ACOG Issues Committee Opinion on Rural Women's Health Disparities

By Rachel Walden — March 9, 2009

The American College of Obstetricians and Gynecologists has issued a committee opinion on the health disparities faced by rural women in the United States, highlighting problems of access to care (with emphasis on access to reproductive health) and encouraging physicians to become involved in efforts to reduce and eliminate these problems. The organization explains that “lack of access to adequate women’s health care puts rural women in the US at a greatly increased risk of poor health outcomes compared with women in urban areas.”

In summarizing the issue for ACOG’s press release, Alan G. Waxman, MD, chair of ACOG’s Committee on Health Care for Underserved Women, stated that although “rural communities are home to 17% of all females 15 and older in the US, and 18% of all US births take place there… nearly one-third of rural women live in counties with no ob-gyn at all.”

Committee member Eliza Buyers, MD also remarked:

“When compared with their urban counterparts, US rural women experience higher rates of cervical cancer, and they receive fewer preventive screenings such as mammograms, Pap tests, and colorectal screening. They are also less likely to have received at least one family planning service in the past year and have an increased risk of receiving inadequate, late, or no prenatal care. Without enough health care facilities and clinicians to provide basic women’s health care, these women are at a higher risk of developing problems that could be prevented.

Their reproductive health care is also in jeopardy. Many of the least-populated communities do not have publicly funded family planning clinics, severely limiting a woman’s contraceptive options.”

Among the recommendations to physicians in the opinion (which is unfortunately not freely available online):

  • Collaborate with maternal-child and rural health agencies in your state to identify the health needs of rural women and barriers to care. Share your professional expertise as a member of an advisory committee or task force focused on improving the health of rural women.
  • Partner with family physicians and other women’s primary care providers to ensure that appropriate consultation and training are available for practitioners in rural areas.
  • Conduct further research to understand acceptable conditions for performance of vaginal birth after cesarean delivery in rural areas and to study the effect of vaginal birth after cesarean delivery policies on access to care for rural women.
  • Advocate for increased access to contraceptive methods and emergency contraception.
  • Advocate for availability of safe, legal, and accessible abortion services.
  • Rural health disparities are only partially due to lack of health care services. Rural communities have disparities in education, employment, and poverty that also should be addressed.

While I’m happy to see ACOG encouraging action, these are large problems that are unlikely to be solved by simply telling providers to do more – federal solutions encouraging providers to go to rural areas (such as medical school loan forgiveness) and systemic change are likely needed. For additional discussion of rural health issues, see the Rural Women’s Health Project and the National Rural Health Association.

7 responses to “ACOG Issues Committee Opinion on Rural Women’s Health Disparities”

  1. What a shame that ACOG has taken such a ridiculously anti-midwifery stance. It has masked them to the benefits licensing homebirth care providers brings to rural areas. Midwives are uniquely poised to meet the needs of rural women, improving their access to health care during the childbearing year. While OBs flee the countryside, midwives are aching to legally practice, yet ACOG treats them like enemy #1. Sad.

  2. “Partner with family physicians and other women’s primary care providers ” makes me think that maybe this is in part reference to mid-level providers- namely NPs, CNMs, and PAs. But interesting that they don’t specifically state this. I’m not sure that their committee opinion was meant to ignore how many CNMs serve rural areas, but Lauren makes a good point. They are not exactly embracing what is already being done.

  3. “Partner with family physicians and other women’s primary care providers to ensure that appropriate consultation and training are available for practitioners in rural areas.”

    :::hurl:::: Because, yeah, MIDWIFE is such a dirty word and surely cannot be spoken aloud. This is utter proof of how threatened ACOG is by midwives (and frankly, with reason, though not defensible ethical or moral reasons).

    I am a homebirth midwife in a rural area. We are privileged to have OB support because the docs learned the hard way that not supporting midwives results in them getting dumped on with terrible situations. No one wants that. And, secondly, because we are blessed in serving a (Plain) community who demands professional midwives, or else birth on their own, period.

    Within several hours of our community there are vast rural areas where no OB has agreed to back up any midwife or birth center. So the same community of women are forced to choose lesser care, and maternal-child outcomes are worse. So much for “primum non nocere” hunh? As if anyone ever thought ACOG cared first and foremost about women and babies – ha!

