. In nonmetropolitan counties the situation is worse int hat only 30% (19/62) have sufficient availability of obstetrical services. If the surplus physicians providing obstetrical care in oversupplied counties were redistributed to counties with shortages, every county would have sufficient availability of services. Furthermore, a surplus equal to the obstetrical services provided by 90 obstetricians or 359 family physicians would remain.

Discussion

This study finds that physician availability to provide obstetrical services is related to Indiana's infant mortality. Approximately 14.4% of the variance in infant mortality in nonmetropolitan counties is explained by the measure of physician availability. To effectively address the problem in the state, Indiana must closely examine the flow of physicians in and out of its rural counties. Also, specific programs to encourage physicians to enter family practice in rural counties need to be developed.

The analysis of the study shows that 53% (49/92) of all Indiana counties and 66% (41/62) of the nonmetropolitan counties do not have an obstetrician providing obstetrical care. These counties are dependent on family physicians for obstetrical care; however, like other states, Indiana is faced with a decreasing number of family physicians offering this service. In 1980, 45% of family physicians in Indiana included obstetrics in their practice. [25] The American Academy of Family Physicians indicates that 39% of family physicians currently practice obstetrics in the census region containing Indiana. [14] According to this study, however, the percentage including obstetrics in Indiana has dropped to 37%. If this decline continues, more nonmetropolitan counties may be without physicians porviding these services in the future.

There are inherent problems with this type of survey. The study used 1989 natality data (the most recent natality information available) from the Indiana State Board of Health; however, the supply of physicians by county is calculated with 1990 data. A majority of Indiana counties were expected to experience an increase in population between 1987 and 1990, [26] so the results may actually be an underestimation of needed physicians. Also, individual physicians may actually be providing more or less obstetrical care than estimated. National averages were used in this analysis and should reflect the trend in Indiana. Patients may also seek care in a surrounding state; this probably occurs frequently in those areas of Indiana that are within commuting distance to Louisville, Cincinnati, and Chicago.