The first time I met Stephanie Stone was swimming. She is not a fast swimmer but a stalwart one. A staunch devotee of open water swimming. Hers is not the kind of personality to be contained by a pool. The lagoons of northern Humboldt County, with the ocean pounding a spit of sand away, Roosevelt elk grazing the brackish shoreline, and the whims of weather calling the shots, all seem to resonate with this midwife who’s grown accustomed to turbulent beauty.
“Swimming is a metaphor for all life,” says Stephanie, who sees about twenty patients a day, and is on 24-hour call two or three times a week. “Swimming and labor are both practices in being present, in the moment, but also flowing with whatever obstacles or challenges the water—or labor—present; one stroke at a time, one contraction at a time.”
Waves of change are coming in how babies will be delivered. And in rural America, in particular, they are already being acutely felt.
To listen to Stephanie, and watch her swim, is to not only get a better understanding of her philosophy regarding childbirth, but also feel her passion.
“I am honored to do this work,” she says. “Women in labor often feel—as I do swimming—like they are being brought to a brink. And then they go beyond that brink again and again to have their baby. I love when the babies come out. I love watching women transform during labor into a mother.”
This midwife who seems reborn by every swim, by every birth, not surprisingly repeats these words frequently: “acceptance … focus … patience … endurance”. She’ll need them. Waves of change are coming in how babies will be delivered. And in rural America, in particular, they are already being acutely felt.
No Slack In The System
According to a study in the New England Journal of Medicine, a county the size of Humboldt should have at least 13 Obstetrician/Gynecologists (OB/GYN’s). But it has only five, and four of them are age 65 or older. Only two of them work full time.
“I’m 65 this year and I had a heart attack three years ago,” says Dr. Deepak Stokes, who is one of those full-time obstetricians. “What would happen if I have a heart attack again tomorrow? Then all of a sudden [there] is a major crisis and you just can’t fill it overnight.”
More than likely, finding a replacement physician would take months. The United States is facing a shortage of OB/GYN’s of nearly 25-percent over the next 15 years. Nationally, the number of OB/GYN training programs—and the number of medical students entering them—has been dropping. The shortage will likely be most acutely felt in rural counties, half of which do not have an OB/GYN.
When Dr. Stokes arrived in Humboldt County in 1980, at the age of 30, the baby-delivering business was much different. “Dr. Loring got me here. There was no contract. We just shook hands,” recalls Stokes. “He told me take 50-thousand dollars or 50-percent, whichever was larger. The result was that I was very busy working every second or third day on call.” Now 50-thousand dollars is almost exactly what Dr. Stokes pays each year in malpractice liability premiums alone.
Over the past decade the number of physicians delivering babies in Humboldt County has dropped by half. Even though the two full-time OB/GYN’s in the county—Dr. Stokes in Eureka and Dr. Jack Anderson in Fortuna—each have three or four midwives working with them, state law still requires that they be close by and reachable for all deliveries in case of complications. This means these two men, ages 65 and 69, have been on-call, 24-7, for most days of their 30-plus-year careers.
“There is no slack in the system. Everybody is working as hard as they can,” says Dr. Chris Cody, a Humboldt pediatrician who has regularly worked alongside local obstetricians over the past 33 years. “We need a couple more bodies. Because if one of these large producers should go down, then you will have a crisis. Then you may be having a problem with patients not being able to find care.”
We Can’t Compete With That
Michelle Voyles is what locals call “Frumboldt”; her family has been in Humboldt County for five generations. Maybe that is why one of the local hospitals enlisted her help as a real estate agent, not only to show potential physician recruits some properties, but also showcase the best of what the area has to offer.
“I think it’s the remoteness and the travel in and out”, says Voyles when asked why it’s so hard to recruit doctors to the scenic north coast. “We only have one airline. We’re not close to shopping. We’re not close to the kind of activities a lot of people like to have. And they’re not really aware of all this until they get here and realize the lifestyle is not for them.”
And lifestyle looms large in other ways.
“Younger physicians—very rightly perhaps—are looking for how they can blend career and family life,” says Dr. Jack Anderson, who has been an OB/GYN in Fortuna since 1977. “We’ve seen a gradual but tectonic shift in what people are looking for when they come out of medical school.”
What most are looking for is a way to quickly pay off an average of 150 to 200-thousand dollars in medical school loans. That’s a hefty sum to chip away at when you practice medicine in a county where 1 out of 4 people is on Medi-Cal, the state’s Medicaid program with notoriously low reimbursement rates.
So when Kaiser or another HMO comes calling and offers a young OB/GYN a fixed 40-hour work week, on-call duties limited to a few times a month, and a guaranteed, fixed salary, it is hard to turn down as Dr. Stokes found out 10 years ago. His wife (also a physician) was being recruited by Kaiser and they knew they had to woo him as well: “At that time they offered me 320-thousand dollars,” he recalls. “That was for a 40-hour week, and anything over that was time-and-a-half. They offered full retirement, health benefits for life, and a 20-percent interest free loan for 20 years on a house up to 1.4-million dollars. I make less now than what they were offering then. We can’t compete with that!”
