Many studies have shown that timely and appropriate access to prenatal and delivery services improves maternal and neonatal outcomes (Helton 1997
). An important component in access to such maternity care services is the availability of providers willing to perform deliveries. Studies have found that when the number of maternity care providers falls in a community, the rate of delayed and inadequate prenatal care and delivery complications and costs rise (Piper, Mitchel, and Ray 1996
; Nesbitt et al. 1997
; Dubay, Kaester, and Waidmann 2001
;). Rural areas that lack local obstetrical services are associated with less adequate prenatal care, higher rates of preterm delivery, infant mortality, and complications during delivery (Nesbitt et al. 1990
; Peck and Alexander 2003
We have previously reported the results of a 2002 study that found a high rate of loss of maternity care providers in Oregon (Smits et al. 2004
). In that study, we found that over half of Oregon maternity care providers had stopped or were planning to stop delivering babies. Of particular concern for Oregon was the finding that rural physicians were stopping maternity care at a significantly higher rate than urban physicians (Smits et al. 2004
). Oregon is a rural state, with the majority of its land area designated rural by federal and state standards. Rural communities in Oregon often have large distances separating them. When a rural-based physician or midwife stops providing maternity care services, women living in that area may have to drive more than 50 miles to the next community with a maternity care provider to obtain these services, often over difficult roads and challenging terrain. According to the Oregon Office of Rural Health, a large proportion (38 percent) of Oregonians live in rural areas and could be affected by changes in rural health care delivery.
Our 2002 study found that physicians were stopping maternity care for several reasons, which echoed the reasons found in other states. These include lifestyle issues, such as lack of desire to be on call, an aging workforce, and issues with deliveries interfering with office practice (Smits et al. 2004
). The most important reason for stopping maternity care found in our previous study, as well as other studies around the nation, was the rising cost of malpractice premiums (Herbst 1990
; Rosenblatt et al. 1991
; U.S. Department of Health and Human Services 2003
; U.S. General Accounting Office 2003
; Menachemi et al. 2005
; Hale 2006
; Xu et al. 2008
;). Malpractice premiums were rising sharply in Oregon during this time. Between 1999 and 2003, premiums for obstetrician/gynecologists (OB/Gyns) in Oregon increased 280 percent while premiums for family physicians (FPs) who delivered babies increased 375 percent (Northwest Physicians Mutual Insurance Company 2003
). For the mostly small business owner physicians in Oregon, this increase was not fiscally sustainable and supported physicians' claims that malpractice premium increases lay behind their decisions to stop maternity care.
Concern over the implications of falling numbers of maternity care providers, particularly in rural Oregon, led the Oregon Legislature to develop a public subsidy for qualifying rural physician malpractice premiums. The amount of subsidy varies by specialty and by whether the physician delivers babies. The subsidy program pays 80 percent of the professional liability premium for an OB/Gyn and 60 percent of the premium for an FP or general practitioner (GP) if they deliver babies, and 40 percent of the premium of all rural physicians regardless of specialty if they do not deliver babies. To qualify for this subsidy, a physician must practice more than 60 percent of the time in a community designated as rural by the Oregon Office of Rural Health. Midwives and employed physicians (those working for government agencies, hospitals, health systems, etc.) did not qualify for this subsidy. The subsidy legislation was passed in 2003 and fully implemented in 2004; the subsidy was set to sunset at the end of 2007.
The impact of the malpractice subsidy on the Oregon maternity care workforce is important to study for several reasons. First, continuing increases in liability premiums are thought to be leading to further declines in the number of maternity care providers since the 2002 survey; however, this assumption needs to be quantitatively evaluated. Second, these subsidies involve large sums of public money. For the first 2 years of implementation (2004–2005), the average subsidy amount for an OB/Gyn was US$47,865 while the average amount for an FP who provided maternity care was US$17,379 (State Accident Insurance Fund, personal communication, March 2007). Before this subsidy is re-authorized, the impact of this public expenditure needs to be re-evaluated. Lastly, while professional liability subsidies have been considered or implemented in several states, little analysis of their effectiveness has been conducted (Anonymous 2003; Liss and Sage 2005
; Salganik 2005
; Sloan 2005
;). Given the lack of rigorous study of the impact of public malpractice subsidies, both the general public and state and national policy makers need well-conducted studies to inform them of how effective these policies are in supporting maternity care services, particularly in rural areas.
To study the effects of the malpractice subsidy policy on the maternity care workforce, we conducted a longitudinal cohort study of Oregon obstetrician/gynecologists, FPs, GPs, and certified nurse midwives (CNMs) to determine (1) the proportion of those trained to provide maternity care who continue to provide such services, (2) the important factors relating to the decision to discontinue providing maternity care services, and (3) how the rural liability subsidy is affecting maternity care providers' ability to provide maternity care services in rural areas.