3. sures resulted in a reduction in the number of
available obstetric beds in the county by approx-
imately 50 percent. Hospital obstetric units that
remained open in the region experienced an av-
erage increase in delivery volume of 57.7 percent
during the same period (calculated from data in
Exhibit 1), according to birth certificate records
and the Maternity Care Coalition.14
These
changes occurred with no real change in the total
number of deliveries in the five-county Philadel-
phia region in the same time period.
This degree of obstetric unit closures was larg-
er than that experienced by any other metropoli-
tan area. However, the trend is consistent with
the results of one previous study showing that
California hospitals often eliminate obstetric
units when they reduce services.15
The Philadel-
phia County hospitals that closed obstetric units
tended to have smaller delivery volumes, to have
no academic affiliation or obstetrics training
program, and to be located in the northeastern
or northwestern areas of the county.16
The closures of Philadelphia obstetric units
were initially associated with an increase in neo-
natal mortality, but that abated over time.16
The
sustained reductions in obstetric units in Phila-
delphia and the observed adverse outcomes pro-
vide an opportunity to understand more broadly
how hospitals respond to closures of nearby clin-
ical units or entire hospitals, regardless of the
reason for the closure. This is an important issue
for any community or public health department.
We conducted a qualitative study of key in-
formants involved in obstetrical care in Philadel-
phia to answer several questions. First, what is
the perceived effect of an acute reduction in ob-
stetric care services on the hospitals that remain
open? Second, what changes do hospitals and
providers in remaining hospitals make in re-
sponse to changes in patterns of care? Third,
what opportunities do obstetric providers iden-
tify to mitigate the adverse effects of changes in
access to obstetric care?
We hypothesized that our informants would
consistently identify changes in delivery volume
and patient characteristics, both medical and
sociodemographic, as important challenges
with closures of obstetric units. Additionally,
we sought to understand the role that a local
public health department or a regional non-
governmental organization could play in re-
sponding to these changes.
Study Data And Methods
Subjects Between October 2011 and Janu-
ary 2012 we conducted semistructured inter-
views with twenty-three key informants at six
urban hospitals and five suburban hospitals in
the greater Philadelphia area. The obstetric units
in these hospitals were still open as of the begin-
ning of 2012 and had remained open as of Oc-
tober 2014.
The hospitals were chosen based on their loca-
tion relative to Philadelphia County and their
change in delivery volume since closures began
in 1997. This volume is reflected in the delivery
volume at each hospital between 1995 and 1996.
Thirteen informants were employed at one of the
six remaining Philadelphia County obstetric
units, and the other ten were employed at one
of five selected units in the four counties that
border Philadelphia.
To build our pool of informants, we first re-
cruited obstetric department chairpersons and
leaders of private obstetric groups that delivered
babies at the eleven study hospitals, because
these people were directly affected by the clo-
sures of obstetric units in Philadelphia County.
Then, based on their suggestions, we identified
and recruited additional clinicians at each study
hospital, including obstetricians, nurses, nurse
managers, and midwives. Each informant had
been at his or her respective hospital for at least
ten years and had been practicing obstetrics for
10–48 years.
Saturation—the point at which no new or rele-
vant information emerged from further inter-
views—was reached with a total of twenty-three
informants. There were eight chairpersons,
eight obstetricians, three nurses, three nurse
managers, and one midwife, with one or two
physicians and one or no nurse from each of
the eleven hospitals.
At the time of the interviews, tacit verbal con-
sent was obtained from each informant. The
Institutional Review Board at the Children’s Hos-
pital of Philadelphia approved all study proce-
dures. The Institutional Review Board did not
allow us to identify informants by title or hospi-
tal, because doing so would breach participants’
confidentiality and result in the identification of
the source of several quotations in the article.
Interview Methods A public health profes-
sional trained in interviewing techniques con-
ducted the in-person and telephone interviews.
Each informant chose the interview method he
or she preferred.
Each interview was digitally recorded and
lasted 30–90 minutes. The interviewer used a
semistructured open-ended interview guide that
included questions about the response of the
informant’s hospital and obstetric unit to the
closures of obstetric units in the area, the biggest
challenges faced by hospitals and obstetricians,
the impact of the closures on the financial health
of the informant’s obstetric unit, and sugges-
tions for how units that remain open can plan
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4. for and respond effectively to future closures.
