Refer to: Minkler DH, Wallace HM: Maternity and perinatal services in an urban-suburban area. West J Med 127:6976, Jul 1977
Special Article
Maternity and Perinatal Services in an Urban-Suburban Area DONALD H. MINKLER, MD, and HELEN M. WALLACE, MD, Berkeley
The need for community-wide planning of maternity and newborn services is illustrated by a survey of services in Alameda County, California. The decline in birthrate, coupled with the persistence of a number of low volume obstetrical and newborn units, is reflected in generally underutilized and unevenly distributed services. Primary, intermediate and tertiary levels of care are represented, but not always in a logical relationship to community needs. Postgraduate training in obstetrics and gynecology and in pediatrics continues to produce increasing numbers of specialists despite declining fertility and a decline (represented by children and youth) in the total population.
THE STIMULI for changes affecting the American health care "system" are a combination of social, technological, political and economic factors. A partial list of current or anticipated forces contributing to the impetus for changes in, the field of maternal and child health includes the following: * Continuing unfavorable comparison of rates of perinatal morbidity and mortality between the United States and certain other developed countries. The American College of Obstetricians and Gynecologists announced as one of its major goals a reduction by 50 percent in infant mortality to 10 per 1,000 live births in the decade 1973
through 1983. * The rapidly rising cost of health care. * The demographic trend toward smaller families and reduced fertility in recent years. From the University of California School of Public Health, Maternal and Child Health Program, Berkeley. Reprint requests to: Donald H. Minkler, MD, MPH, Maternal and Child Health Program. GK 02, Dept. of Social and Administrative Health Sciences, UC School of Public Health, Berkeley, CA 94720.
* The anticipation of federal legislation creating some form of national health insurance. * The maldistribution and malutilization of trained personnel in reproductive medicine and
pediatrics. * Technological advances available in fetal and perinatal medicine, including a plan for regionalized centers for intensive care. * The increased role of consumers in the evolution of policy regarding health care. * The "malpractice crisis" currently affecting the practice of medicine. * The growth of the health team concept, with professionals other than physicians functioning in extended roles in primary health care. This list could be extended further, but it is sufficient to show the melange of changes contributing to "future shock" among practitioners and consumers alike. Because it is the modification of what exists rather than the creation of a totally new system that we now face, the apTHE WESTERN JOURNAL OF MEDICINE
69
MATERNITY AND PERINATAL SERVICES
proach wvill probably be in the recognition that change must take the form of the art of the possible in a free democratic society. The authors, in cooperation with other Maternal and Child Health (MCH) faculty members of the University of California School of Public Health and the staff of the Alameda County Health Services Agency, recently surveyed the resources for the care of mothers and newborn infants in Alameda County, California. Alameda County has many features that typify the problems to be addressed in attempts to improve the care of mothers and infants. Therefore, it is hoped that the results of this survey will provide a realistic framework for practical planning so that the process of change can be orderly and constructive. Alameda County, with a population of 1,073,184 in the 1970 census, had an 18.2 percent population increase from 1960 to 1970. A further 13.1 percent increase is expected from 1970 to 1980. Two thirds of the county's population is white, (67.2 percent), 15.0 percent is black, and 12.6 percent is of Spanish surname. Of all families in the county, 8 percent are considered to be in the poverty group. Composite perinatal mortality for 1970 through 1974 included 10.7 fetal and 12.4 neonatal deaths per 1,000 live births, compared with 10.7 and 11.2, respectively, for California as a whole.
Changes in the Live Birth Rate Affecting Alameda County In the past 25 years the birth rate in Alameda County generally has reflected the demographic trends characteristic of California and the United States as a whole. While the county's live birth rate is consistently lower than those of the state and the nation, it reflects the same progressive downward trend that began in the late 1950's. Data collected in the course of this survey indicate no significant change in the trend to date. Table 1 compares the live birth rate of Alameda County with rates for California and the United States at intervals from 1950 to 1975.
Changes in the Number of Deliveries by Hospital The pattern of hospital deliveries in Alameda County is significant in the light of growing national interest in planning and providing perinatal services regionally. Table 2 indicates the number of deliveries occurring among the 13 hospitals providing obstetrical service in the county. (A
70
JULY 1977 * 127 * 1
TABLE 1.-Crude Live Birth Rates Year
United States
California
1950 1955 1960 1965 1970 1971 1972 1973 1974 1975
23.6 24.6 23.7 19.4 18.4 17.3 15.6 15.0 14.9 14.8 (prov.)
23.3 24.4 23.7 19.1 18.2 16.3 15.0 14.5 14.9 14.8 (prov.)
Alameda County*
NA. 23.3 23.0 18.6 17.5 15.7 13.7 12.8 13.3 13.4 (prov.)
*Excluding Berkeley and Albany. Sources: Statistician, Alameda County Health Services Agency and Vital Statistics of the United States, Annual reports.
TABLE 2.-Number of Annual Deliveries in Alameda County by Hospital, 1973 Through 1975 Hospital*
1 2 3 4 5 6 7 8 9 10 11 12 13
1973
1974
1975
1,886 1,874 1,868 1,862 1,039 956 861 725 702 672 552 421 298
2,000 1,965 2,010 1,944 1,048 895 892 656 600 695 492 431 326
2,144 1,983 1,993 1,876 1,089 787 903 686 570 763 528 397 302
TOTAL ...... 13,716
13,954
14,021
........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ...........
*Numbers correspond to location on map, Figure 1.
14th, the United States Naval Hospital, Oakland, provides obstetrical services for armed forces personnel and their dependents, and is not included in this survey.) Four of the 13 hospitals have obstetrical caseloads between approximately 1,800 and 2,000 deliveries a year. These are scattered geographically along a roughly north-south axis through the most densely populated areas of the county (see map, Figure 1). Seven hospital have caseloads between approximately 500 and 1,000 deliveries a year. While two of these serve less densely populated and geographically more isolated areas, the others are in the same general axis and in reasonable proximity to one another or to the four institutions with the county's higher volume services, or to both. The eastern district, which is the high priority health district in terms of health needs, contains no hospital with a large obstetric and newborn service. Of the two hospitals with less than 500 deliveries a year, one serves a traditionally relatively isolated population on an island separated -from
MATERNITY AND PERINATAL SERVICES
the city of Oakland by an estuary, and the other is near the geographic center of a low income, high density population characterized by the highest infant mortality among the four health districts of the county. All four of the high volume hospitals had small increases in their total deliveries in 1974 over their 1973 levels. However, these increases (the largest being 7 percent) were generally slight and can hardly be interpreted as reflecting a significant trend toward concentration of maternity care in large volume institutions. A total of six other Alameda County hospitals with modest obstetric caseloads discontinued maternity services between 1955 and 1967, but there has been no further consolidation since then. (Since this survey was completed, one other intermediate volume hospital in Oakland has discontinued its obstetrical service. ) Review of Selected Survey Findings In the sections to follow, those hospitals with annual deliveries in the 1,500 to 2,000 range will be designated as high volume, those with 500 to 1,500 as intermediate volume and those with less than 500 as low volume institutions.
