Using data to save the lives of mothers and newborns
Sullivan_DoctorDeficiency
1. Doctor Deficiency: Disparities in Physician Availability in the Baby Business and
Birth Outcomes in New York State
Julie A. Sullivan,
Siena College
Abstract
Recent reports and research suggest a looming national shortage of primary care physicians,
particularly in rural and urban poor communities. Of the primary care fields, I specifically
investigate the current workforce of OB/GYNs by county in New York and suspect that lack of
access to high quality care in underserved counties leads to poor birth outcomes. Though New
York has one of the highest employment levels of OB/GYNs, this number is misleading due to
the state’s uniquely wide spectrum of developed environments, ranging from tiny farming
communities to the United States’ most populous city. Data on the number of women ages 15 to
44 was acquired from the United States Census Bureau. I obtained the zip codes of each
OB/GYN in the state through HealthGrades.com and use this information to determine how the
reported 4,235 OB/GYNs are dispersed throughout the state. Combining these data sets, I show
evidence of significant disparities among counties: while Manhattan has about 7.54 OB/GYN
doctors per 3,500 females ages 15 to 44, three of New York’s counties have no OB/GYNs at all
(populations of females ages 15 to 44 in these counties range from 6,897-12,714). I use data on
infant mortality, low birthweight births, and birth defects such as gastroschisis, cleft lip, and
spina bifida to analyze the relationship between birth outcomes and the population weighted
availability of OB/GYN physicians in each county of New York State. Controlling for economic
barriers and risk factors, I find that a local presence of OB/GYNs has little effect on birth
outcomes.
3. 3
1. Introduction
Basic economic theory explains that as demand and prices for goods increase, suppliers
will enter the market to earn their share of profits. Over time, supply will rise to equal demand.
However, health care economics does not follow this simple market story. Despite rising demand
for health services due to the expansion of health insurance coverage through the Patient
Protection and Affordable Care Act and the incentive of earning a high income practicing in the
medical field, recent reports and research suggest a looming shortage of physicians. Primary care
fields are especially prone to physician shortages.
According to some reports, pregnant women in the United States may have difficulty
finding a physician to deliver their children. Obstetrics and gynecology (OB/GYN) is one
primary care specialty that is becoming especially scarce in certain areas. High malpractice
premiums, fear of lawsuits, and lifestyle factors deter medical students from choosing OB/GYN
as their specialty, and the baby boomer generation of OB/GYNs will soon retire. In many areas,
there may not be enough OB/GYNs to sufficiently meet patients’ needs. This lack of access to
high quality care could have serious repercussions for women and their infants.
This paper investigates the relationship between local presence of OB/GYNs and birth
outcomes in New York State. Based on the literature on this topic, I expect to find significant
disparities between the population-weighted number of OB/GYNs in urban and rural counties.
Data on each reported physician was compiled to determine how OB/GYNs are dispersed
throughout New York State, and the number of physicians is weighted based on the number of
women ages 15 to 44 in each particular county. I predict that these differences are problematic
and lead to poor birth outcomes in counties with fewer OB/GYN physicians per capita. Records
on infant mortality, low birthweight births, and birth defects such as spina bifida and
gastroschisis were compiled to define birth outcomes. Additionally, I use certain risk factors and
barriers to care for controls. Combining these datasets, I use regressions run on IBM SPSS
Statistics software to analyze the connection between these birth outcomes and the population-
weighted availability of OB/GYN physicians. Ultimately, my findings suggest that availability of
OB/GYNs has little to no impact on birth outcomes, and I offer explanations as to why the data
demonstrates this.
2. Background
The Patient Protection and Affordable Care Act (ACA) was passed into law by President
Barack Obama in March 2010 and is considered the most dramatic overhaul of the United States’
health care system since the passage of Medicare and Medicaid in 1965. One of the primary
goals of the ACA is to expand access to coverage by requiring most United States citizens and
legal residents to purchase health insurance. The creation of health insurance exchange markets
for individuals, the requirement for employers to provide health insurance to their employees,
and the expansion of Medicaid to low income individuals under age 65 in some states aim to
reduce the number of uninsured people in the United States (Kaiser, 2013). Millions of
individuals who were previously uncovered are expected to purchase private health insurance or
claim Medicaid eligibility this year.
