Stacy Longmore knew she'd be waiting awhile. Six months pregnant with her fourth child, she always reserved the morning's first appointment at the often overbooked Frankford Avenue Health Center.
Today, she had arrived 10 minutes late for her 8:30 a.m. obstetrics appointment, which the 32-year-old knew she would regret. She waited about three hours while other women, some who arrived after her, were called to the back for their prenatal checkup.
"Once you get into the [checkup] room, that part of the visit is fine," she says. "But, getting to that room is time-consuming. They serve too many people. They need a bigger practice for all the people."
Others have chosen to avoid this scene altogether. Aishia Muhammad has given up on clinics and hospitals; she and her husband delivered two of their five children in their North Philadelphia home. "You're waiting there so long," she explains, "you might as well have your baby while [you're] there because it's going to be nine months until you are seen."
Muhammad, who also works as a doula supporting expecting mothers emotionally throughout the pregnancy, sees a lot of first-time mothers delaying their first prenatal checkup or missing appointments because of these time constraints. "It definitely pushes first-time mothers away," she says. "It ends up being like a job and they miss a lot of school or work."
Overcrowding in obstetrics programs is not a problem exclusive to the city's clinics. Throughout Philadelphia and its suburbs, these programs are becoming crises for major hospitals, community hospitals and birthing centers. And, it's a trend that some worry could eventually compromise the health of women and their babies.
Since 1997, 13 obstetrics programs in southeastern Pennsylvania have closed, cutting the area's offerings by 28 percent, according to a September 2006 study by the Maternity Care Coalition (MCC), a Philadelphia-based group advocating for children and women's health through pregnancy.
That number will reach 14 at the end of May, when Temple University Health System's Jeanes Hospital in Fox Chase closes its OB program. Jeanes' closing will leave 28 hospitals and two birthing centers in the area, which in a year will deliver the more than 50,000 babies in southeastern Pennsylvania — about 20,000 of them in the city of Philadelphia.
But health care is not a normal business in which demand of a service ensures success of that business. There may be plenty of mothers-to-be looking for care, yet obstetrics programs are facing big financial challenges from soaring malpractice rates and low health-care reimbursement.
Earlier this month, Chestnut Hill Hospital riled mothers and health-care advocates when it announced the administration was reviewing the fate of its OB program. The review is ongoing, and a hospital spokesperson has said that doesn't mean the program will close, but Brooks Turkel, Chestnut Hill Health System CEO, says obstetrics programs are financially straining services to provide.
"Obstetrics has a very small profit margin," says Deborah A. Driscoll, professor and chair of the Department of Obstetrics and Gynecology at University of Pennsylvania. Add malpractice concerns, and programs that deliver fewer than 2,000 babies a year cannot survive.
In fact, Nancy Kirsh, executive director of The Birth Center in Bryn Mawr, says the center's malpractice premium jumped 93 percent this year. "It's hard to absorb that kind of increase," she says.
Compounding that, reimbursements from both public and private insurance cover only part of the costs. For obstetrics, reimbursement is particularly low because care is labor-intensive — a 22-hour labor and delivery will be reimbursed the same as a two-hour delivery, says William F. McCool, director and associate professor of Penn's midwifery graduate program. He also says there is less chance of surgery and extensive use of medical equipment, services that could lead to higher reimbursement.
With high costs closing some hospital programs, those remaining face overcrowding, which hurts the quality of care; it can even lead to the shuttering of some programs, like Jeanes.
"It may be more difficult for patients to receive early prenatal care; there will be limited access to care," Driscoll says. "Some hospitals may not have the physical capacity to care for an increased number of patients."
Ellen Felley, a doula who has participated in more than 400 deliveries in Philly area hospitals, says obstetrics programs will become unreliable as they overcrowd.
"We turn our lives over to the experts there. But women can't depend on their hospitals anymore to provide birthing care," she says. "We need to have healthy babies and healthy mommies."
Felley and Muhammad agree that the health of both the mother and baby could suffer because of overcrowding. "They aren't getting the personal care they should be," says Muhammad. "By the time they are in labor, they are clueless about almost everything going on with their bodies."
Abington Memorial Hospital, which delivers more than 4,500 babies per year, received additional patients after the closing of Frankford Hospital's obstetrics program last June. In preparing for Jeanes' closing, it's adding three beds to its natal intensive care unit.
Meg McGoldrick, the chief operations officer at Abington, says the hospital can expand to accommodate hundreds more that will likely arrive with Jeanes' closing, but if other programs close, such as nearby Chestnut Hill, Abington might see a problem.
"We can't just keep going up," she says.
At the Hospital of the University of Pennsylvania and Pennsylvania Hospital, the combined number of births is expected to reach a record high this year. "We're at capacity," says Driscoll of HUP, which is built to serve 3,600 deliveries but is projected to deliver about 3,700 this year.
Penn and HUP have accommodated the growing numbers by being "innovative about how we use the rooms and patient flow," she says. They use different rooms for pre-labor monitoring and operating rooms for Caesarean sections, and in the rare case that a natal intensive care bed is not available for a newborn, Driscoll says the mother will be sent to the other hospital to deliver.
But, she says the hospitals shouldn't just focus on increasing beds.
"We really need to focus on quality of care," she says, "and so there's only a limit to how many patients we can care for adequately."
Meanwhile, MCC is looking to the next mayor to find solutions. Last week, MCC provided each mayoral candidate with a list of recommendations, asking whomever is elected next November to talk with the area's health-care providers to glean from them what is needed to improve the area's obstetrics programs.
"We are no longer at a crossroads, we are in a crisis," wrote MCC Executive Director JoAnne Fischer. "While the birth rate remains steady, obstetric units continue to disappear.Each closure puts more pressure on remaining hospitals, increasing the likelihood that they, too, will decide to close their OB units."
Luckily, Longmore had her son Bayna more than two months ago, so she doesn't have to endure the long waits anymore. Still, she's concerned for the mothers who do.
"Sometimes, I didn't want to ask certain questions because I felt they wouldn't have time to explain it," she says. "Mothers are not going to get care as detailed as it could be. It's a revolving door."
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