Staffing All 13 hospitals have an obstetrics and gynecology staff chaired by a board certified specialist. All but one have a corresponding pediatric staff; three of the four high volume hospitals, and one intermediate hospital have a separate pediatrician in charge of the newborn service in addition to a chairman of pediatrics. With the exception of the two Kaiser Foundation hospitals, which have full time staffs to serve Kaiser Health Plan patients, these department chairmen are all private practitioners who serve part-time. Most of the hospitals reported that most deliveries are attended by specialists in obstetrics and gynecology. While the number of general practitioners who include obstetrics in their practices has been declining for a number of years, the current malpractice crisis has accelerated this trend. In today's liability insurance market few physicians other than specialists with a significant obstetrical caseload can afford the increased premiums charged physicians who provide obstetrical services.
Dublin &Livermore
Pleasanton
Sunol
Figure 1.-Location of hospitals with maternity units in Alameda County. Numbers correspond to those in Table 2. THE WESTERN JOURNAL OF MEDICINE
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Perinatal Mortality Committee All four of the high volume hospitals conduct a review of perinatal deaths weekly, biweekly or monthly. Two of them are multidisciplinary, with obstetrics, pediatrics, neonatology, anesthesiology and pathology represented. The others are conducted in the form of a joint obstetric-pediatric perinatal review with the other departments not routinely involved. Among the nine intermediate and low volume hospitals, four had no perinatal mortality committee at the time of the survey. Three had quarterly or monthly perinatal death reviews by representatives of obstetrics and pediatrics, one by the obstetrics department alone, and one (intermediate) included its perinatal death review with the hospital's standing committee review of all hospital deaths. Reports of perinatal mortality committee reviews of individual deaths were not made available for review in this survey. The county medical association (AlamedaContra Costa- Medical Association), to which a majority of practicing obstetricians and gynecologists and practicing pediatricians belong, conducts an annual perinatal mortality and morbidity survey through its standing Perinatal Mortality Committee. While the county medical association strongly encourages each hospital to have its own perinatal committee, compliance is optional and incomplete-and there is no mechanism to require standard reporting of perinatal events in the annual survey. Consequently, comparisons among the various individual hospitals' perinatal mortality rates is invalidated by differences in reporting criteria. Despite these shortcoming in documentation, the county medical association's Perinatal Mortality Committee is a potentially useful vehicle for communication among representatives of the various hospitals, an advocate of using standard perinatal review procedures yielding results that can be compared and a multidisciplinary in-house peer review vehicle for physicians in the private medical community concerned with the health care of mothers and newborn infants. Anesthesiology Service in Maternity Care Three hospitals (two high volume, one intermediate) provide coverage by a physician anesthesiologist for all deliveries. The remainder, with a single exception, rely on nurse anesthetists, with an anesthesiologist generally available from the surgical operating room for backup service or 72
JULY 1977 *
127 *
1
complicated cases. Only one hospital reported no backup anesthesiology coverage for its nurse anesthetists, but in this institution an anesthesiologist is available for cesarean sections. In general, anesthesia coverage in delivery rooms appears oriented primarily to care of the mothers. While Apgar scoring is routine (generally at one and five minutes) at all of the hospitals, only two of the 13 report that an anesthesiologist is responsible for the Apgar scoring, and in one of these the anesthesiologist is not present at all deliveries. In most of the hospitals Apgar scoring is done by the attending physician or the delivery room nurse, or both. In five hospitals a nurse anesthetist has this responsibility. Prenatal Care Most hospitals surveyed indicated that deliveries occurring with no history of prenatal care were rare or occasional, or not more than 1 or 2 percent of deliveries. Only one hospital reported as high as 10 percent and another hospital 15 percent (estimated) deliveries without prenatal care; both of these were low volume hospitals.
Maternity Beds A precise tabulation of available maternity beds is no longer possible since most hospitals have abandoned strictly separated maternity wards in favor of flexible arrangements with "swing" beds that may be occupied either by postpartum or clean gynecology cases, depending on daily needs. In general obstetrical bed space in Alameda County hospitals is considerably over-provided and underutilized. Several of the hospitals reported 50 percent or less average occupancy, reflecting the county-wide decline in births in recent years.
Special Maternity Services for High Risk Mothers Only one hospital (high volume) conducts a special clinic for high risk maternity patients. In this instance all maternity patients are screened at intake according to a locally designed protocol. Those with identified risk factors, approximately 10 percent, are referred to a special prenatal clinic attended by the senior obstetric staff and chief resident, with special consultants and dietary assistance available. Of the remaining 12 hospitals, only one reported significant identification and transfer of high risk mothers to tertiary care institutions in the area. With this sole exception, the hospitals
MATERNITY AND PERINATAL SERVICES
generally reported a reluctance by to transfer high risk patients before though high risk newborns are not transferred to hospitals with special tensive care units in the area.
obstetricians delivery, alinfrequently newborn in-
Fetal Monitoring Electronic monitoring of labor, both internal and external, is available at all 13 hospitals. In no instance is monitoring routinely done, although seven hospitals reported that it is done in most cases, with varying ratios of external versus internal techniques. In general, obstetricians appear to be withholding judgment on routine monitoring in uncomplicated cases, while there is a consensus on its use in cases involving risk factors.