Dr. Stokes says he turned it down “because I enjoy what I do and want to be a free man.”
Finally, studies have proven what local doctors have known for a long time. A patient mix like Humboldt County’s is more likely to be older, impoverished, chemically addicted, unemployed, and suffer from under-treated and severe chronic illness. So, it’s easy to understand how even bucolic Humboldt could lose its luster.
Is It Really A Crisis?
Is There Really A Solution?
There is no question that obstetrics in this country is changing. Half of the country’s obstetricians are now over age 50. Not only do they get sued an average of three times in their career, but their malpractice premiums have soared to levels about a third of their total income. Roughly half of their deliveries are now C-sections. Some in the industry are predicting a 35-percent shortage of obstetricians by 2050. But does this translate into a crisis?
“If you consider crisis as opportunity than, yes, I think there is a crisis.” This is how Stephanie Stone speaks (and thinks) … outside the box. Not surprising for a woman who swims outside a pool and in a lagoon. She doesn’t think the solution to the OB shortage is more OB’s. “I’ve always felt that midwives were the best providers for most obstetric and gynecologic care, since most of that kind of care is normal and routine. So it’s a crisis here in that we don’t have many OB/GYN’s. It’s an opportunity here because we have many, many certified nurse midwives.”
Doctor Jack Anderson has been delivering babies for nearly 40 years and thinks it may be time to turn the prevailing US childbirth model upside down.
In the United States midwives deliver only about 10-percent of the babies despite the fact that most births are considered normal. In countries like Australia, France, and the United Kingdom about three out of four deliveries are attended by midwives. Doctor Jack Anderson has been delivering babies for nearly 40 years and thinks it may be time to turn the prevailing US childbirth model upside down.
“We can get by with less obstetricians than we’ve had in the past. We need to take a look at the approach the rest of the world is essentially using, and that is midwives taking care of the vast majority of people and the obstetrician just taking care of the complicated cases.”
This is not a comfortable proposition, not only for many obstetricians, but also many expectant mothers who equate the surgical approach—or at least a medical setting—with safety.
Eureka obstetrician Deepak Stokes thinks the solution for a rural county like Humboldt may be two-fold. First, is more aggressive recruiting of OB doctors with state and local subsidies. Second, may be consolidating the three existing birthing centers in Arcata, Eureka, and Fortuna.
“Each place can’t independently support and OB/GYN because they would be on-call every day,” says Stokes. “So we need a central system. I think that may be a solution where it is a neutral, free-standing birthing unit.”
Such a centralized facility could drastically improve the call schedule for obstetricians and midwives alike. And that could make the area more appealing in recruiting young doctors. But it’s uncertain if such a center could survive in a low reimbursement climate in which half the state’s deliveries are paid for by Medi-Cal. Or, would it even be accepted by mothers, many of whom already drive long distances for labor and delivery?
Another solution that is gaining traction in many rural areas is employing ‘laborists’—these are on-call obstetricians who typically cover a hospital for a 24-hour shift. “Therefore, there is always someone here, whether it be an OB/GYN or a midwife,” says Leslie Broomall of St. Joseph’s Hospital in Eureka. “But the days of, you know, the doctor you go to delivering your baby, that’s not necessarily going to happen anymore.”
For many expectant mothers, knowing that an expert will be there is a comfort. That it might not be someone they know, is a compromise.
And compromise will be the operative word as Humboldt, and other rural counties, decide how to balance helping their existing overworked OB’s and midwives, recruit qualified replacements, and provide expectant mothers with what they want most: a healthy baby.
Michael Joyce is a freelance multimedia producer based in Arcata, CA. To hear an audio version of this story, as well as others he has produced for JPR, visit: http://ijpr.org/people/michael-joyce
________________________________________________________
OB-GYN In California And Oregon By The Numbers:
OREGON
. ‑480 OB-GYN’s serving 1.6 million women.
. ‑2.99 OB-GYN’s per 10,000 women or 6.32 per 10,000 women of childbearing age (15–45) [National Average = 2.65 & 5.42 respectively]
. ‑Oregon’s female population expected to increase by 28% by 2030
. ‑1 out of 3 Oregon counties do NOT have an OB-GYN.
. ‑Oregon has one OB-GYN residency training program graduating 7 physicians each year.
. ‑45% of Oregon births are financed by Medicaid [National Average is 45%]
CALIFORNIA
. ‑3,711 OB-GYN’s serving 15.2 million women.
. ‑2.44 OB-GYN’s per 10,000 women or 4.69 per 10,000 women of childbearing age (15–45)
. ‑California’s female population expected to increase by 22% by 2030
. ‑9 of 58 California counties do NOT have an OB-GYN.
. ‑California has 9 OB-GYN residency training programs graduating 98 physicians each year.
. ‑48% of California births are financed by Medicaid (aka Medi-Cal).
Source: American College of Obstetrics & Gynecology 2014 Workforce Fact Sheet (acog.org)