Analysis The interviews were transcribed and
edited to remove identifying information. The
transcripts were imported into Atlas.ti, version
6.2—a qualitative data analysis software package
used for coding—and a codebook was developed
using grounded theory.17,18
Two experienced in-
dependent coders separately analyzed the data
and then compared findings to reduce the
chance of errors from coding and increase the
reliability of the themes identified in the data.
The themes presented in the Study Results
section were not chosen a priori but were devel-
oped from informants’ responses. We assessed
the reliability and validity of the analyses
through four criteria described in previous re-
search: prolonged engagement with the data,
credibility, transferability, and confirmability.19
With the exception of some minor edits to im-
prove clarity, all quotes are provided verbatim.
Limitations Our study had several limita-
tions. First, this project was not designed to as-
sess changes in patient satisfaction resulting
from closures.
Second, there are elements of the perinatal
system in Philadelphia that may occur in only
a few areas of the country, such as women receiv-
ing care at hospital clinics. These elements may
limit the generalizability of our results about the
prenatal care system to other areas where clini-
cians in private practice deliver the majority of
prenatal care.
Third, the ability of the local public health
department to intervene within the obstetric
care system that we found in Philadelphia might
not exist in other regions. Thus, they may need
other solutions, such as regional hospital collab-
orations outside of the governmental system.
Finally, because this was a qualitative study,
we could not use our results to show a causal
association between any changes in response
to the closures in Philadelphia that were made
by the obstetric units that remained open and
any change in perinatal outcomes. Nor could we
assess whether the decision to participate in this
study was related to either positive or negative
experiences surrounding the closures. However,
no informant gave information that was entirely
negative or positive during his or her interview.
Study Results
Informants generally described a severely
strained obstetric care system following the
widespread closures of units or hospitals in
the region. In most cases, informants described
the closures as happening abruptly. Other hos-
pitals “did not have a lot of warning,” one infor-
mant said, and thus each closure precipitated
immediate challenges in the remaining obstetric
units.
Several themes and subthemes emerged from
our interviews (Exhibit 2) that confirmed data
presented in Exhibit 1. First, informants identi-
fied economic challenges in obstetrics as a major
underlying reason for obstetric unit closures and
ongoing challenges within open units.
Second, informants described both acute and
chronic stresses to the system that arose from
changes in patient volume and mix, precipitated
by the closures, in the remaining obstetric units.
Informants said that they were able to adapt to
some of these stresses but not others.
Third, informants described an ad hoc re-
sponse to obstetric unit closures with little ad-
vance planning. The response was reactive,
based on changing volumes and patient mix.
Fourth, informants offered suggestions for
preventing adverse effects from future closures.
Reasons For Closures Of Obstetric Units
Our informants identified the low financial mar-
gins and high fixed costs of running obstetric
units as primary reasons for closures. “In Philly,
you get paid less, it costs more, and the liability is
higher. So ‘perfect storm’ is an overused phrase,
but it’s at least a triple whammy,” one person
said. Informants identified several unique fac-
tors related to obstetrics that led to high fixed
costs: high community malpractice rates, which
in turn reinforced the need for hospitals to em-
ploy obstetricians directly; and high overall per-
sonnel costs to run a labor and delivery floor.
Informants reported that payments did not
keep pace with these expenses. This fact was
exacerbated by the high percentage of women
with public or no insurance who had been cared
for by obstetric units immediately before they
closed (Exhibit 3), who might have had lower
reimbursement for services compared to women
with private insurance.
If hospitals are not willing or able to use other
service lines to subsidize obstetric units, the
pressure to close the units increases. As one in-
formant said, “If you don’t own the hospital and
Each closure
precipitated
immediate challenges
in the remaining
obstetric units.
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5. you can’t circle the finances around to support
obstetric practice, the obstetric practice is un-
sustainable.”
Acute And Chronic Stresses Resulting
From Closures Informants identified three ma-
jor challenges to obstetric units that remained
open: increased delivery volume; changes to pa-
tient mix and continuity of prenatal care; and
issues with staff morale and support (Exhibit 2).