Newborn Services As with maternity beds, no instance of crowded or overutilized newborn nursery facilities was encountered among the 13 hospitals surveyed. Several hospitals have considerable unused nursery space which has been closed in recent years. Of the four high volume hospitals, the two that serve the Kaiser prepaid health care system have their own neonatal intensive care network. The Kaiser Oakland hospital has a fully equipped and staffed neonatal intensive care unit which receives referrals from several other Kaiser hospitals in the. area, and which shares a full-time neonatologist with the Kaiser Hayward hospital. The latter, with intermediate intensive care facilities, however, transferred only four of 82 low birth weight babies delivered in 1974. The remaining two high volume private hospitals in the county also have intermediate newborn intensive care facilities and have developed a close working relationship with the neonatal intensive care unit of the Children's Hospital Medical Center of Oakland. The latter, through its transport and educational outreach program, provides in-service training of local hospital nursery staffs, consultation and staff training visits, assignment of neonatal intensive care unit nurses and pediatric residents in rotation, and special neonatal transport service with in-transit intensive care. During 1974 the Children's Hospital Medical Center unit was responsible for the care of approximately 900 high risk newborns transported from some 30 Northern California hospitals. In contrast to the underutilization of available newborn nursery facilities in general, the resources in Alameda County for intensive neo-
natal care have been overtaxed. A report based upon 1972-1973 data indicated an average occupancy rate of 139 percent (range 77 to 160) for the neonatal intensive care units serving the East Bay area which includes Alameda County. This pressure is now being alleviated by the opening of a newly constructed unit at the Children's Hospital Medical Center with a capacity of 20 infants in 1974, and an increase to 40 by July 1976. The medical director of the Children's Hospital Medical Center noted that the specialized training of the neonatal intensive care unit nursing staff was the key item in completing this expansion, since it requires 11 weeks of intensive on-the-job training to prepare each of these nurses for the new responsibilities in the unit. Pending completion of Children's Hospital Medical Center's expansion, several hundred newborns were transported each year to alternate centers in the San Francisco Bay Area. The Children's Hospital Medical Center staff assists in finding an alternate unit when needed, and recently Stanford University Medical Center, in a nearby county, has been designated as one of two Infant Medical Dispatch Centers in California, so that immediate location of alternate neonatal intensive care unit facilities can be made available with minimal delay. Though pediatricians were found to be generally less resistant to organizing perinatal services regionally than their obstetrical colleagues, both groups preferred selective transfer of high risk neonates. In general, transport of low birth weight infants to a regional neonatal intensive care unit is reserved for those in whom there is evidence of respiratory distress or complications other than prematurity per se. Several informants expressed confidence in their hospitals' ability to provide adequate care for an increasing proportion of low birth weight infants as local equipment and sophistication in the care of these infants grow.
Manpower Considerations Alameda County does not suffer from the shortage of trained manpower that affects some areas of the United States. A desirable geographic location, pleasant climate, abundance of social, cultural, and recreational resources, and a growing population (increase of 18.2 percent from 1960 to 1970) combine to make it an attractive location for the practice of medicine. It does, however, reflect the uneven distribution typical of combined urban-suburban American communTHE WESTERN JOURNAL OF MEDICINE
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ities with heterogeneous populations, with the heaviest concentration of physicians in the downtown area and suburbs, and with relative scarcity in the rural areas and low-income residential districts. The 1975 directory of the Alameda-Contra Costa Medical Association listed 115 pediatricians practicing in Alameda County, or a ratio of approximately 1:9,000 population, and 90 specialists in obstetrics and gynecology, a ratio of 1: 11,000 population. Comparison with listings in the Directory of American Medical Specialties indicates that virtually all of the Board Certified specialists are represented in the membership of the county medical association. Therefore, even though not all of the specialists in obstetrics and gynecology are currently practicing obstetrics, it is evident that ample trained personnel exist, if evenly distributed, to afford specialist care to all mothers and infants in the county. Moreover, the growth of residency training both in pediatrics and in obstetrics and gynecology suggests that sufficient specialists in these fields will be produced to more than maintain these ratios in the face of the anticipated 13.1 percent population increase projected for the county between 1970 and 1980. Residency positions in obstetrics and gynecology nationwide increased by 25 percent from 1963 to 1973 and pediatric residency positions more than doubled in the same period. The role of paramedical personnel in enhancing the efficiency, reducing the cost or compensating for unequal distribution of specialist physicians is not yet sufficiently established to measure in Alameda County. Both maternity and pediatric nurse practitioners have been trained in California training programs for several years, but their place in the health team remained legally uncertain until revision of the California Nurse Practice Act in 1974. Their diffusion into employment by the private medical community, while it has begun, has been slowed by the current apprehension over liability and rising costs of insurance which concern many would-be physician employers. They are, however, being widely and effectively used in a number of hospitals and clinics, both public and independent, and in a few private practices, where their acceptance by patients and physician colleagues has been favorable. It is simply too early to say quantitatively what their ultimate contribution to the health team will be in Alameda County.
74
JULY 1977 * 127 * 1
The same observation applies even more to nurse-midwifery in California, since the legislation allowing nurse-midwives to attend normal obstetrical cases was enacted only in late 1974. Only seven of the 90 specialists in obstetrics and gynecology listed were women. Consumer advocates in general, and the feminist movement in particular, have been increasingly vocal in their criticism of male dominated obstetrical care. As opportunities grow for women to pursue careers in the health professions, increased participation of women in maternity care undoubtedly can be expected, whether as physicians, nurse-midwives or nurse-practitioners. Training New Medical Specialists Obstetrics and Gynecology According to data from the American Medical Association, from 1950 through 1962 the number of programs approved for training residents in obstetrics and gynecology in the United States increased. Beginning in 1962 the number of approved residency programs has decreased by a fourth (Table 3). However, from 1950 through 1973 the number of total positions for residents, and the number of these positions filled has considerably increased. The percentage of resident positions filled rose from 1950 to 1959, decreased somewhat in 1961, and has been at the level of 86 to 93 percent since 1961 (Table 3). Pediatrics From 1950 through 1963 the number of programs approved for residency training in pediatrics increased. Since 1963 the number of approved programs has decreased by a fourth. (Table 4). However, from 1961 through 1973 the number of total positions for residents and the positions for residents filled has consistently increased. The percentage of resident positions filled rose from 1950 to 1958, decreased to a lower level from 1959 to 1969, and rose again from 1970 to 1973 (Table 4). Therefore, an overall summary of the national effort to train medical specialists in obstetrics and gynecology and in pediatrics is that, while the number of approved programs has decreased, the number of persons being prepared has increased. This increase in both obstetrician-gynecologists and in pediatricians has occurred in
MATERNITY AND PERINATAL SERVICES TABLE 3.-Residency Training in Obstetrics and Gynecology in the United States, 1950-1973* Year
Approved Program
381 1950 406 1951 326 1952 352 1953 374 1954 406 1955 473 1956 484 1957 477 1958 446 1959 462 1960 491 1961 483 1962 483 1963 434 1964 402 1965 391 1966 381 1967 358 1968 364 1969 350 1970 346 1971 1972 . 337 1973 . 347
Positions
Positions
1,599
1,266 564 520 589 637 763 800 942 956 908 880 844 2,403 2,457 2,500 2,526 2,507 2,526
Offered
754 616 688 737 839 904
1,014 1,013 960 942 944
2,705 2,728 2,806 2,824 2,829 2,897 2,872 3,042 3,081 3,177 3,368 3,413
Filled
2,503 2,572 2,655 2,800 3,006 3,183
Positions Percentage Filled Vacant
333 190 96 99 100 76 104 72 67 52 62 100 242 271 306 298 322 371 369 470 426 377 362 230
79 75 84 86 86 91 89 93 93 95 93 80 91 90 89 89 89 87 87 85 86 88 89 93
*Figures do not include separate residencies in obstetrics or gynecology alone which were available only until 1961. Source: The American Medical Association's Annual Directories of Approved Internships and Residencies.