4. 4
Although this health reform legislature has expanded health care coverage to more
people, it is unclear if the current physician workforce in the United States is capable of
satisfying the increased demand. An adequate supply of physician services is often cited as a
crucial factor in accessing health care. As 32 million people become newly insured, a report by
the Association of American Medical Colleges (AAMC) indicates a nationwide shortage of
physicians that will continue to worsen as years pass, particularly in primary care fields
(HANYS, 2012).
Obstetrics and gynecology is a primary care specialty that is especially prone to shortage
for a number of reasons. In addition to the increase in demand for health services that all medical
professions are expected to face with the passage of the ACA, the OB/GYN workforce faces a
unique set of obstacles. One problem surrounding the supply of OB/GYNs is the fact that the
workforce is aging; 35% of OB/GYNs in the United States are over the age of 50 (Anderson et
al., 2008). Another significant factor that contributes to a declining workforce is that fewer
medical students are choosing OB/GYN as their specialty (Loafman & Nanda, 2009).
Meanwhile, the decreasing number of OB/GYNs is exacerbated as fewer doctors perform
particular services. One survey by the American Congress of Obstetricians and Gynecologists
found that one in seven OB/GYNs has stopped delivering babies, 20% have cut back on high-
risk obstetrics, and 5% have dropped obstetrics altogether (Greywolfe, 2014).
Career dissatisfaction is often a focus of studies that seek to determine why OB/GYN
practice, and obstetric practice in particular, is becoming increasingly unpopular. One study that
measured career satisfaction found that OB/GYNs had significantly lower overall career
satisfaction than other primary care physicians (Kravitz et al., 2003). Malpractice premiums,
medical liability and lifestyle factors are typically cited as reasons for current OB/GYNs’
discontent and deterrents for medical students choosing a specialty.
OB/GYNs are more likely than other medical doctors to be targeted in medical
malpractice cases. A 2009 National Survey on Professional Liability by the American Congress
of Obstetricians and Gynecologists found that 94.9% of respondents from New York State had
had at least one professional liability claim filed against them during their careers; of these,
49.9% had four or more claims filed against them (ACOG, 2012). The absurdly high number of
malpractice claims results in skyrocketing malpractice premium prices for OB/GYNs in New
York State in the last few decades.
Compared to the malpractice premiums of other American OB/GYNs, New York’s
physicians tend to pay more as a percentage of their operating costs. On average, 11% of an
American OB/GYN’s operating expenses are devoted to malpractice insurance; in New York’s
Rockland County, insurance accounts for 29% of an OB/GYN’s operating costs (ACOG, 2012).
The Medical Society of the State of New York (MSSNY) reports that medical liability
insurance costs for OB/GYNs increased by 63-72% between 2003 and 2008, and by another 5-
9% in 2010 when temporary rate freezes were removed. The Medical Liability Mutual Insurance
Company (MLMIC) insures 60% of all physicians in New York State and determines its rates
based on a physician’s location. The most extreme instance is the $186,772 premium assigned to
Nassau and Suffolk counties’ OB/GYNs. Approximately half of New York State’s deliveries are
covered by Medicaid, and physicians are currently reimbursed at the Medicaid Fee for Service
rate of $1,370 per delivery. For an OB/GYN in Nassau or Suffolk to cover her malpractice
5. 5
insurance premium alone, she must deliver one baby every three days if she accepts mostly
Medicaid patients. Though these doctors do earn higher salaries than doctors in more rural
counties, their cost of living on Long Island is typically much higher than other parts of the state
(ACOG, 2012). The stress and lost time due to malpractice lawsuits and the high price of
medical liability insurance are persuasive enough for some students to choose other specialties
and some doctors to discontinue their practices.
Lifestyle is also often cited as a reason for avoiding obstetrics. A survey of fourth year
medical students at the Indiana University School of Medicine demonstrates how much students
are influenced by lifestyle. When the respondents of the survey were asked what the most
important factor was in choosing a specialty other than OB/GYN, close to 40% cited “lifestyle”
(Gariti et al., 2005). Some medical specialties offer doctors flexibility in their schedules;
obstetrics does not. It is time-consuming and very unpredictable. In addition to long hours,
OB/GYNs are often on-call and must work at erratic times as births can occur at any time of the
day. The pressure from the high stakes of the job is stressful; obstetricians care for two patients
rather than just one and poor results can be disastrous for families (Friedman, 2005). For medical
students who want to have leisure and personal time, obstetrics is not an attractive specialty.
