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Obstacles to Accepting Care: Understanding Why Obstetric Patients Leave against Medical Advice
Connie F Lu1, Chloe N Matovina2, Ashish Premkumar3
1Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior St, Suite 03-2303, Chicago, IL, 60611, USA. connie.lu@nm.org.
Insights
Obstetric patients leaving against medical advice (AMA) face systemic barriers, not just personal choices. Addressing extrinsic and intrinsic obstacles can improve maternal and infant health outcomes.
Area of Science:
- Obstetrics and Gynecology
- Public Health
- Health Services Research
Background:
- Discharge against medical advice (AMA) in obstetrics is under-studied and disproportionately impacts marginalized populations.
- AMA discharges are linked to adverse perinatal outcomes, yet reasons remain unclear.
- Understanding patient obstacles is crucial for improving care and reducing disparities.
Purpose of the Study:
- To identify obstacles preventing obstetric patients from accepting recommended care.
- To highlight structural reasons contributing to AMA discharges in obstetrics.
- To inform strategies for reducing AMA discharges and improving perinatal health.
Main Methods:
- Qualitative thematic analysis of clinician and social worker progress notes.
- Review of electronic health records for obstetric patients discharged AMA (2008-2018).
- Categorization of documented reasons for discharge.
Main Results:
- Fifty-seven obstetric patients (0.12%) were discharged AMA.
- Extrinsic obstacles (childcare, family duties) were cited by 50.9% of patients.
- Intrinsic obstacles (disagreement, distress, mistrust, substance use) were cited by 40.4% of patients.
- No reason was documented for 19.3% of AMA discharges.
Conclusions:
- The term AMA unfairly blames patients, masking systemic barriers.
- Obstetric patients face both extrinsic and intrinsic obstacles leading to AMA discharge.
- Addressing structural barriers and partnering with patients can prevent AMA discharges, improving maternal-infant health and reproductive justice.
Introduction:
Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated with worse perinatal outcomes. Reasons for discharges AMA are not well understood. The objective of this study is to identify the obstacles that prevent obstetric patients from accepting recommended care and highlight the structural reasons behind AMA discharges.
Methods:
Electronic health records of patients admitted to antepartum, peripartum, or postpartum services between 2008 and 2018 who left "AMA" were reviewed. Progress notes from clinicians and social workers were extracted and analyzed. Reasons behind discharge were categorized using qualitative thematic analysis.
Results:
Fifty-seven (0.12%) obstetric patients were discharged AMA. Reasons for discharge were organized into two overarching themes: extrinsic (50.9%) and intrinsic (40.4%) obstacles to accepting care. Eleven participants (19.3%) had no reason documented for their discharge. Extrinsic obstacles included childcare, familial responsibilities, and other obligations. Intrinsic obstacles included disagreement with provider regarding medical condition or plan, emotional distress, mistrust or discontent with care team, and substance use.
Discussion:
The term "AMA" casts blame on individual patients and fails to represent the systemic barriers to staying in care. Obstetric patients were found to encounter both extrinsic and intrinsic obstacles that led them to leave AMA. Healthcare providers and institutions can implement strategies that ameliorate structural barriers. Partnering with patients to prevent discharges AMA would improve maternal and infant health and progress towards reproductive justice.
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