TABLE 4.-Residency Training in Pediatrics in the United States, 1950-1973* Year
1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973
Approved Program .. 242 ..237 ..244 ..249 ..246 ..265 ..266 ..281 ..291 ..295 ..309 ..315 ..342 ..356 ..308 ..297 ..289 ..277 ..260
..24;50
..258 ..250 ..251 ..274
Positions
Positions
1,258 670 639 739 722 738 802 843 934 937 981 1,056 2,100 2,234 2,290 2,397 2,430 2,508 2,539 2,764 2,830 3,086 3,496 4,409
1,073 533 526 634 638 637 715 737 864 838 886 843 1,735 1,820 1,935 2,043 2,070 2,186 2,185 2,445 2,592 2,844 3,238 4,231
Offered
Filled
Positions Percentage Vacant Filled
185 137 113 105 84 101 87 106 70 99 95 213 365 414 355 354 360 322 354 319 238 242 258 178
85 80 82 86 88 86 89 87 93 89 90 80 83 81 85 85 85 87 86 89 92 92 93 96
*Figures do not include specialized residencies in pediatric allergy and cardiology. Source: The American Medical Association's Annual Directories of Approved Internships and Residencies.
spite of the pronounced reduction in the live birth rate, in the fertility rate and in the proportion of the total population represented by children and youth. California data for 1974 show a beginning reversal in the downward trend in recent years in fertility, prompting demographic analysts to suggest that some women who have postponed marriage and childbearing do not intend to remain childless and may be starting to make up for lost time. Yet, while current projections of population trends for the immediate future include some increase in annual births over the coming decade, these generally do not anticipate a baby boom of a magnitude of that after World War II. The fact remains thlat the output of trained medical specialist manpower both in obstetrics and gynecology and in pediatrics has neither corrected the maldistribution of specialists nor allowed for fluctuations in the need for specialists according to demographic trends. As a result of this lack of an overall plan, dislocations and adjustments in patterns of practice, neither planned nor welcomed by the physicians themselves or their patients, are bound to occur. Krassner and Muller, in a recent analysis of manpower trends in obstetrics and gynecology2 point out that the greatest impact of oversupply will be on new entrants into the specialty of obstetrics and gynecology. They suggest that the reallocation of physician time to allow for the increased need for fertility control will come about through market forces. Ward, in a subsequent comment,3 emphasizes that nonphysician professionals are now being trained to provide family planning services and suggests instead that rendering primary health care to women is more likely to fill obstetricians' time released by declining births. Whatever the nature of the adjustment, no corresponding compensatory market mechanism appears on the horizon for pediatricians, whose relative oversupply parallels that of obstetricians.
Discussion The findings of this survey illustrate the need for community planning directed at four specific problems in the care of mothers and newborn infants in Alameda County. These may be summarized as follows: 1. There is need for further consolidation of obstetrical and newborn facilities. Despite general acceptance of the concept of a regional apTHE WESTERN JOURNAL OF MEDICINE
75
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proach in principle, there has been virtually no consolidation of small obstetrical and newborn units since 1967. (As previously noted, one intermediate volume hospital has discontinued its obstetrical service since this survey was completed.) The resulting underutilization of generally overbuilt hospital maternity and nursery units is costly and inefficient. Among the general principles for consideration in a possible consolidation are-the grouping or regrouping of the smaller maternity services into reasonable geographic service areas, which the various segments of the county community would find acceptable. This might include large urban areas such as the city of Oakland, on the one hand, and other parts of the outlying county which are geographically close to each other and within a reasonable travel time. For example, the maternity services of hospitals within the metropolitan area of Oakland might be consolidated for an overall total of 2,800 annual deliveries, thereby meeting the criteria for a bona fide level II obstetric service. 2. There is need for a comprehensive multidisciplinary program to provide high-risk maternity and neonatal care in the central city area where perinatal and infant morbidity and mortality rates are highest. Such a program, patterned after successful maternal and infant projects in a number of American cities, should include screening for risk factors and special nutrition, education, social welfare, consultative medical and laboratory resources for those who meet appropriate criteria for intensive prenatal and perinatal care. Special emphasis should be given to care for pregnant teenagers, to provide them with preconceptional care (including health care, health education, family life education and nutrition education and service). 3. There is need for a coordinated plan to assure appropriate geographic distribution of health manpower in the face of * demographic trends, notably the pronounced reduction in fertility in recent years;
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JULY 1977 * 127 * 1
* a relative overproduction of medical special-
ists; * continued maldistribution of health personnel, and * increasing reliance on allied health personnel in the delivery of primary care. 4. There is need for more effective planning and coordination of services provided by public and voluntary community health agencies, professional societies and private practitioners in order to avoid wasteful duplication and oversupply of resources and assure equitable access to quality care in all areas of the county.
Conclusion The findings of this survey of one urban-suburban community in California have significant implications for similar communities throughout the United States. Similar surveys to identify the strengths, weaknesses and imminent needs of communities throughout the country would be useful in establishing a framework for constructive planning of health delivery systems in the continuing quest for equitable, efficient and high quality health services for all families. It is suggested that official health agencies and professional societies take the leadership in these surveys, as a first step toward planning organized, community-wide health care of maternity patients and newborn infants. REFERENCES 1. Hawes WE: A survey of newborn intensive care centers in California. West J Med 123:81-84, Jul 1975 2. Krassner M, Muller C: Manpower in obstetrics-gynecology in a period of declining birth rate. Med Care 12:1031-1037, Dec 1974 3. Ward R: Comments on "Manpower in ob/gyn in a period of declining birth rate." Med Care 13:695-696, Aug 1975 4. Lipson AJ: California health manpower: An overview of trends in policy issues. Prepared for the California Department of Health, R-1572-CHD Mar 1974 (Rand Corporation) 5. Committee on Perinatal Health: Toward improving the outcome of pregnancy-Recommendations for the regional development of maternal and perinatal health services. The National Foundation, March of Dimes, White Plains, NY, 1976 6. Russell KP, Gardner SH., Nichols EE: A conceptual model for regionalization and consolidation of obstetric-gynecologic services. Am J Obstet Gynec 121:756-764, Mar 15, 1975 7. Moriarity D, Hecomovich D: Physician manpower-An approach to estimation of need in California. Comprehensive Health Planning Sep 1973. Now available from California Dept of Health, Office of Health Professions Development, Sacramento
Special Article
Maternity and Perinatal Services in an Urban-Suburban Area DONALD H. MINKLER, MD, and HELEN M. WALLACE, MD, Berkeley
The need for community-wide planning of maternity and newborn services is illustrated by a survey of services in Alameda County, California. The decline in birthrate, coupled with the persistence of a number of low volume obstetrical and newborn units, is reflected in generally underutilized and unevenly distributed services. Primary, intermediate and tertiary levels of care are represented, but not always in a logical relationship to community needs. Postgraduate training in obstetrics and gynecology and in pediatrics continues to produce increasing numbers of specialists despite declining fertility and a decline (represented by children and youth) in the total population.