▸INCREASED VOLUME: Consistent with data
shown in Exhibit 1, providers reported “dramat-
ically increased volumes” as the primary chal-
lenge from obstetric unit closures. Informants
did not distinguish between the closure of the
Exhibit 1
Changes In Hospitals’ Delivery Volume And Insurance Status In The Philadelphia Region, By County, 1995–2009
Deliveries Change in deliveries, 1995 to 2009 (%)
Hospital Status 1995 2009 All With public or no insurance
Bucks
A Open 1,051 1,363 29.69 247.72
B Open 1,107 1,596 44.17 61.39
C Open 1,390 1,128 −18.85 152.38
D Open 1,414 1,920 35.79 114.65
E Hospital closed 142
Chester
F Open 2,042 2,567 25.71 94.60
G Newly open —a
418 —a
—a
H Open 296 2,280 670.27 −30.76
I Open 1,209 924 −23.57 299.80
J Unit closed 760
Delaware
K Open 2,603 2,107 −19.05 447.26
L Open 1,226 1,657 35.15 987.16
M Open 814 833 2.33 199.02
N Unit closed 1,319
Montgomery
O Open 3,243 5,155 58.96 76.38
P Open 2,021 1,915 −5.24 −15.16
Q Open 1,791 2,770 54.66 746.70
R Open 1,714 2,666 55.54 57.91
S Open 674 776 15.13 309.14
T Open 773 694 −10.22 21.21
U Unit closed 812
V Unit closed 565
Philadelphia
W Open 1,507 2,932 94.56 142.10
X Open 1,597 2,081 30.31 321.58
Y Open 2,307 4,004 73.56 110.99
Z Open 3,585 4,790 33.61 268.98
AA Open 1,644 3,171 92.88 122.45
AB Open 2,340 2,174 −7.09 21.30
AC Hospital closed 476
AD Hospital closed 1,034
AE Hospital closed 967
AF Hospital closed 844
AG Hospital closed 771
AH Unit closed 655
AI Unit closed 279
AJ Unit closed 1,264
AK Unit closed 330
AL Unit closed 1,208
AM Unit closed 1,865
AN Unit closed 711
AO Unit closed 1,144
SOURCE Authors’ analysis of birth certificate records, Pennsylvania Department of Vital Statistics. NOTE Data confidentiality
agreements precluded listing hospitals by name. a
Not applicable.
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6. first obstetric unit and the closure of the fourth
or the thirteenth unit.
The acute pressures from a closure were exac-
erbated by two other factors: when the time be-
tween the announcement that an obstetric unit
would close and the actual closure was just a
matter of weeks; and other surges in volume that
are part of the normal practice of obstetric care.
Theincreased delivery volumesled informantsto
report that their obstetric unit “was packed to the
gills” and that “it was not uncommon to see
patients in a cubbyhole, patients outside my of-
fice.” One informant reported that “we had peo-
ple deliver in the hallway or in the bathroom.”
Increases in delivery volume, whether acute or
chronic,raised concerns about thequality of care
provided to patients.
▸CHANGES IN PATIENT MIX AND CONTINUITY
OF CARE: After the closures, obstetric units that
remained open experienced an average increase
of 216 percent in women with public or no in-
surance between 1995 and 2009 (calculated from
data in Exhibit 1). Informants confirmed these
changes to their overall patient mix, reporting “a
shift to more Medicaid patients and just in gen-
eral a more urban, poor, less insurance, late pre-
natal care” population. As a result, informants
described a greater need for support services,
including those provided by social workers.
In addition, after the closures more patients
received prenatal care at a different setting from
where they delivered their child. In Philadelphia
the majority of patients used to receive care at the
hospital clinic where they eventually delivered
their child.20
After the closures, the system of
prenatal and antenatal care was described as
“fractured.” One informant said that patients
now “get your prenatal care and then you end
up somewhere else to have a baby, and it’s not
geographically rational.”
As a result, many informants reported that “we
are seeing some people with no prenatal care.We
are seeing some people who said they had care
elsewhere and when we called elsewhere, wher-
ever that may be, they either could not locate
their record or told us that there was no care
provided there.” Care became more inefficient,
which worsened the effects of surges in delivery
volume.
▸STAFF MORALE AND SUPPORT: With in-
creases in delivery volume, new obstacles to pa-
tient care, and increased financial pressures, in-
formants reported decreases in staff morale and
enthusiasm. Changes to obstetric unit volume
resulted in people feeling that their unit was
“constantly understaffed” and that it was “not
uncommon to do three or four deliveries in a
shift…and have a two-patient assignment.”
Additionally, recruiting additional staff to
those obstetric units that remained open became
difficult. Informants believed that these recruit-
ment issues occurred because of the pressures of
seeing patients more quickly with less support,
which led to lower job satisfaction and morale.
