The North Carolina obstetrics access and professional liability study: a rural-urban analysis

During the 1980s a rapid rise in the costs of malpractice coverage for obstetrical services caused many practitioners to stop delivering babies. Other factors also influenced the decision by physicians to exclude obstetrics from their practices, including: increases in malpractice claims made against obstetrical providers and the subsequent fear of being sued; closures of hospital obstetrics units; issues involving Medicaid; and the daily stresses inherent in providing obstetrical care. Rural areas were particularly vulnerable to these factors. North Carolina was not unlike other states in recognizing a severe drop in access to obstetrical services in many communities, and policies were proposed to address this problem through tort reform, malpractice subsidies, and Medicaid program expansion. The exodus of obstetrical providers seemed especially critical in rural areas, and this article presents a metropolitan-nonmetropolitan analysis of the results of a survey of all obstetricians and gynecologists active and licensed to practice in North Carolina. The analysis is focused on provider responses to proposed policies and also examines the clinical support networks for these physicians to determine if this might also be an area for future policy activity. Important differences were found between rural and urban providers in terms of intensity of obstetrical practice, adequacy of backup, Medicaid participation and caseload, ideas about tort reform, and recent changes in obstetrical practice. The results indicate that policies to increase demand or income can help solve the rural obstetrical access problem but that states should pay equal attention to the clinical support system for practitioners.