THE STIMULI for changes affecting the American health care "system" are a combination of social, technological, political and economic factors. A partial list of current or anticipated forces contributing to the impetus for changes in, the field of maternal and child health includes the following: * Continuing unfavorable comparison of rates of perinatal morbidity and mortality between the United States and certain other developed countries. The American College of Obstetricians and Gynecologists announced as one of its major goals a reduction by 50 percent in infant mortality to 10 per 1,000 live births in the decade 1973
through 1983. * The rapidly rising cost of health care. * The demographic trend toward smaller families and reduced fertility in recent years. From the University of California School of Public Health, Maternal and Child Health Program, Berkeley. Reprint requests to: Donald H. Minkler, MD, MPH, Maternal and Child Health Program. GK 02, Dept. of Social and Administrative Health Sciences, UC School of Public Health, Berkeley, CA 94720.
* The anticipation of federal legislation creating some form of national health insurance. * The maldistribution and malutilization of trained personnel in reproductive medicine and
pediatrics. * Technological advances available in fetal and perinatal medicine, including a plan for regionalized centers for intensive care. * The increased role of consumers in the evolution of policy regarding health care. * The "malpractice crisis" currently affecting the practice of medicine. * The growth of the health team concept, with professionals other than physicians functioning in extended roles in primary health care. This list could be extended further, but it is sufficient to show the melange of changes contributing to "future shock" among practitioners and consumers alike. Because it is the modification of what exists rather than the creation of a totally new system that we now face, the apTHE WESTERN JOURNAL OF MEDICINE
69
MATERNITY AND PERINATAL SERVICES
proach wvill probably be in the recognition that change must take the form of the art of the possible in a free democratic society. The authors, in cooperation with other Maternal and Child Health (MCH) faculty members of the University of California School of Public Health and the staff of the Alameda County Health Services Agency, recently surveyed the resources for the care of mothers and newborn infants in Alameda County, California. Alameda County has many features that typify the problems to be addressed in attempts to improve the care of mothers and infants. Therefore, it is hoped that the results of this survey will provide a realistic framework for practical planning so that the process of change can be orderly and constructive. Alameda County, with a population of 1,073,184 in the 1970 census, had an 18.2 percent population increase from 1960 to 1970. A further 13.1 percent increase is expected from 1970 to 1980. Two thirds of the county's population is white, (67.2 percent), 15.0 percent is black, and 12.6 percent is of Spanish surname. Of all families in the county, 8 percent are considered to be in the poverty group. Composite perinatal mortality for 1970 through 1974 included 10.7 fetal and 12.4 neonatal deaths per 1,000 live births, compared with 10.7 and 11.2, respectively, for California as a whole.
Changes in the Live Birth Rate Affecting Alameda County In the past 25 years the birth rate in Alameda County generally has reflected the demographic trends characteristic of California and the United States as a whole. While the county's live birth rate is consistently lower than those of the state and the nation, it reflects the same progressive downward trend that began in the late 1950's. Data collected in the course of this survey indicate no significant change in the trend to date. Table 1 compares the live birth rate of Alameda County with rates for California and the United States at intervals from 1950 to 1975.
Changes in the Number of Deliveries by Hospital The pattern of hospital deliveries in Alameda County is significant in the light of growing national interest in planning and providing perinatal services regionally. Table 2 indicates the number of deliveries occurring among the 13 hospitals providing obstetrical service in the county. (A
70
JULY 1977 * 127 * 1
TABLE 1.-Crude Live Birth Rates Year
United States
California
1950 1955 1960 1965 1970 1971 1972 1973 1974 1975
23.6 24.6 23.7 19.4 18.4 17.3 15.6 15.0 14.9 14.8 (prov.)
23.3 24.4 23.7 19.1 18.2 16.3 15.0 14.5 14.9 14.8 (prov.)
Alameda County*
NA. 23.3 23.0 18.6 17.5 15.7 13.7 12.8 13.3 13.4 (prov.)
*Excluding Berkeley and Albany. Sources: Statistician, Alameda County Health Services Agency and Vital Statistics of the United States, Annual reports.
TABLE 2.-Number of Annual Deliveries in Alameda County by Hospital, 1973 Through 1975 Hospital*
1 2 3 4 5 6 7 8 9 10 11 12 13
1973
1974
1975
1,886 1,874 1,868 1,862 1,039 956 861 725 702 672 552 421 298
2,000 1,965 2,010 1,944 1,048 895 892 656 600 695 492 431 326
2,144 1,983 1,993 1,876 1,089 787 903 686 570 763 528 397 302
TOTAL ...... 13,716
13,954
14,021
........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ...........
*Numbers correspond to location on map, Figure 1.
14th, the United States Naval Hospital, Oakland, provides obstetrical services for armed forces personnel and their dependents, and is not included in this survey.) Four of the 13 hospitals have obstetrical caseloads between approximately 1,800 and 2,000 deliveries a year. These are scattered geographically along a roughly north-south axis through the most densely populated areas of the county (see map, Figure 1). Seven hospital have caseloads between approximately 500 and 1,000 deliveries a year. While two of these serve less densely populated and geographically more isolated areas, the others are in the same general axis and in reasonable proximity to one another or to the four institutions with the county's higher volume services, or to both. The eastern district, which is the high priority health district in terms of health needs, contains no hospital with a large obstetric and newborn service. Of the two hospitals with less than 500 deliveries a year, one serves a traditionally relatively isolated population on an island separated -from
MATERNITY AND PERINATAL SERVICES
the city of Oakland by an estuary, and the other is near the geographic center of a low income, high density population characterized by the highest infant mortality among the four health districts of the county. All four of the high volume hospitals had small increases in their total deliveries in 1974 over their 1973 levels. However, these increases (the largest being 7 percent) were generally slight and can hardly be interpreted as reflecting a significant trend toward concentration of maternity care in large volume institutions. A total of six other Alameda County hospitals with modest obstetric caseloads discontinued maternity services between 1955 and 1967, but there has been no further consolidation since then. (Since this survey was completed, one other intermediate volume hospital in Oakland has discontinued its obstetrical service. ) Review of Selected Survey Findings In the sections to follow, those hospitals with annual deliveries in the 1,500 to 2,000 range will be designated as high volume, those with 500 to 1,500 as intermediate volume and those with less than 500 as low volume institutions.