Response To Closures By Remaining Hospi-
tals Many responses by hospitals to the chal-
lenges mentioned above were reactive rather
Exhibit 2
Themes And Subthemes In Philadelphia Region Obstetric Unit Closures, Identified By
Twenty-Three Key Informants
Reasons for closures
Liability
Poor reimbursement
Minimal finances
System stressors
Delivery volume surges
Changes to patient mix and continuity of prenatal care
Staffing challenges
Responses to closures
Structural changes
Staffing model changes
Ways to prevent adverse effects
Communication between hospitals
Regionwide protocols
SOURCE Authors’ analysis.
Exhibit 3
Percentage Of Deliveries With Public Or No Insurance At Closed Obstetric Units In The
Philadelphia Region, 1995 And Last Year Open
Deliveries with public or no insurance (%)
Hospital 1995 Last year open
E 14.8 12.3
J 16.8 52.2
N 14.3 53.4
U 4.8 11.8
V 1.9 31.7
AC 51.2 32.4
AD 23.6 13.6
AE 11.7 4.5
AF 59.6 77.7
AG 37.6 54.1
AH 15.6 49.0
AI 17.1 16.7
AJ 38.6 74.4
AK 25.4 70.0
AL 23.4 40.6
AM 5.7 29.1
AN 2.1 47.1
AO 2.5 38.9
SOURCE Authors’ analysis of birth certificate records, Pennsylvania Department of Vital Statistics.
NOTES Data confidentiality agreements precluded listing hospitals by name. See Exhibit 1 for more
details on hospitals by letter name.
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7. than proactive. The responses reflect two prima-
ry areas of change: structural changes to the
obstetric units and changes to the units’ staffing.
▸STRUCTURAL CHANGES: In response to deliv-
ery volume changes, there were a large number
of changes to the obstetric units that remained
open. However, these changes often occurred
months or years after the change in volume at
the hospital level, and hospitals “outgrew what
they built.” One informant recommended:
“Whatever you’re building, build it double what
you think you need.You will fill it and regret that
your units are not bigger.”
Instead of having its patients recover in labor
rooms, one hospital built “a [separate] three-bed
recovery room to focus the use of labor rooms for
active labor patients [only].” This hospital’s tri-
age area was expanded from a three-bed to a six-
bed unit: “We were actually at a point at times
that we could use more than six beds. We added
an additional ultrasound room because the OB
ultrasound volume was going up.”
Another hospital committed extra space and
modified it over the past four years. “We’ve got-
ten support from the hospital, from the admin-
istration, and the state to build three recovery
rooms.We built an antenatal testing unit [where]
we do over 12,000 tests a year, and we built a six-
bedded triage unit which we previously hadn’t
had,” an informant from this hospital explained.
▸STAFFING MODELS: Staffing increased on the
labor and delivery units. However, respondents
reported that they needed a “crystal ball, because
we didn’t really know what volume was going to
come.” This resulted in significant lag times be-
fore staffing could be permanently increased.
For some units, increased hiring was at the
level of advanced-practice professionals such as
nurse midwives, physician assistants, and nurse
practitioners. Other units put new staffing mod-
els in place because of the increased volume and
concerns about the quality of care and patient
safety. “We actually have two obstetrical pro-
viders in house 24=7, and three [in house] Mon-
day through Friday, during the day,” one infor-
mant explained.
However, the increased number of providers
often came at a cost to communication and lead-
ership. “It’s different communicating with eight
or nine people than it is [with] four people,” an
informant said. “And I think that’s something
we’re still working on. You know, how do you
get everybody to be part of the big picture? How
do you know what’s happening somewhere else
and how that’s going to impact your unit or an-
other unit?”
As with the increased delivery volume, there
were concerns that these communication chal-
lenges could affect the quality of patient care.
Preventing Adverse Effects From
Future Closures
Several informants described a severely strained
obstetric care system following the widespread
closures. Their experience with these closures
led them to identify two areas for improvement:
better communication between hospitals in ad-
vance of closures, and the development of re-
gional solutions to coordinate prenatal care and
care at the time of delivery.
Communication Between Hospitals To An-
ticipate Closures One key lesson our inform-
ants provided was that when an obstetric unit is
about to close, leaders from local or state health
departments or regional nongovernment organ-
izations need to help improve discussion with
fellow institutions and hospital leaders. “If I was
closing my maternity program, I would try to
reach out to other programs in the area and
try to have as smooth a transition as possible,”
one informant observed. “It’s a tough decision to
close a hospital, and I think hospital administra-
tors would want to work with other hospitals in
their region, and also departments should see
how we can best care for this population.”
Hospitals compete with each other for obstet-
ric patients. Thus, local and state health depart-
ments and other organizations may be needed to
facilitate discussions among hospitals to opti-
mize the transition of care for patients in the
local community and give remaining hospitals
time to adequately staff their units in prepara-
tion for potential surges in delivery volume.