The State University of New York (SUNY) Center for Health Workforce Studies found
that between 2000 and 2004, the overall number of OB/GYN physicians decreased. The most
concerning finding was that the number of OB/GYNs in upstate areas that are already considered
underserved declined significantly more than birth rates, while certain urban areas experienced
increased numbers of OB/GYNs (SUNY, 2005).
3. Model
According to the previously mentioned SUNY report and much of the other literature on
this topic, regional shortages and spatial disparities of physicians are thought to be major threats
to public health. I will use information from New York State to explore this hypothesis by
analyzing the relationship between the number of OB/GYNs per females ages 15 to 44 in a
county and birth outcomes.
Due to New York State’s unique developed environment, which ranges from small rural
communities to the United States’ most populated city, I expect to find significant disparities in
the number of OB/GYNs in each county. Weighted for population, I suspect that cities and urban
areas will have more OB/GYNs than rural and less densely populated counties.
The World Health Organization cites maternal and child health outcomes among the most
fundamental indicators to assess health status and health care infrastructure. I predict that fewer
OB/GYNs in a particular county limits access to care for women who live in that area; therefore,
I anticipate finding poorer birth outcomes in counties with lower numbers of OB/GYNs per
capita. Poor birth outcomes are defined by the infant mortality rate (DEATH), low birthweight
births per 1,000 births (WGHT), and the number of certain defects per 1,000 births (DEFECT). I
also control for certain variables that can act as potential determinants of infant health. In
addition to the number of OB/GYNs per capita (OB/GYN), the variables used are abortions per
1,000 births (ABT), median household income (Y), the number of births to mothers over the age
6. 6
of 40 per 1,000 births (MFP), the percent of births financially covered by Medicaid or private
insurance (INSU), the adult obesity rate (OBESE), and the adult smoking rate (SMOKE).
My
basic specifications are the following:
DEATH = β1 + OBGYNβ2 + ABTβ3 + SMOKEβ4 + MFPβ5 +Yβ6 + INSURβ7 + OBESEβ8
WGHT = β1 + OBGYNβ2 + ABTβ3 + SMOKEβ4 + MFPβ5 +Yβ6 + INSURβ7 + OBESEβ8
DEFECT = β1 + OBGYNβ2 + ABTβ3 + SMOKEβ4 + MFPβ5 +Yβ6 + INSURβ7 + OBESEβ8
Abortions per 1,000 births are considered because they may affect the number of
unhealthy infants born in particular counties. Understanding of genetics and increasing use of
medical technology allow doctors and women to monitor infant development, and birth defects
can be detected and diagnosed fairly early during pregnancy. Upon learning of birth defects,
some women may choose to terminate their pregnancies; meanwhile, women living in more
conservative or religious communities may be less likely to do so. As a result, some counties
may show lower levels of defects because unhealthy pregnancies are not brought to term.
The adult smoking rate is also included in this analysis because smoking during
pregnancy has been linked to a variety of infant health problems. Smoking can cause an array of
problems with the placenta, an infant’s source of food and oxygen during pregnancy. Some
babies born to smokers are born prematurely, causing them to have a low birthweight and a
higher chance of having certain birth defects like cleft lip or cleft palate. Some infants born to
smokers die because of these complications (“Tobacco”, 2014).
Similarly, the adult obesity rate is taken into account because it has been linked with
pregnancy complications. Studies suggest that women who are overweight before becoming
pregnant have a higher chance of giving birth to infants with health problems (“Complications”,
2014).
Age is also a major risk factor in child bearing, so I consider births to women over the
age of forty as well. Women who conceive in their 40s are more likely than younger women to
have a baby with certain chromosomal abnormalities or a baby that is born with a low
birthweight (Mayo, 2014). Again, these complications can lead to infant death in some cases.
Health insurance coverage and median household income must also be included because
they indicate whether or not a woman can receive proper prenatal care. Despite the passage of
the Affordable Care Act, many Americans remain uninsured because the law allows citizens to
opt out of purchasing insurance by paying a fine (Kaiser, 2013). Income also plays a role because
even with insurance, some women may forego seeing a doctor to avoid travel expenses and high
co-pays. A woman’s ability to remain healthy during pregnancy by having good nutrition and
taking dietary supplements can also be dependent on her income and may affect the health of her
child.