Staffing All 13 hospitals have an obstetrics and gynecology staff chaired by a board certified specialist. All but one have a corresponding pediatric staff; three of the four high volume hospitals, and one intermediate hospital have a separate pediatrician in charge of the newborn service in addition to a chairman of pediatrics. With the exception of the two Kaiser Foundation hospitals, which have full time staffs to serve Kaiser Health Plan patients, these department chairmen are all private practitioners who serve part-time. Most of the hospitals reported that most deliveries are attended by specialists in obstetrics and gynecology. While the number of general practitioners who include obstetrics in their practices has been declining for a number of years, the current malpractice crisis has accelerated this trend. In today's liability insurance market few physicians other than specialists with a significant obstetrical caseload can afford the increased premiums charged physicians who provide obstetrical services.
Dublin &Livermore
Pleasanton
Sunol
Figure 1.-Location of hospitals with maternity units in Alameda County. Numbers correspond to those in Table 2. THE WESTERN JOURNAL OF MEDICINE
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Perinatal Mortality Committee All four of the high volume hospitals conduct a review of perinatal deaths weekly, biweekly or monthly. Two of them are multidisciplinary, with obstetrics, pediatrics, neonatology, anesthesiology and pathology represented. The others are conducted in the form of a joint obstetric-pediatric perinatal review with the other departments not routinely involved. Among the nine intermediate and low volume hospitals, four had no perinatal mortality committee at the time of the survey. Three had quarterly or monthly perinatal death reviews by representatives of obstetrics and pediatrics, one by the obstetrics department alone, and one (intermediate) included its perinatal death review with the hospital's standing committee review of all hospital deaths. Reports of perinatal mortality committee reviews of individual deaths were not made available for review in this survey. The county medical association (AlamedaContra Costa- Medical Association), to which a majority of practicing obstetricians and gynecologists and practicing pediatricians belong, conducts an annual perinatal mortality and morbidity survey through its standing Perinatal Mortality Committee. While the county medical association strongly encourages each hospital to have its own perinatal committee, compliance is optional and incomplete-and there is no mechanism to require standard reporting of perinatal events in the annual survey. Consequently, comparisons among the various individual hospitals' perinatal mortality rates is invalidated by differences in reporting criteria. Despite these shortcoming in documentation, the county medical association's Perinatal Mortality Committee is a potentially useful vehicle for communication among representatives of the various hospitals, an advocate of using standard perinatal review procedures yielding results that can be compared and a multidisciplinary in-house peer review vehicle for physicians in the private medical community concerned with the health care of mothers and newborn infants. Anesthesiology Service in Maternity Care Three hospitals (two high volume, one intermediate) provide coverage by a physician anesthesiologist for all deliveries. The remainder, with a single exception, rely on nurse anesthetists, with an anesthesiologist generally available from the surgical operating room for backup service or 72
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127 *
1
complicated cases. Only one hospital reported no backup anesthesiology coverage for its nurse anesthetists, but in this institution an anesthesiologist is available for cesarean sections. In general, anesthesia coverage in delivery rooms appears oriented primarily to care of the mothers. While Apgar scoring is routine (generally at one and five minutes) at all of the hospitals, only two of the 13 report that an anesthesiologist is responsible for the Apgar scoring, and in one of these the anesthesiologist is not present at all deliveries. In most of the hospitals Apgar scoring is done by the attending physician or the delivery room nurse, or both. In five hospitals a nurse anesthetist has this responsibility. Prenatal Care Most hospitals surveyed indicated that deliveries occurring with no history of prenatal care were rare or occasional, or not more than 1 or 2 percent of deliveries. Only one hospital reported as high as 10 percent and another hospital 15 percent (estimated) deliveries without prenatal care; both of these were low volume hospitals.
Maternity Beds A precise tabulation of available maternity beds is no longer possible since most hospitals have abandoned strictly separated maternity wards in favor of flexible arrangements with "swing" beds that may be occupied either by postpartum or clean gynecology cases, depending on daily needs. In general obstetrical bed space in Alameda County hospitals is considerably over-provided and underutilized. Several of the hospitals reported 50 percent or less average occupancy, reflecting the county-wide decline in births in recent years.
Special Maternity Services for High Risk Mothers Only one hospital (high volume) conducts a special clinic for high risk maternity patients. In this instance all maternity patients are screened at intake according to a locally designed protocol. Those with identified risk factors, approximately 10 percent, are referred to a special prenatal clinic attended by the senior obstetric staff and chief resident, with special consultants and dietary assistance available. Of the remaining 12 hospitals, only one reported significant identification and transfer of high risk mothers to tertiary care institutions in the area. With this sole exception, the hospitals
MATERNITY AND PERINATAL SERVICES
generally reported a reluctance by to transfer high risk patients before though high risk newborns are not transferred to hospitals with special tensive care units in the area.
obstetricians delivery, alinfrequently newborn in-
Fetal Monitoring Electronic monitoring of labor, both internal and external, is available at all 13 hospitals. In no instance is monitoring routinely done, although seven hospitals reported that it is done in most cases, with varying ratios of external versus internal techniques. In general, obstetricians appear to be withholding judgment on routine monitoring in uncomplicated cases, while there is a consensus on its use in cases involving risk factors.
