Health Policy$ense

Drawing Lessons from Philadelphia’s Large-Scale Obstetric Unit Closures

13 Out of 19 Units Closed From 1972 to 2012

A version of this article was originally published by The Children’s Hospital of Philadelphia.

What does it mean for expectant mothers and hospitals when there are large-scale closures of maternity units? A new study by LDI Senior Fellows Scott Lorch, Sindhu Srinivas and David Grande, with colleagues from CHOP’s Center for Outcomes Research provides an inside view from hospital staff members in Philadelphia, where 13 out of 19 obstetric units closed from 1997 to 2012.

Scott Lorch, MD, MSCE, Associate
Professor, Pediatrics, Children's
Hospital of Philadelphia.

The researchers found that sharp surges in patient volume in the remaining units strained the health care system, eroded workforce morale, and fragmented care for mothers and babies until hospitals adjusted to added demands. They suggest that better planning is needed to improve mother-infant outcomes, and reduce stress on health systems and staff when hospital OB units close.

“While the degree of obstetric unit closures was larger in Philadelphia than in any other metropolitan area, analyzing the situation may provide useful lessons for other areas as hospital consolidations, closures and mergers have accelerated since the enactment of the Affordable Care Act,” Lorch noted.

Insights from key staff members at hospitals with open maternity units
In a previous study, Lorch’s team reported that infant mortality rates in Philadelphia rose by nearly 50% over a three-year period after a series of hospitals began closing obstetric units in 1997. Those mortality rates subsequently leveled off by 2007.

In contrast, the current study did not analyze patient outcomes, but instead summarized semi-structured interviews with 23 key staff members at 11 hospitals whose maternity units remained open. Six hospitals were in Philadelphia and five were in the surrounding suburbs.

The key informants were obstetric department chairs, leaders of private obstetric groups, and other experienced clinicians: obstetricians, nurses, nurse managers and midwives.

The informants said dramatic surges in delivery volume were their greatest challenge. Maternity units averaged 58% in increased volume, resulting in frequent overcrowding, understaffing and lower staff morale. Moreover, the overall patient mix shifted toward poorer patients who were more likely to receive late or no prenatal care. From 1995 to 2009, the surviving obstetric units had on average a three-fold increase in patients with public insurance or no insurance.

Unlike the previous pattern, in which patients often received prenatal care at the same hospital where they gave birth, prenatal care became more fragmented, as patients had to choose another birthing hospital. Their prenatal health information did not always follow them to the new hospital. “One clear message from this study is that women need help from their health care system in obtaining better continuity of care throughout their pregnancies,” said Lorch.

Areas for improvement
Overall, the informants identified two main areas for improvement: better communication among hospitals before closures occurred, and the development of regional solutions to coordinate prenatal care with care at delivery. “Because hospitals compete with each other for patients, local health departments may need to exercise foresight and planning, identifying hospital units at risk for closing,” said Lorch. He added, “Public health officials may need to take on a communications role among affected hospitals to smooth the transition for patients.”

Another suggestion from the study team’s informants is to establish systems for exchanging health information and to standardize protocols among regional providers to improve continuity of care. “Easing the transition when obstetric units close should improve the experience of both patients and caregivers,” said Lorch.