4. Data
The United States Census Bureau collects information about the nation’s people and
economy. New York’s State population data and projections from the Census was found through
7. 7
the New York State Department of Labor. The data contains 2009 civilian population estimates
organized by demographics, including a breakdown by age and sex by county. I narrowed the
data to focus on women of childbearing age. Childbearing age in this report is defined as ages 15
to 44 because these are the ages that the National Center for Health Statistics typically uses to
determine fertility rates.
To determine how OB/GYNs are dispersed throughout New York State, I obtained each
reported OB/GYN’s zip code from HealthGrades.com. HealthGrades provides consumers with
information to make informed decisions about their medical care. Physicians also use
HealthGrades to represent their practice online and to make them more discoverable
(HealthGrades, 2014). Though the New York State Department of Health offers information
through a Physician Profile website called nydoctorprofile.com, I found that HealthGrades.com
is the superior source for the information I was looking for. Many physicians that were listed on
nydoctorprofile.com were currently practicing out of state or did not have the location of their
main practice listed at all; meanwhile, HealthGrades.com clearly listed each doctor’s current
practice address. Using the doctors’ zip codes, I was able to sort them by county.
The United States Department of Health and Human Services Health Resources and
Services Administration has developed a shortage designation criteria to determine if a
geographic area is a Health Professional Shortage Area (HPSA). Primary Care HPSAs are based
on a physician to population ratio of 1 to 3,500, meaning that an area is considered to have a
doctor shortage when there are 3,500 or more people per primary care physician. It is essential to
note that there is no universally accepted definition of physician shortage as community needs
and the number of additional services such as nurse practitioners and physician assistants differ,
but the 1:3,500 physician to population relationship that I use is the long standing ratio used to
identify high need areas (HRSA, 2014).
Based on this ratio, the number of OB/GYNs per county, and the number of women ages
15 to 44 in each county, ten of New York’s counties have critical shortages of OB/GYNs:
Delaware, Columbia, Genesee, Livingston, Oswego, Schoharie, Schuyler, Seneca, Washington,
and Yates. Of these, Delaware, Seneca, and Washington counties have no OB/GYNs at all.
Meanwhile, larger cities like Manhattan had 7.54 OB/GYNs per 3500 females.
Infant mortality and low birthweight rates were acquired from the New York State
Department of Health Vital Records Office. The Vital Records Office files all certificates on
births and deaths that occur in New York State and makes these statistics available to the public
through a series of annual vital statistics tables. A death is considered an infant mortality when
the child is under the age of one. Infants are considered low birthweight when they weigh less
than 2,500 grams upon birth. Data from years 2000-2007 is used; because of the small
populations of some counties, it is necessary to average the data over a longer period of time to
get a large enough sample size. Throughout this time period, Hamilton had an extremely high
number of low birthweight births relative to the other counties, leading me to remove it from my
regression analysis.
The New York State Department of Health Congenital Malformations Registry archives
cases of children born in New York State diagnosed before the age of two with any structural,
functional, or biochemical abnormality. The recorded defects are specifically genetic or induced
during gestation and are not due to birthing events. Like with infant mortality and low
8. 8
birthweight, I collected information on several common birth defects from years 2000-2007 to
get a large enough sample size. The defects I use can occur due to environmental factors and are
often preventable. For instance, the Centers for Disease Control and Prevention suggests that
women take adequate amounts of a B vitamin called folic acid to prevent neural tube defects
such as spina bifida and anencephaly. Folic acid can be purchased over the counter, but doctors
can prescribe prenatal vitamins that contain higher dosages (OWH, 2012). I was also certain to
use birth defects that are considered harmful. Though heart defects in infants are common, many
structural abnormalities require little to no medical attention, even through adulthood (Mayo,
2014). Interestingly, large hospitals often screen for such defects more frequently. Data including
congenital heart defects may inaccurately demonstrate that certain areas have more birth defects,
even though many of those defects are actually harmless. For this reason, I exclude some of the
most common birth defects such as atrial and ventricular septal defects.
I also obtained data for the variables that I believe could act as determinants of infant
health. The number of births by mothers over the age of 40, financial coverage of births, the
adult obesity rate, the number of abortions per 1000 births, and adult smoking rates for years
2000-2007 was found through the New York State Department of Health’s Vital Statistics Office
and averaged. Median household income for the years between 2006 and 2010 was obtained
from the U.S. Census Bureau’s American Community Survey.