Newborn Services As with maternity beds, no instance of crowded or overutilized newborn nursery facilities was encountered among the 13 hospitals surveyed. Several hospitals have considerable unused nursery space which has been closed in recent years. Of the four high volume hospitals, the two that serve the Kaiser prepaid health care system have their own neonatal intensive care network. The Kaiser Oakland hospital has a fully equipped and staffed neonatal intensive care unit which receives referrals from several other Kaiser hospitals in the. area, and which shares a full-time neonatologist with the Kaiser Hayward hospital. The latter, with intermediate intensive care facilities, however, transferred only four of 82 low birth weight babies delivered in 1974. The remaining two high volume private hospitals in the county also have intermediate newborn intensive care facilities and have developed a close working relationship with the neonatal intensive care unit of the Children's Hospital Medical Center of Oakland. The latter, through its transport and educational outreach program, provides in-service training of local hospital nursery staffs, consultation and staff training visits, assignment of neonatal intensive care unit nurses and pediatric residents in rotation, and special neonatal transport service with in-transit intensive care. During 1974 the Children's Hospital Medical Center unit was responsible for the care of approximately 900 high risk newborns transported from some 30 Northern California hospitals. In contrast to the underutilization of available newborn nursery facilities in general, the resources in Alameda County for intensive neo-
natal care have been overtaxed. A report based upon 1972-1973 data indicated an average occupancy rate of 139 percent (range 77 to 160) for the neonatal intensive care units serving the East Bay area which includes Alameda County. This pressure is now being alleviated by the opening of a newly constructed unit at the Children's Hospital Medical Center with a capacity of 20 infants in 1974, and an increase to 40 by July 1976. The medical director of the Children's Hospital Medical Center noted that the specialized training of the neonatal intensive care unit nursing staff was the key item in completing this expansion, since it requires 11 weeks of intensive on-the-job training to prepare each of these nurses for the new responsibilities in the unit. Pending completion of Children's Hospital Medical Center's expansion, several hundred newborns were transported each year to alternate centers in the San Francisco Bay Area. The Children's Hospital Medical Center staff assists in finding an alternate unit when needed, and recently Stanford University Medical Center, in a nearby county, has been designated as one of two Infant Medical Dispatch Centers in California, so that immediate location of alternate neonatal intensive care unit facilities can be made available with minimal delay. Though pediatricians were found to be generally less resistant to organizing perinatal services regionally than their obstetrical colleagues, both groups preferred selective transfer of high risk neonates. In general, transport of low birth weight infants to a regional neonatal intensive care unit is reserved for those in whom there is evidence of respiratory distress or complications other than prematurity per se. Several informants expressed confidence in their hospitals' ability to provide adequate care for an increasing proportion of low birth weight infants as local equipment and sophistication in the care of these infants grow.
Manpower Considerations Alameda County does not suffer from the shortage of trained manpower that affects some areas of the United States. A desirable geographic location, pleasant climate, abundance of social, cultural, and recreational resources, and a growing population (increase of 18.2 percent from 1960 to 1970) combine to make it an attractive location for the practice of medicine. It does, however, reflect the uneven distribution typical of combined urban-suburban American communTHE WESTERN JOURNAL OF MEDICINE
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ities with heterogeneous populations, with the heaviest concentration of physicians in the downtown area and suburbs, and with relative scarcity in the rural areas and low-income residential districts. The 1975 directory of the Alameda-Contra Costa Medical Association listed 115 pediatricians practicing in Alameda County, or a ratio of approximately 1:9,000 population, and 90 specialists in obstetrics and gynecology, a ratio of 1: 11,000 population. Comparison with listings in the Directory of American Medical Specialties indicates that virtually all of the Board Certified specialists are represented in the membership of the county medical association. Therefore, even though not all of the specialists in obstetrics and gynecology are currently practicing obstetrics, it is evident that ample trained personnel exist, if evenly distributed, to afford specialist care to all mothers and infants in the county. Moreover, the growth of residency training both in pediatrics and in obstetrics and gynecology suggests that sufficient specialists in these fields will be produced to more than maintain these ratios in the face of the anticipated 13.1 percent population increase projected for the county between 1970 and 1980. Residency positions in obstetrics and gynecology nationwide increased by 25 percent from 1963 to 1973 and pediatric residency positions more than doubled in the same period. The role of paramedical personnel in enhancing the efficiency, reducing the cost or compensating for unequal distribution of specialist physicians is not yet sufficiently established to measure in Alameda County. Both maternity and pediatric nurse practitioners have been trained in California training programs for several years, but their place in the health team remained legally uncertain until revision of the California Nurse Practice Act in 1974. Their diffusion into employment by the private medical community, while it has begun, has been slowed by the current apprehension over liability and rising costs of insurance which concern many would-be physician employers. They are, however, being widely and effectively used in a number of hospitals and clinics, both public and independent, and in a few private practices, where their acceptance by patients and physician colleagues has been favorable. It is simply too early to say quantitatively what their ultimate contribution to the health team will be in Alameda County.
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The same observation applies even more to nurse-midwifery in California, since the legislation allowing nurse-midwives to attend normal obstetrical cases was enacted only in late 1974. Only seven of the 90 specialists in obstetrics and gynecology listed were women. Consumer advocates in general, and the feminist movement in particular, have been increasingly vocal in their criticism of male dominated obstetrical care. As opportunities grow for women to pursue careers in the health professions, increased participation of women in maternity care undoubtedly can be expected, whether as physicians, nurse-midwives or nurse-practitioners. Training New Medical Specialists Obstetrics and Gynecology According to data from the American Medical Association, from 1950 through 1962 the number of programs approved for training residents in obstetrics and gynecology in the United States increased. Beginning in 1962 the number of approved residency programs has decreased by a fourth (Table 3). However, from 1950 through 1973 the number of total positions for residents, and the number of these positions filled has considerably increased. The percentage of resident positions filled rose from 1950 to 1959, decreased somewhat in 1961, and has been at the level of 86 to 93 percent since 1961 (Table 3). Pediatrics From 1950 through 1963 the number of programs approved for residency training in pediatrics increased. Since 1963 the number of approved programs has decreased by a fourth. (Table 4). However, from 1961 through 1973 the number of total positions for residents and the positions for residents filled has consistently increased. The percentage of resident positions filled rose from 1950 to 1958, decreased to a lower level from 1959 to 1969, and rose again from 1970 to 1973 (Table 4). Therefore, an overall summary of the national effort to train medical specialists in obstetrics and gynecology and in pediatrics is that, while the number of approved programs has decreased, the number of persons being prepared has increased. This increase in both obstetrician-gynecologists and in pediatricians has occurred in
MATERNITY AND PERINATAL SERVICES TABLE 3.-Residency Training in Obstetrics and Gynecology in the United States, 1950-1973* Year
Approved Program
381 1950 406 1951 326 1952 352 1953 374 1954 406 1955 473 1956 484 1957 477 1958 446 1959 462 1960 491 1961 483 1962 483 1963 434 1964 402 1965 391 1966 381 1967 358 1968 364 1969 350 1970 346 1971 1972 . 337 1973 . 347
Positions
Positions
1,599
1,266 564 520 589 637 763 800 942 956 908 880 844 2,403 2,457 2,500 2,526 2,507 2,526
Offered
754 616 688 737 839 904
1,014 1,013 960 942 944
2,705 2,728 2,806 2,824 2,829 2,897 2,872 3,042 3,081 3,177 3,368 3,413
Filled
2,503 2,572 2,655 2,800 3,006 3,183
Positions Percentage Filled Vacant
333 190 96 99 100 76 104 72 67 52 62 100 242 271 306 298 322 371 369 470 426 377 362 230
79 75 84 86 86 91 89 93 93 95 93 80 91 90 89 89 89 87 87 85 86 88 89 93
*Figures do not include separate residencies in obstetrics or gynecology alone which were available only until 1961. Source: The American Medical Association's Annual Directories of Approved Internships and Residencies.