    Shame on you, ACOG.

  4. Between the ER doctor, the Family doctor, and the General Surgeon, rural communities are capable of handling birth and other women’s health issues without OB/Gyns or midwives, thank you very much.

    The reason women’s issues don’t get much attention in rural areas is rural doctors tend to be men. Put a woman in any one of the above physician positions and you will see a dramatic improvement. Even rotating a female emergency doctor in from a near-by city helps. Make sure she has double coverage, because local women come out in droves for their gyny issues when they get wind.

    The reason midwives aren’t popular has nothing to do with OB/gyns trying to put them out of business due to competition. By the time a midwife transfer gets from a rural area to an OB, the situation is usually unsavable. The midwives usually have no or little insurance, and are part of the local community. Therefore, the lawyer goes after the OB. This is why they don’t like midwives. They try to handle things that are extremely risky with an unproven solution they have only read about in a textbook. Worse yet, they don’t recognize problems until they are far out of control.

    In addition, rural families think of them as last-resort, better-than-nothing providers. That’s the real reason midwives aren’t making much headway, even in places where there isn’t the traditional OB. We’re actually not as dumb as we look! Outcomes are poorer with independent delivery as opposed to a hospital, but no worse than with a midwife. They are probably better. The average Joe and Jane calls an ambulance when the baby pops out a leg or a behind first. They don’t sit there and “trust birth” and end up with a brain damaged or dead child.

    The above comment about how OBs better back midwives or else is telling. If you call an ambulance when you should, why would it make a difference? They have a legal obligation to treat whoever rolls in the door. If you want free advice over the phone, I can see why they might be pissed. This is healthcare, not Who Wants to Be A Millionaire. There’s no lifeline call when you are in over your head. BTW, if didn’t speak latin you’d fit in better. We don’t talk to dead people in fly-over country.

  5. “Between the ER doctor, the Family doctor, and the General Surgeon”

    Oh yeah, because so many women want to be attended by an ER doc or a general surgeon! I agree with you on the family doc, though, an important part of the team.

    BTDT, where was the “better back midwives or else” in my post?

    And notice I said professional midwives. CNMS are licensed and do carry malpractice insurance. And heck, can work in the hospital too. I have hospital privileges.

    “Outcomes are poorer with independent delivery as opposed to a hospital, but no worse than with a midwife. They are probably better.”

    Uggh, show me the evidence of this, doc. (holding breath)

  6. An aquaintance of mine ran headfirst into this problem a year ago when she moved to a rural area, 200 miles from the nearest hospital equiped for child-birth and 150 from the nearest midwife. A few weeks after the move, they found out her husband’s vasectomy had failed (8 or 10 years later). The only family practitioner in the area had dropped his childbirth malpractice insurance, so even HE couldn’t help her.

    Some midwives in my area, upon hearing of the problems in that county, banded together to try to find someone, liscenced by the state midwife board, to move into the area, but by the time they succeeded, it was a bit late for my friend. She had already had some really nasty complications that ended with a micro-preeme in the NICU of a hospital in another state.

    This is simply NOT RIGHT! It’s time to quit the petty bickering within the women’s health community and throw ALL our resources at the problems. Properly trained midwives are more than adaquate care providers for uncomplicated low-risk births and are very good at identifying those pregnancies which they are not prepared to handle. Doctors in areas with midwives need to be able to work WITH those midwives to provide continuity of care to women who need to transfer. And an increase in the number of CNMs and CMs who provide well-woman care would reduce the burden of emergency or critical care needed for conditions that can and should be caught early.

    My midwives (a CNM, CM and 2 CPMs) always err on the side of caution and are very quick to transfer (or refer to an ob-gyn) with anything that tilts outside the “norm.” Which is why they only cover a reasonably small area: if there’s no nearby hospital equipped for an emergency birth, they won’t provide care. The only way to increase their ability to provide care over a larger area is to see more access to maternity care at the small-community hospitals and more OBs and support staff manning those hospitals.

    All of that is going to take a lot of creativity and energy to solve. So I’m glad ACOG is recognizing the problems. I just hope that the Federal government will take notice and put their thinkers to work on some solutions. *sigh*

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