Table 1: Summary Statistics of Key Variables
Variable Mean Median Std. Dev Min Max N
DEATH 6.210685484 6.2875 1.108036604 4.2875 9.3875 62
WGHT (w/
Hamilton)
76.2431166 72.89117171 26.42764086 58.81851815 271.8333912 62
WGHT (w/o
Hamilton)
73.03672 72.5683 7.874999 58.81852 96.69472 61
DEFECT 2.177949 2.10252 0.842987 0 4.483706 62
OB/GYN 2.243911 1.960011 1.476565 0 7.543599 62
Y 52288.39 48215 12438.99 34264 93613 62
INSU 0.93582 0.960644 0.06973 0.634345 0.990694 62
OBESE 0.269452 0.2755 0.046908 0.15 0.375 62
MFP 0.297998 0.270876 0.112332 0.131952 0.665002 62
ABT 268.7329 240.87 154.403 60.19 938.74 62
SMOKE 0.19871 0.19 0.054336 0.09 0.31 62
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5. Analysis
5.1 Infant Mortality
Table 2: Regression on DEATH Results
Variable B Std. Error Beta T Sig.
(Constant) 12.026 2.147 5.601 .000
OBGYN -.043 .096 -.058 -.452 .653
Y -6.157E-005 .000 -.691 -3.808 .000
INSU -.039 .019 -.243 -2.055 .045
OBESE -.006 .036 -.025 -.160 .874
MFP .032 .020 .321 1.544 .128
ABT -.001 .001 -.080 -.603 .549
SMOKE .024 .030 .120 .825 .413
Median household income, the percentage of the population that is insured, and the
percentage of births to mothers over the age of 40 all play a statistically significant role in the
number of infant deaths per 1,000 live births.
Health insurance likely affects infant mortality because they determine whether or not
some women utilize health care. Health insurance may ensure women can access expensive,
insurance-based acute interventions during pregnancy and after birth, such as surgeries to correct
life-threatening birth defects. Despite the passage of the ACA, many people remain uninsured,
and high co-pays can deter patients from visiting physicians’ offices; as a result, regular
checkups during pregnancy may still be unaffordable for some women and correctable problems
may go undetected. Low incomes may also prevent some women from eating proper diets and
remaining healthy throughout pregnancy. Both the lack of access to care and inability to take
care of oneself through pregnancy could lead to unhealthy births that result in infant deaths.
The percentage of births to mothers over the age of 40 also has a slight effect on infant
mortality. Women who conceive in their 40s are more likely than younger women to have a baby
with certain chromosomal abnormalities that could lead to infant death.
5.2 Birth Defects
Table 3: Regression on DEFECT Results
Variable B Std. Error Beta T Sig.
(Constant) 3.270 1.751 1.867 .067
OBGYN -.073 .078 -.129 -.942 .350
Y -3.524E-006 .000 -.052 -.267 .790
INSU .002 .015 .020 .161 .873
OBESE -.031 .030 -.175 -1.054 .297
10. 10
MFP -.023 .017 -.307 -1.379 .174
ABT -.001 .001 -.111 -.777 .441
SMOKE .036 .024 .234 1.505 .138
No variables in this regression appear very statistically significant. While some birth
defects can be caused by environmental or behavioral factors, most are caused by genetics. The
adult smoking rate indicates some significance, which is likely because particular defects like
cleft palate that are included in my aggregate birth defects per 1,000 births are more closely
linked to smoking than, say, gastroschisis. If I looked for correlations between specific birth
defects rather than looking at them as a collective number, there might be more significant links.
5.3 Low Birthweight
Table 4: Regression on WGHT Results
Variable B Std. Error Beta T Sig.
(Constant) 75.806 13.385 5.664 .000
OBGYN 1.912 .604 .356 3.167 .003
Y .000 .000 .177 1.014 .315
INSU -.204 .117 -.182 -1.734 .089
OBESE -.043 .228 -.026 -.190 .850
MFP -.231 .139 -.326 -1.664 .102
ABT .036 .006 .704 5.619 .000
SMOKE .229 .186 .158 1.230 .224
Insurance is somewhat significant to the prevalence of low birthweight births. When
women have the means to visit their doctors for regular checkups during pregnancy, pregnancies
can be monitored and physicians can intervene by offering strategies to manage risky
pregnancies.
