Tag Archives: pregnant women

More hospital closings in rural America add risk for pregnant women

Dr. Nicole Arthur (R), visits Tariyana Wiggins, a high school teacher, shortly after the birth of Troy O’Brien Williams in the hospital room at the North Baldwin Infirmary, a 70-bed hospital in rural Bay Minette, Alabama, U.S. on June 22, 2017. REUTERS/Jilian Mincer

By Jilian Mincer

Bay Minette, Alabama (Reuters) – Dr. Nicole Arthur, a family practice physician, was trained to avoid Cesarean deliveries in child-birth, unless medically necessary, because surgery increases risks and recovery time.

But she has adjusted her approach since arriving last year at the 70-bed North Baldwin Infirmary in rural, southern Alabama.

Low patient admissions and high costs mean the hospital does not have doctors on site around-the-clock to administer anesthesia in the case of an unexpected emergency Cesarean.

As a result, Dr. Arthur performs the surgery if there are any signs of complication, rather than waiting and running the risk that comes with the 20 to 30 minutes it takes for an anesthesiologist to arrive in the middle of the night.

“It’s better for me to do a C-section when I suspect that something may happen,” she said of her new strategy. “Getting the baby out healthy and happy outweighs some of the risk.”

Physicians in rural communities across America are facing the same tough choices as Dr. Arthur. Hospitals are scaling back services, shutting their maternity wards or closing altogether, according to data from hospitals, state health departments, the federal government and rural health organizations.

Nationally, 119 rural hospitals that have shut since 2005, with 80 of those closures having occurred since 2010, according to the most recent data from the North Carolina Rural Health Research Program.

To save on insurance and staffing costs, maternity departments are often among the first to get shuttered inside financially stressed rural hospitals, according medical professionals and healthcare experts.

“It’s been a slow and steady decline,” said Michael Topchik, the National Leader for the Chartis Center for Rural Health, about maternity ward closings. “It’s very expensive care to offer, especially when it’s lower volume.”

More than 200 maternity wards closed between 2004 and 2014 because of higher costs, fewer births and staffing shortages, leaving 54 percent of rural counties across the United States without hospital-based obstetrics, data from the University of Minnesota’s Rural Health Research Center show.

The trend has escalated recently even though the national healthcare law, known as Obamacare, was designed in part to help rural hospitals thrive. But unpaid patient debt has risen among rural hospitals by 50 percent since the Affordable Care Act was passed, according to the National Rural Health Association, especially in states that decided not to expand Medicaid – the state and federal insurance program for the poor.

The outlook for these hospitals was not poised to improve had Congress approved legislation to replace Obamacare. Senate Republicans’ proposed cuts to Medicaid would have pushed about 150 more rural hospitals into the red, according to the Chartis Center for Rural Health, mainly in states that voted Republican in the last election.

But late on Monday, Senate Majority Leader Mitch McConnell said the Republican effort to repeal and immediately replace Obamacare will not be successful, after two of McConnell’s Senate conservatives announced that they would not support the bill.

PAIN FELT BEYOND THE BELTWAY

The consequences go beyond politics.

When local doctors and midwives leave town, rural women lose access to essential services. Many skip or delay prenatal care that could prevent complications, premature birth or even death. The U.S. infant mortality rate is among the highest in developing countries at 5.8 deaths per 1,000 births.

Pregnant woman in rural areas are more likely to have their deliveries induced or by Cesarean section that, while potentially life-saving, are more expensive and risky than a normal vaginal birth, according to patients, medical professionals and researchers.

Almost a year after her second son’s birth, Courtney Cross is still repaying money she borrowed because of the smaller paychecks and larger gas bills she had from driving 60 minutes each way to a specialist in Mobile, Alabama.

“There were some days I had to reschedule because of the money factor,” said Cross, a medical technician and mother of two, who some months made the trip multiple times. “I had to make money.”

Cross is not alone. The most common reasons for the hospital closures are people and money. More and more people are moving to urban areas in pursuit of work and a better paycheck. And in most states, lower revenue from insurance and U.S. government payments are pushing these hospitals into financial stress, particularly in states that did not build out their Medicaid programs as Obamacare allowed.