TABLE 4.-Residency Training in Pediatrics in the United States, 1950-1973* Year
1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973
Approved Program .. 242 ..237 ..244 ..249 ..246 ..265 ..266 ..281 ..291 ..295 ..309 ..315 ..342 ..356 ..308 ..297 ..289 ..277 ..260
..24;50
..258 ..250 ..251 ..274
Positions
Positions
1,258 670 639 739 722 738 802 843 934 937 981 1,056 2,100 2,234 2,290 2,397 2,430 2,508 2,539 2,764 2,830 3,086 3,496 4,409
1,073 533 526 634 638 637 715 737 864 838 886 843 1,735 1,820 1,935 2,043 2,070 2,186 2,185 2,445 2,592 2,844 3,238 4,231
Offered
Filled
Positions Percentage Vacant Filled
185 137 113 105 84 101 87 106 70 99 95 213 365 414 355 354 360 322 354 319 238 242 258 178
85 80 82 86 88 86 89 87 93 89 90 80 83 81 85 85 85 87 86 89 92 92 93 96
*Figures do not include specialized residencies in pediatric allergy and cardiology. Source: The American Medical Association's Annual Directories of Approved Internships and Residencies.
spite of the pronounced reduction in the live birth rate, in the fertility rate and in the proportion of the total population represented by children and youth. California data for 1974 show a beginning reversal in the downward trend in recent years in fertility, prompting demographic analysts to suggest that some women who have postponed marriage and childbearing do not intend to remain childless and may be starting to make up for lost time. Yet, while current projections of population trends for the immediate future include some increase in annual births over the coming decade, these generally do not anticipate a baby boom of a magnitude of that after World War II. The fact remains thlat the output of trained medical specialist manpower both in obstetrics and gynecology and in pediatrics has neither corrected the maldistribution of specialists nor allowed for fluctuations in the need for specialists according to demographic trends. As a result of this lack of an overall plan, dislocations and adjustments in patterns of practice, neither planned nor welcomed by the physicians themselves or their patients, are bound to occur. Krassner and Muller, in a recent analysis of manpower trends in obstetrics and gynecology2 point out that the greatest impact of oversupply will be on new entrants into the specialty of obstetrics and gynecology. They suggest that the reallocation of physician time to allow for the increased need for fertility control will come about through market forces. Ward, in a subsequent comment,3 emphasizes that nonphysician professionals are now being trained to provide family planning services and suggests instead that rendering primary health care to women is more likely to fill obstetricians' time released by declining births. Whatever the nature of the adjustment, no corresponding compensatory market mechanism appears on the horizon for pediatricians, whose relative oversupply parallels that of obstetricians.
Discussion The findings of this survey illustrate the need for community planning directed at four specific problems in the care of mothers and newborn infants in Alameda County. These may be summarized as follows: 1. There is need for further consolidation of obstetrical and newborn facilities. Despite general acceptance of the concept of a regional apTHE WESTERN JOURNAL OF MEDICINE
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proach in principle, there has been virtually no consolidation of small obstetrical and newborn units since 1967. (As previously noted, one intermediate volume hospital has discontinued its obstetrical service since this survey was completed.) The resulting underutilization of generally overbuilt hospital maternity and nursery units is costly and inefficient. Among the general principles for consideration in a possible consolidation are-the grouping or regrouping of the smaller maternity services into reasonable geographic service areas, which the various segments of the county community would find acceptable. This might include large urban areas such as the city of Oakland, on the one hand, and other parts of the outlying county which are geographically close to each other and within a reasonable travel time. For example, the maternity services of hospitals within the metropolitan area of Oakland might be consolidated for an overall total of 2,800 annual deliveries, thereby meeting the criteria for a bona fide level II obstetric service. 2. There is need for a comprehensive multidisciplinary program to provide high-risk maternity and neonatal care in the central city area where perinatal and infant morbidity and mortality rates are highest. Such a program, patterned after successful maternal and infant projects in a number of American cities, should include screening for risk factors and special nutrition, education, social welfare, consultative medical and laboratory resources for those who meet appropriate criteria for intensive prenatal and perinatal care. Special emphasis should be given to care for pregnant teenagers, to provide them with preconceptional care (including health care, health education, family life education and nutrition education and service). 3. There is need for a coordinated plan to assure appropriate geographic distribution of health manpower in the face of * demographic trends, notably the pronounced reduction in fertility in recent years;
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JULY 1977 * 127 * 1
* a relative overproduction of medical special-
ists; * continued maldistribution of health personnel, and * increasing reliance on allied health personnel in the delivery of primary care. 4. There is need for more effective planning and coordination of services provided by public and voluntary community health agencies, professional societies and private practitioners in order to avoid wasteful duplication and oversupply of resources and assure equitable access to quality care in all areas of the county.
Conclusion The findings of this survey of one urban-suburban community in California have significant implications for similar communities throughout the United States. Similar surveys to identify the strengths, weaknesses and imminent needs of communities throughout the country would be useful in establishing a framework for constructive planning of health delivery systems in the continuing quest for equitable, efficient and high quality health services for all families. It is suggested that official health agencies and professional societies take the leadership in these surveys, as a first step toward planning organized, community-wide health care of maternity patients and newborn infants. REFERENCES 1. Hawes WE: A survey of newborn intensive care centers in California. West J Med 123:81-84, Jul 1975 2. Krassner M, Muller C: Manpower in obstetrics-gynecology in a period of declining birth rate. Med Care 12:1031-1037, Dec 1974 3. Ward R: Comments on "Manpower in ob/gyn in a period of declining birth rate." Med Care 13:695-696, Aug 1975 4. Lipson AJ: California health manpower: An overview of trends in policy issues. Prepared for the California Department of Health, R-1572-CHD Mar 1974 (Rand Corporation) 5. Committee on Perinatal Health: Toward improving the outcome of pregnancy-Recommendations for the regional development of maternal and perinatal health services. The National Foundation, March of Dimes, White Plains, NY, 1976 6. Russell KP, Gardner SH., Nichols EE: A conceptual model for regionalization and consolidation of obstetric-gynecologic services. Am J Obstet Gynec 121:756-764, Mar 15, 1975 7. Moriarity D, Hecomovich D: Physician manpower-An approach to estimation of need in California. Comprehensive Health Planning Sep 1973. Now available from California Dept of Health, Office of Health Professions Development, Sacramento