On the other hand, not all intervention may be beneficial; alarmingly, a strong positive
correlation exists between the number of OB/GYNs and low birth weight births. In other words,
this analysis suggests that the more OB/GYN physicians a county has, the more low birthweight
births occur in that county. This finding is opposite of what I suspected and is very troubling.
One explanation is that increased medical intervention can be harmful to an extent.
Another possible explanation is that although there may be more OB/GYNs in a county,
they may not be available to all pregnant women. Although the ACA mandates that individuals
obtain health insurance, expanded access to health insurance does not necessarily mean
expanded access to health care. Through the ACA, the number of uninsured Americans has
fallen from 46 million to 41 million. However, 60% of these insurance gains are the result of
Medicaid enrollment, and having Medicaid is not guaranteed access to care. Compared to private
insurance, Medicaid pays physicians very little, so they are less likely to accept and treat
Medicaid patients. One study found that Medicaid patients are six times more likely to be denied
11. 11
an appointment with a specialist than people with private insurance, and those who are accepted
wait 42 days on average to see a doctor—two times longer than private insurance carriers
(Bisgaier and Rhodes, 2011).
According to this regression, as the number of births to mothers over the age of 40
increases, the number of low birthweight births per 1,000 births decreases. This finding
contradicts the literature that asserts that it can be dangerous for middle-aged women to bear
children. These numbers could be the result of social and cultural change. Today’s women are
more educated and career-driven than any throughout history. It is not socially unacceptable or
particularly unusual for a woman to wait longer to settle down and start a family. As a result,
there may be more births to women over the age of 40, but these women may have better
financial ability to maintain healthy pregnancies thanks to careers with higher incomes and
health insurance benefits.
Another interesting finding is a slightly positive correlation between the number of
abortions in a county and the number of low birthweight births. Again, this result is surprising,
but it could indicate socioeconomic factors that are not included in this regression, such as the
prevalence of single parent headed households and out-of-wedlock pregnancies. Many women
may have abortions because of their financial inability to raise a child alone. Meanwhile, those
single mothers who do carry their pregnancies to term may produce low birthweight children
because they lacked the financial and health support of another person throughout pregnancy.
6. Discussion
According to these regression analysis results, the availability of physicians is not very
influential to infant health. There are multiple reasons why I did not see the expected correlation
between local presence of OB/GYNs and birth outcomes. A limitation of this study is that I am
currently unable to determine how many of the reported OB/GYNs actually practice obstetrics.
The literature explains that many OB/GYNs do not practice obstetrics; many recent medical
school graduates have subspecialized in other aspects of women’s health and about 5% of
OB/GYNs nationally have dropped obstetrics (Greywolfe, 2014).
An additional restraint to this study is that I am unable to determine how many hours
each doctor works. The number of hours worked by physicians, especially between the sexes,
can differ considerably. While OB/GYN was once a male-dominated specialty, more women are
entering the field: in 2001, 70.3% of residency spots were filled by women (Lewin, 2001). A
more diversified choice of physicians is desirable for patients; however, female physicians on
average work significantly fewer hours than their male colleagues because they reportedly
devote more time to other responsibilities. This, combined with a stagnant number of medical
schools and residency spots, has led to the same number of physicians as years ago working
fewer hours for a larger population (Lobosky, 2012). I did not track the working hours of each
reported OB/GYN, which could have given me an incomplete picture of the availability of
doctors. As a result of these limitations, this study may not contain an accurate assessment of the
obstetric care available in each county. I am uncertain of how the results may shift given this
information.
12. 12
The previous limitations aside, another possible explanation for the lack of connection
between OB/GYN physicians and birth outcomes is the increasing role of other medical
professionals in our health care system. More hospitals are shifting from using strictly physician
care for certain treatments to allocating more responsibility to other professionals like physician
assistants (PAs) and nurse practitioners (NPs) (Beck, 2014). These professionals are trained to
provide comprehensive care to patients; for example, PAs are able to perform physical exams,
diagnose and treat illnesses, order tests, recommend directions for preventative care, aid
physicians during surgery, and write prescriptions. Many PAs work in settings in which they
provide OB/GYN services to women: 2.3% of PAs work in OB/GYN practices and 26% work in
family practices. A survey of the Association of Physician Assistants in Obstetrics and
Gynecology found that members did report that they often assist patients in family planning and
prenatal care (AAPA, 2010).