“The majority of births in rural America are paid for by Medicaid, and Medicaid is not the most generous payer,” said Diane Calmus, government affairs and policy manager for the National Rural Health Association. “For most hospitals it is a money losing proposition.”

This is the main reason why Connie Trujillo shuttered her midwife practice this spring in Las Vegas, New Mexico. The local hospital had closed its maternity ward, and the closest hospital to deliver babies was at least 60 miles away. She sees more elective inductions because the patients live far away and can’t afford to go back and forth.

“Some of them just don’t have the resources,” she said. A year after shuttering, the hospital is trying to hire additional staff to reopen the ward.

MORE SCHEDULED DELIVERIES

The number of induced U.S. deliveries nationally has doubled since 1990 to about 23.3 percent, but rates are significantly higher in rural areas, where it is routinely offered to women traveling long distances, especially if the weather is bad.

Induced labor and surgery come at a high cost. Commercial insurance and Medicaid paid about 50 percent more for Cesarean than vaginal births, according to a 2013 Truven Health Analytics report. The report said Medicaid payments for maternal and newborn care for a vaginal birth was $9,131 versus $13,590 for a C-section.

In largely rural West Virginia – where the Summersville Regional Medical Center became the latest hospital to stop delivering newborns earlier this year – elected inductions for first time mothers rose to 28.7 percent in 2015 from 24.1 percent in 2011, according to data provided to Reuters by the West Virginia Perinatal Partnership, a statewide effort to improve care.

“Inductions allow the physicians to manage their case loads and timing of deliveries,” said Amy Tolliver, director of the Perinatal Partnership. “We know that inductions are happening in small hospitals that have difficulty with staffing.”

To address staffing issues at Dr Arthur’s hospital in Alabama, the facility paid temporary doctors for a year to keep the department open when one of its two maternity doctors stopped doing deliveries.

“It’s important to have access (to obstetrics),” said hospital president Benjamin Hansert, who also organized a group of doctors from Mobile about 40 minutes away to cover some of the shifts so that staff doctors would not always be on call. “Where the mother goes for care, the rest of the family will follow.”

For the full graphic on hospital closures, click http://tmsnrt.rs/2us7qDM

(Editing by Caroline Humer and Edward Tobin)

Zika virus findings show hearing loss to some babies

An Aedes aegypti mosquito is seen inside a test tube as part of a research on preventing the spread of the Zika virus and other mosquito-borne diseases at a control and prevention center in Guadalupe,

CHICAGO (Reuters) – A study in Brazil of 70 babies whose mothers had confirmed Zika infections found that nearly 6 percent had hearing loss, adding a new complication to the list of ills the virus can cause when women are infected during pregnancy.

The Brazilian study, published on Tuesday in the U.S. Centers for Disease Control and Prevention’s weekly report on death and disease, confirmed less rigorous reports of deafness among infants born to mothers with Zika infections.

The finding is part of an effort to fully characterize the harm caused by the Zika virus during pregnancy. The virus is best known for causing the severe birth defect microcephaly, characterized by undersized heads and underdeveloped brains. But other studies have shown that Zika can cause other brain abnormalities, vision problems and joint deformities.

In the latest study, a team led by Dr. Marli Tenório and Dr. Ernesto Marques of the Oswaldo Cruz Foundation in Pernambuco, Brazil, examined records from 70 infants with microcephaly whose mothers had laboratory-confirmed Zika infections during pregnancy.

They found that nearly 6 percent had hearing loss without any other plausible cause.

Several other viral infections during pregnancy can cause hearing loss, including rubella and cytomegalovirus, or CMV, infections. The current study adds Zika infection to that list.

Scientists say Zika should now be considered a risk factor for hearing loss, and children who were exposed during pregnancy but have normal hearing at birth should be screened regularly for delayed or progressive hearing loss.

The connection between Zika and microcephaly first came to light last fall in Brazil, which has since confirmed more than 1,800 cases of microcephaly.

