Katherine Bakke, MD, MPH; Ciara Michel, MPH
WMJ. 2024;123(6):468-470.
Maternal morbidity and mortality in the United States is a critical public health issue, particularly in rural areas, which have significantly higher rates compared to urban areas.1 Reasons for this disparity are multifactorial; however, lack of access to maternal health care, hospital disruptions and closures, inequitable resource distribution, and workforce shortages are major contributors.1 In many respects, rural Wisconsinites have better maternity care access compared to other rural residents in neighboring states, as demonstrated in the Table. (See full-text pdf for Table.)
When defining “maternity care provider,” March of Dimes does not include general surgeons as part of the obstetric workforce, instead counting only obstetric/gynecologic (OB/GYN) physicians, midwives, and family medicine physicians.2 While general surgeons typically only participate in operative obstetric care, like cesarean deliveries, the availability of a clinician who can perform a cesarean delivery is essential for safe, high-quality, and lifesaving obstetric care. Indeed, cesarean delivery availability is associated with increased local deliveries and decreased preterm births.3 Often in rural hospitals, the only provider available to perform a cesarean delivery is a general surgeon.
According to the Wisconsin Office of Rural Health (WORH) 2024 report “Obstetric Delivery Services and Workforce in Rural Wisconsin Hospitals,” 100% of rural Wisconsin hospitals with labor and delivery units provide cesarean deliveries.4 However, from 2009 through 2018, 11 rural Wisconsin hospitals closed their labor and delivery units, primarily due to clinician shortages.5 OB/GYN physicians perform cesarean deliveries at 45% of rural Wisconsin hospitals.4 In 34% of hospitals, a combination of OB/GYNs, family medicine physicians, and/or general surgeons split this responsibility; in 3% of hospitals, it is the responsibility of general surgeons alone.4 Interestingly, the 2018 WORH report stated that general surgeons alone performed cesarean deliveries in 9% of rural hospitals.5 One hypothesis for this 6% decrease is that older surgeons with operative obstetric skills are retiring, and younger surgeons replacing them do not have the same skills.
Advanced obstetrics fellowships (such as those at Gundersen Health System and the University of Wisconsin) exist for family medicine physicians, yet no equivalent training is available to general surgeons. Furthermore, general surgery residents are no longer required by the American College of Graduate Medical Education to complete an OB/GYN rotation, which has implications for residents preparing for rural practice.6 While the general surgeon’s role in obstetric care is small, it requires an understanding of operative obstetrics and the unique management of resuscitation in pregnant patients. An operative obstetric training course for general surgeons is one way to expand the availability of rural obstetric care in Wisconsin, the Midwest, and, potentially, the United States.
As the director of the Regional General Surgery Outreach Program at the University of Wisconsin, Dr Bakke has been in conversation with rural general surgeons throughout Wisconsin about obstetric care. Most surgeons state that they, intending to practice in a rural community, took it upon themselves during residency to foster relationships with OB/GYNs and trained for extra hours to learn how to perform cesarean deliveries. Others state that a senior OB/GYN or general surgeon supervised them in cesarean deliveries at their start of practice until they were competent to perform the procedure independently. These conversations also revealed there are essentially no formal operative obstetrics training opportunities available to surgeons in the US. The only course available, which one rural Wisconsin surgeon attended, is a 2-day global health training at Stanford University that teaches basic operative obstetrics along with orthopedics, plastic surgery, and burn care.9
Most surgeons said that learning the steps of a cesarean delivery is not difficult; rather, learning how to anticipate and troubleshoot problems is the foremost challenge of operative obstetrics. The amount of bleeding, twin deliveries, fetal or maternal distress, repeat cesarean deliveries, patient obesity, prolonged labor, and breech presentations were cited as clinical challenges they have learned to manage – often emergently with little or no assistance. The risk of litigation looms in these surgeons’ minds as to whether they should provide a surgery they are not expected to master by the American Board of Surgery. Yet, their commitment to their patients is strong, with most rural surgeons offering their surgical skills to provide an essential component of care to their community.
The Canadian Association of General Surgeons (CAGS) recognized that rural surgeons in Canada often are responsible for operative obstetrics and created a training program to increase the number of general surgeons able to perform cesarean deliveries.10 CAGS members can enroll in the “Operative Delivery and Maternal Care for General Surgeons Program,” a 10-week online course with a 1-day simulation skills course at the CAGS annual conference and hands-on training at host hospitals where surgeons perform a minimum of 25 cesarean deliveries, 5 dilation and curettage procedures, and 5 tubal ligations.10 The program results in a “Certificate of Recognition in Operative Delivery and Maternal Care for General Surgeons” for surgeons to demonstrate competency in operative obstetrics to gain hospital privileges.10
As evidenced by numerous discussions on the American College of Surgeons “rural surgery” community forum, there is both interest and need for such a program in the US. To be successful, an operative obstetrics training course would require similar rigor as the CAGS program, collaboration between rural and urban hospitals, recognition by the American College of Surgeons and the American College of Obstetricians and Gynecologists, and have the support of both trainee and host hospital leadership.
Existing didactic curricula for operative obstetrics in OB/GYN training programs could be refined for general surgeons, and academic centers with simulation centers could offer operative obstetrics simulation courses. The more challenging piece is how to provide hands-on patient experience in operative obstetrics to general surgeons. In Wisconsin, many rural hospitals are part of a larger health system network, and many have established relationships with academic centers. Leveraging these relationships could allow the creation of “mini fellowships” for general surgeons seeking hands-on patient experience and exposure to operative obstetrics in a proctored setting.
