Clinicians at a federally qualified health center are collaborating with their colleagues at a nearby medical center to operate a four-bed labor and delivery unit.
They're bucking a trend in Centreville, AL.
Most rural hospitals in Alabama closed their obstetrics programs decades ago, owing to a combination of low volumes and high costs and liability. Instead, expectant mothers were sent to the nearest big city hospital for deliveries.
Last November, Centreville's Bibb Medical Center opened a new, four-bed labor and delivery unit that is on track to deliver about 100 babies in its first year. The opening marked the first time in 20 years that babies have been delivered in Centreville, located about 53 miles southwest of Birmingham.
Obstetrics a Money-Losing Challenge for Rural Hospitals
Despite the low volume, averaging eight to 10 births per month, the program works because of a commitment and collaboration between Bibb administrators and clinicians and their colleagues at the nearby Cahaba Medical Care, the town's federal qualified health center, and the Cahaba Family Medicine Residency Program.
"We have a good relationship, and that is not always a foregone conclusion," says John B. Waits, MD, a family physician, CEO of the FQHC, and director of the residency program.
"It has been a very deliberate intentional relationship, where we have cultivated trust with each other, given a little, taken a little, and it is a very positive symbiotic relationship. Often there is a firewall between hospitals and ambulatory, but our model is completely different."
While there is risk and cost associated with such a low-volume service line, Waits says the hospital, the FQHC and the residency program each gain something, too.
"For the hospital, having a maternity center means having more volume in the hospital as a whole and better relationships for mothers bringing their children back for services," Waits says.
"That doesn't make them whole, but the second piece is that we have built a family medicine residency in a rural area to address the workforce disparities. To be accredited, we need to have maternity care happening. We put it in the budget for our health center. Obviously, our residency program can't fund labor and delivery, but that helps. Part of that cost is in the budget."
"For our community health center, we have written several portions of our grant portfolio around maternity care, around prenatal care, postnatal care and the first five years of life," he says.
"Some of the people we have hired in our community health center and in our residency program, nurse anesthetists, some of the labor and delivery nurses, we share some of the personnel costs it takes to run this labor and delivery unit."
"So, you have three relatively distinct but interwoven institutions with their own mission statements. It's a collaboration and we make ourselves whole with this low-volume unit."
Who Pays for What?
"We keep it very simple," Waits says. "We told the hospital that we would handle the medical staff costs. The hospital knew going in that they did not have to hire doctors to cover the labor and delivery. It's our group. If we are short a doctor, we work a little extra. We recruit our nurse partners. When we do a delivery, we bill for the physician fee like most groups do. But there are no hospital-employed physicians."
"The hospital bills for their stuff. They have put up the capital costs to build the unit. The hospital hires nearly two-thirds of the nursing. When a patient comes in, the hospital does the supplies, the equipment costs, which is traditional. The hospital bills Medicaid, BlueCross, whomever, for the facilities fees and per diems and that sort of thing."
The medical group includes nurse practitioners who function as midwives, and help hospital staff as needed. "The nurse anesthetists are on the faculty for the residency program, and they're teaching the residents to put in central lines and manage airways and lumbar punctures or help with the labor epidurals or the C-sections."
Why Bother?
Waits says delivering babies helps preserve the community's care continuum.
"Numerous studies in lots of rural contexts have shown that the loss of a rural labor delivery unit worsens infant mortality rates and portends the loss of many other services," he says. "In Bibb County, once labor and delivery went, so did local prenatal care. Similarly, care in the first five years of life became more difficult to achieve."
And when hospitals stop delivering babies, they're no longer prepared for emergency or even precipitous deliveries, Waits says.
"Institutional memory is lost. Harm comes because people aren't prepared for these routine things," he says.
"Then, there are emergencies and urgencies and care that needs to happen in the first year of life for the child, the first five years of life, etc. The focus tends to turn away from mother/baby in those first five years and that's when you lose that knowledge."
"The final part of that answer is just the reality of doctors and nurses who train and fall in love with this time of life as a part of their profession," Waits says.
"If these services aren't being rendered, you're not able to recruit and retain that work force. They're going to go somewhere where they're taking care of mothers and babies, not just nursing home patients."
John Commins is the news editor for HealthLeaders.