(Reporting by Julie Steenhuysen; Editing by Jonathan Oatis)

Pregnant in Miami: Zika’s arrival adds new anxieties

Visitors walk through the Wynwood arts district of Miami

By Letitia Stein and Jilian Mincer

TAMPA, Fla./NEW YORK (Reuters) – Since Florida officials declared that the Zika virus is circulating in the state, Miami-area resident Karla Maguire has avoided taking her toddler son to a playground where mosquitoes may be biting. She walks her dogs less frequently and vigilantly applies bug repellent when she must go outside.

An obstetrician and gynecologist who is herself pregnant, Maguire has become scrupulous about following the advice that she gives patients to protect against Zika, which can cause a rare but devastating birth defect. Maguire works near the city’s Wynwood neighborhood identified on Friday as the first site of local Zika transmission in the continental United States.

“It is frustrating to spend a lot of time avoiding mosquitoes,” said Maguire, a physician at the University of Miami Miller School of Medicine, noting the discomfort of wearing long sleeves during Florida’s steamy summer. “You just end up being inside a lot.”

Physicians in Miami and beyond have seen this week a spike in concerned calls from pregnant women, particularly after health officials advised them not to travel to Wynwood and said any expecting mothers who had done so since mid-June should be tested for Zika.

On Wednesday, Florida said it would provide Zika testing to pregnant women at county health departments at no cost, and make available additional lab services to handle “the expected increase in tests being administered.”

The warnings raised anxiety in a city already on high alert for Zika’s arrival from Latin America, where it has spread quickly since first being detected in Brazil last year. The threat to newborns aside, Zika is otherwise considered a mild illness, and up to 80 percent of people infected have no symptoms.

All summer, Florida health officials have issued daily notices tallying the rise in cases acquired through travel to countries where Zika is widespread and advised the public to protect against mosquito bites. Along with 15 local cases, Florida is monitoring 391 picked up through travel abroad, which include 55 cases involving pregnant women.

One baby born in the state to a woman infected in Haiti has been diagnosed with the birth defect microcephaly, a condition defined by small head size that can lead to developmental problems.

TAILORING THE MESSAGE

Health officials expect that southern U.S. states vulnerable to mosquito-borne disease will see smaller, localized Zika outbreaks, given widespread use of window screens and air conditioning, compared with Latin American countries.

In Miami’s trendy Wynwood district, known as a place to hop between art galleries and tour outdoor murals, some doctors fear that a counterculture ethos may diminish the impact of medical recommendations to combat Zika.

Batsheva Stern, who is 28 weeks pregnant, sees no reason to avoid the district, where her husband, Zak, owns a popular bakery.

“I’m not so nervous,” said Stern, 27, recounting the advice of her midwife: “Don’t freak out, nothing is happening.”

But Dr. Elizabeth Etkin-Kramer, a gynecologist in private practice nearby, worries about birth defects resulting from unplanned pregnancies in some of her Wynwood-area patients who eschew birth control pills, noting the community is also skeptical of vaccines and antibiotics.

On Tuesday, she met with a patient who is 18 weeks pregnant and working near the affected area. The patient questioned her recommendation to be tested for Zika infection.

“Her feeling is, if something is going on, there is nothing you can do about it, short of termination,” said Etkin-Kramer, an officer in the Florida district of the American Congress of Obstetricians and Gynecologists. “I think it would be important to know, and if God forbid she is positive, then we can look closely by ultrasound and get a lot more information.”

Beatriz Mendes Pereira Lopes, 26, an attorney who is five months pregnant, has moved twice trying to avoid Zika. She went to Miami in April, as the hot months in her home of Brazil spurred mosquito breeding.

Last month, she returned to Brazil, now in its cooler winter, anticipating its mosquitoes would be in hibernation. Now that Zika has begun circulating in Miami, she concedes that her future options may be limited until a vaccine is developed.

“It’s impossible to get rid of all the world’s mosquitoes,” she said via email.

(Reporting by Letitia Stein in Tampa, Fla. and Jilian Mincer in New York; Additional reporting by Zachary Fagenson in Miami; Editing by Michele Gershberg and Bernard Orr)