One concern is how such a training course may “take away” cases from trainees in the existing obstetrics programs. This concern is valid but not insurmountable. Data suggest that new learners should perform between 10 and 40 cesarean deliveries before becoming safe for independent practice.11 These studies were performed with resident physicians; it can be assumed that practicing general surgeons knowledgeable in instrument exchange, tissue handling, and pelvic anatomy would have a shorter learning curve. With Meriter Hospital in Madison, Wisconsin, performing over 1000 cesarean deliveries per year, as one example, there are plenty of educational opportunities for learners at all stages of their careers.12
There are logistic and financial issues that must be addressed for an operative obstetrics training program to succeed. To encourage surgeon enrollment, hospitals could reimburse for registration, travel, and lodging via continuing medical education (CME) funds. Certainly, CME credit would be provided to the surgeon for course completion. Host hospitals would need to streamline rapid credentialing of visiting surgeons and have medical staff willing to teach. Rural hospitals would need to hire a locum tenens surgeon to take call while a staff surgeon is training; however, training could be split over several weekends (as opposed to a month-long intensive) to allow rural general surgeons to return to their practice during the week. The cost of providing the training and the administrative overhead at the host hospital also would need to be addressed.
Overcoming such challenges would be well worth the benefit. According to WORH, “hospital OB units with fewer than four providers covering surgical obstetric services (cesarean deliveries) can be considered ‘at risk’ of closure due to the non-sustainable nature of coverage.”5 Indeed, one of the most frequently requested services requested from the UW Health Regional Services Program is cesarean delivery coverage, according to Allison Henke, vice president of UW Health Regional Services (personal conversation, June 24, 2024) . This suggests there is already a strained rural obstetric workforce in Wisconsin. Increasing operative obstetrics training for general surgeons is not just a maternal morbidity and mortality issue, but also an issue of physician well-being and workforce retention.
In Wisconsin, the number of rural hospitals offering obstetric services is higher than the national average, but some of these units undoubtedly will be at risk of closure in the future. As seen throughout the US, closure of rural labor and delivery units worsens maternal morbidity and mortality for already vulnerable rural populations. General surgeons play a vital role in keeping the doors of labor and delivery units open. Projections predict shortages for both OB/GYN and family medicine physicians, with declines in OB/GYN physicians practicing in rural areas and family medicine physicians practicing obstetrics.13 The demand for general surgeons who provide operative obstetric care can only be expected to increase in the future. To expand obstetric services in rural Wisconsin and across the Midwest, collaborative postgraduate training in operative obstetrics for general surgeons should be a priority of the State, its academic medical centers, and its large network of hospital systems. Doing so could position Wisconsin as a leader in maternal health care and contribute to efforts urgently needed to reduce the morbidity and mortality facing rural mothers.
REFERENCES
- Kozhimannil KB, Interrante JD, Henning-Smith C, Admon LK. Rural-urban differences in severe maternal morbidity and mortality in the US, 2007-15. Health Aff (Millwood). 2019;38(12):2077-2085. doi:10.1377/hlthaff.2019.00805
- Stoneburner A, Lucas R, Fontenot J, Brigance C, Jones E, DeMaria AL. Nowhere to go: maternity care deserts across the US: 2024 report. March of Dimes. 2024. Accessed October 7, 2024. https://www.marchofdimes.org/peristats/assets/s3/reports/2024-Maternity-Care-Report.pdf
- Lynch N, Thommasen H, Anderson N, Grzybowski S. Does having cesarean section capability make a difference to a small rural maternity service? Can Fam Physician. 2005;51(9):1238-1239.
- Ledger J, Olson M, Black P. Obstetric delivery services and workforce in rural Wisconsin hospitals. Wisconsin Office of Rural Health. August 2024. Accessed October 7, 2024. https://worh.org/wp-content/uploads/2024/08/2024-OB-Report_13Aug2024.pdf
- Wisconsin Office of Rural Health. Delivery services and workforce in rural Wisconsin hospitals. Revised July 2019. Accessed May 27, 2024. https://worh.org/wp-content/uploads/2019/09/ObstetricServicesReport2018Revised.pdf
- Doescher MP, Jackson JE, Fordyce MA, Lynge DC. Variability in general surgical procedures in rural and urban US Hospital inpatient settings. WWAMI Rural Health Research Center. Final Report #142. February 2015. Accessed October 10, 2024. https://depts.washington.edu/uwrhrc/uploads/General%20Surgery_%20Final_2015.pdf
- Cesarean Delivery Rate by State, 2022. National Center for Health Statistics. Accessed October 10, 2024. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm
- Harrington KA, Cameron NA, Culler K, Grobman WA, Khan SS. Rural–urban disparities in adverse maternal outcomes in the United States, 2016–2019. Am J Public Health. 2023;113(2):224-227. doi:10.2105/AJPH.2022.307134
- International Humanitarian Surgical Skills Course– 2024. Stanford Center for Innovation in Global Health. September 13, 2023. Accessed September 23, 2024. https://globalhealth.stanford.edu/education/international-humanitarian-surgical-skills-course-2024.html/
- Operative Delivery and Maternal Care for General Surgeons Program. Canadian Association of General Surgeons. Accessed May 27, 2024. https://cags-accg.ca/operative-delivery-and-maternal-care-for-general-surgeons-postgraduate-course/
- Madsen K, Grønbeck L, Rifbjerg Larsen C, et al. Educational strategies in performing Cesarean section. Acta Obstet Gynecol Scand. 2013;92(3):256-263. doi:10.1111/aogs.12055
- Cesarean birth trends for UnityPoint-Meriter (lower is better). Wisconsin Hospital Association. Accessed May 27, 2024. https://checkpoint.wha.org/TrendReport/TrendReport?measurementID=84&facilityID=061
- ACOG Committee Opinion No. 586: Health disparities in rural women. Obstet Gynecol. 2014;123(2 Pt 1):384-388. doi:10.1097/01.AOG.0000443278.06393.d6