In addition to PAs and NPs, midwives are also trained to provide obstetric care by
helping women maintain healthy pregnancies, delivering infants, and monitoring recoveries in
the postpartum period. Though midwife care is not as common in the United States as it is in
other countries, many births are attended by midwives. Genesee County has only 0.8684
OB/GYN physicians per 3500 females according to the data I collected; however, its hospital
that provides maternity care, United Memorial Medical Center, reported that 321 out of its 651
births in 2012 were attended by a midwife (NYSDOH, 2012). Similarly, the data reports that
Livingston County had only 0.9503 OB/GYN physicians per 3500 females, but 64 of 268 births
at Nicholas H. Noyes Memorial Hospital were attended by a midwife (NYSDOH, 2012). Though
these areas may have a small number of OB/GYN physicians, it is evident that other
professionals capable of providing obstetric care are present. Birth outcomes in New York State
may not be related to the number of OB/GYNs because other health professionals are available
to provide adequate access to care. If the presence of other medical professionals like PAs, NPs,
and midwives in OB/GYN practices does lead to more desirable birth outcomes, policy should
aim to increase the number of students entering these fields.
Aside from more information about individual OB/GYNs’ practices and the presence
other clinical professionals, there are a number of other variables that could be added to this
analysis. The inclusion of factors such as the percentage of college educated mothers and the
prevalence of single parent headed households may offer further explanation for poor birth
outcomes.
Another possibility is that the quantity of services provided is irrelevant because certain
birth outcomes are inevitable. While I aimed to use birth outcomes that can occur due to
environmental factors and could be considered preventable, genetics are an important
determinant of infant health (Lobo & Zhaurova, 2008). The significance of the percentage of
births to mothers over the age of 40 and its increased risk for abnormalities in two of the three
regressions supports this conclusion. In these cases, the number of OB/GYN physicians in a
given area is unimportant. No amount of prenatal care can change genetic makeup and prevent
certain chromosomal abnormalities. If genetics do play the most important role in birth
outcomes, policy should be geared toward encouraging further genetic research rather than
offering incentives for students to specialize in OB/GYN.
On the other hand, genetics do not explain the disparity between birth outcomes in the
United States and other wealthy nations. The Organization for Economic Co-Operation and
13. 13
Development (OECD) tracks health outcomes and expenditures of developed countries. New
York’s infant mortality rate is about the same as the national average, but year after year the
United States has higher levels of infant mortality than many other wealthy countries; the United
States’ infant mortality rate is 6.1 deaths per 1,000 births while the OECD average is 4.0 deaths
per 1,000 births (Health Statistics, 2014). This data infers that there must be some other
significant difference between the way our and other developed countries’ health care systems
deliver OB/GYN care. The regression analyses in this study suggest that health insurance may
play a large role in this difference. Further comparative research into the health care procedures,
health insurance systems, and OB/GYN care strategies of other developed countries could shed
more light on this disparity.
7. Concluding Remarks
The purpose of this paper is to ask if OB/GYN shortages and disparities lead to
undesirable birth outcomes in New York State. After collecting data and running regression
analyses, the results do not uphold the concerns described in other research on physician
shortages. Though much of the literature I have cited frets about problems and major
repercussions associated with national physician spatial disparities, this particular study
concludes that local availability of OB/GYN physicians is generally unimportant to birth
outcomes in New York. Birth defects appear to be largely genetic while infant mortalities and
low birthweight births seem to be more closely tied with health insurance than with the presence
of physicians.
14. 14
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18. 18
9. Acknowledgements
I would like to acknowledge and extend my heartfelt gratitude to the following people who made
the completion of this research possible:
Thank you to Dr. James Booker, my faculty adviser, for his tireless assistance and the invaluable
advice he offered each week for the duration of this project. I must sincerely thank Dr. Lois Daly
as well for her research guidance and inspiration for the subject of this paper. I would also like to
express my appreciation for all the professors who have taught me about health care policy in the
last four years in the pursuit of my Bachelor’s degree.
I very gratefully acknowledge the support and generosity of the Siena College Center for
Undergraduate Research and Creative Activity.
Finally, thank you to my family and friends for their support and encouragement.