Regional Ways To Facilitate Efficient And
High-Quality Care Informantsfeltthat regional
solutions were needed to address the disconnect
between where prenatal care is delivered and the
hospital where a delivery occurs. One suggested
solution was “evidence-based protocols” that
would standardize care across providers and in-
stitutions. An informant noted that “care is au-
tomatically less fragmented if everyone is using
the same protocols.”
Regional health information exchange that
would facilitate access to prenatal care informa-
tion and protocols was another solution pro-
posed to decrease the fragmentation of care.
Even though such a system of standardized pro-
tocols does not exist across hospitals in the re-
gion, several informants noted that individual
obstetric units should develop “good systems
and protocols” to manage both the increased
volume and surges in patient numbers experi-
enced by the hospitals that remained open.
Discussion
The case of obstetrical care in Philadelphia Coun-
ty highlights issues that patients and providers
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8. may experience when access to care decreases.
The primary challenges in Philadelphia included
sharp surges in delivery volume, changes in pa-
tient mix at individual hospitals, loss of continu-
ity between prenatal and delivery care, and lag
times of months to years before new staffing
needs could be met and bed capacity could be
increased at the hospitals that remained open.
All of these challenges contributed to concerns
about acute erosion in the quality of care.
Our informants emphasized the importance of
communication and planning when even one or
two obstetric units close.When a hospital or unit
closes without warning, there can be large-scale
effects on public health, even if the closure is
justified by the hospital’s economic health or
the number of deliveries it performed. Commu-
nication and planning will become increasingly
important with the continued hospital consoli-
dations and mergers that are expected with the
ACA’s full implementation.21
The greatest challenge identified by our in-
formants was related to delivery volume. Hospi-
tals experienced an average increase in volume
of 57.7 percent, and several county hospitals ex-
perienced increases of over 70 percent. These
volume changes were most disruptive when a
closure occurred suddenly and the remaining
providers had no warning of it.
The increased number of volume surges re-
ported by our informants parallels similar surges
in other areas, such as those caused by emergen-
cy department closures in Los Angeles,22
urban
hospital closures,23
and the routine operation of
obstetric units24
and provision of pediatric hos-
pital care.25
Similar concerns have been raised
when public health departments and hospitals
discuss the potential for mass-casualty care.26,27
Any mechanism that allows hospitals adequate
time to adjust their staffing and structural mod-
els might help minimize some of the adverse
effects of these closures.
Another challenge was that patient mix
changed at the hospitals that remained open.
They saw an increasing proportion of women
having public or no insurance who previously
had received care at hospitals that since closed.
These changes support informants’ concerns
about the financial challenges of running an ob-
stetric unit, which could result in decreased job
satisfaction by providers of obstetrical care. Pre-
vious surveys of obstetricians suggest that mal-
practice premiums are a strong driver of job
dissatisfaction28
but that job satisfaction also
declines as workloads increase and personal
control over day-to-day activities at work de-
creases.29
Potential solutions for these changes include
adding specific personnel, such as social work-
ers, to help both patients and providers adapt to
these changes. Additionally, hospitals and
health careworkersneed toensurethat theyhave
the cultural competency training to work with
changing patient populations.30
We found that the responses from informants
at urban academic centers were similar to those
from informants at community-based practices
both in Philadelphia and in the surrounding sub-
urban counties. This fact emphasizes a need for
coordination and communication across county
lines and among different hospital systems and
public health departments. There is little pub-
lished literature about such direct discussions
between hospitals that otherwise compete for
patients within a given health care market.
Obstetrics is particularly challenging because
of the time-limited nature of pregnancy. Thus,
our informants identified public health depart-
ments or other regional collaborative bodies as
potential stakeholders in both monitoring
changes in access to health care and assisting
patients and hospitals in transferring care dur-
ing pregnancy.
Conclusion
In the future, public health officials should work
to identify hospitals and specific units at risk of
closing. Furthermore, they should collaborate
with affected providers to plan for changes in
patient mix and delivery volume to ensure a
smooth transition for patients. ▪
When a hospital or
unit closes without
warning, there can be
large-scale effects on
public health, even if
the closure is
justified.
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9. This research was presented at the
AcademyHealth Annual Research
Meeting, Boston, Massachusetts,
June 24, 2012. Funding for the research
was provided by the Agency for
Healthcare Research and Quality (Grant
No. R01HS018661).
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