Doctor Deficiency: Disparities in Physician Availability in the Baby Business and Birth Outcomes in New York State

Julie A. Sullivan, Siena College

Abstract

Recent reports and research suggest a looming national shortage of primary care physicians, particularly in rural and urban poor communities. Of the primary care fields, I specifically investigate the current workforce of OB/GYNs by county in New York and suspect that lack of access to high quality care in underserved counties leads to poor birth outcomes. Though New York has one of the highest employment levels of OB/GYNs, this number is misleading due to the state’s uniquely wide spectrum of developed environments, ranging from tiny farming communities to the United States’ most populous city. Data on the number of women ages 15 to 44 was acquired from the United States Census Bureau. I obtained the zip codes of each OB/GYN in the state through HealthGrades.com and use this information to determine how the reported 4,235 OB/GYNs are dispersed throughout the state. Combining these data sets, I show evidence of significant disparities among counties: while Manhattan has about 7.54 OB/GYN doctors per 3,500 females ages 15 to 44, three of New York’s counties have no OB/GYNs at all (populations of females ages 15 to 44 in these counties range from 6,897-12,714). I use data on infant mortality, low birthweight births, and birth defects such as gastroschisis, cleft lip, and spina bifida to analyze the relationship between birth outcomes and the population weighted availability of OB/GYN physicians in each county of New York State. Controlling for economic barriers and risk factors, I find that a local presence of OB/GYNs has little effect on birth outcomes.

 

 

 

 

 

 

 

 

 

 

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Table of Contents

1. Introduction……………………………………………………………………3 2. Background……………………………………………………………………3 3. Model………………………………………………………………………….5 4. Data……………………………………………………………………………6 5. Analysis

5.1 Infant Mortality………………………………………………………..9 5.2 Birth Defects…………………………………………………………..9 5.3 Low Birthweight……………………………………………………..10

6. Discussion……………………………………………………………………11 7. Concluding Remarks…………………………………………………………13 8. References……………………………………………………………………14 9. Acknowledgements…………………………………………………………..18

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1. Introduction

Basic economic theory explains that as demand and prices for goods increase, suppliers will enter the market to earn their share of profits. Over time, supply will rise to equal demand. However, health care economics does not follow this simple market story. Despite rising demand for health services due to the expansion of health insurance coverage through the Patient Protection and Affordable Care Act and the incentive of earning a high income practicing in the medical field, recent reports and research suggest a looming shortage of physicians. Primary care fields are especially prone to physician shortages.

According to some reports, pregnant women in the United States may have difficulty finding a physician to deliver their children. Obstetrics and gynecology (OB/GYN) is one primary care specialty that is becoming especially scarce in certain areas. High malpractice premiums, fear of lawsuits, and lifestyle factors deter medical students from choosing OB/GYN as their specialty, and the baby boomer generation of OB/GYNs will soon retire. In many areas, there may not be enough OB/GYNs to sufficiently meet patients’ needs. This lack of access to high quality care could have serious repercussions for women and their infants.

This paper investigates the relationship between local presence of OB/GYNs and birth outcomes in New York State. Based on the literature on this topic, I expect to find significant disparities between the population-weighted number of OB/GYNs in urban and rural counties. Data on each reported physician was compiled to determine how OB/GYNs are dispersed throughout New York State, and the number of physicians is weighted based on the number of women ages 15 to 44 in each particular county. I predict that these differences are problematic and lead to poor birth outcomes in counties with fewer OB/GYN physicians per capita. Records on infant mortality, low birthweight births, and birth defects such as spina bifida and gastroschisis were compiled to define birth outcomes. Additionally, I use certain risk factors and barriers to care for controls. Combining these datasets, I use regressions run on IBM SPSS Statistics software to analyze the connection between these birth outcomes and the population-weighted availability of OB/GYN physicians. Ultimately, my findings suggest that availability of OB/GYNs has little to no impact on birth outcomes, and I offer explanations as to why the data demonstrates this.

2. Background

The Patient Protection and Affordable Care Act (ACA) was passed into law by President Barack Obama in March 2010 and is considered the most dramatic overhaul of the United States’ health care system since the passage of Medicare and Medicaid in 1965. One of the primary goals of the ACA is to expand access to coverage by requiring most United States citizens and legal residents to purchase health insurance. The creation of health insurance exchange markets for individuals, the requirement for employers to provide health insurance to their employees, and the expansion of Medicaid to low income individuals under age 65 in some states aim to reduce the number of uninsured people in the United States (Kaiser, 2013). Millions of individuals who were previously uncovered are expected to purchase private health insurance or claim Medicaid eligibility this year.

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Although this health reform legislature has expanded health care coverage to more people, it is unclear if the current physician workforce in the United States is capable of satisfying the increased demand. An adequate supply of physician services is often cited as a crucial factor in accessing health care. As 32 million people become newly insured, a report by the Association of American Medical Colleges (AAMC) indicates a nationwide shortage of physicians that will continue to worsen as years pass, particularly in primary care fields (HANYS, 2012).

Obstetrics and gynecology is a primary care specialty that is especially prone to shortage for a number of reasons. In addition to the increase in demand for health services that all medical professions are expected to face with the passage of the ACA, the OB/GYN workforce faces a unique set of obstacles. One problem surrounding the supply of OB/GYNs is the fact that the workforce is aging; 35% of OB/GYNs in the United States are over the age of 50 (Anderson et al., 2008). Another significant factor that contributes to a declining workforce is that fewer medical students are choosing OB/GYN as their specialty (Loafman & Nanda, 2009). Meanwhile, the decreasing number of OB/GYNs is exacerbated as fewer doctors perform particular services. One survey by the American Congress of Obstetricians and Gynecologists found that one in seven OB/GYNs has stopped delivering babies, 20% have cut back on high-risk obstetrics, and 5% have dropped obstetrics altogether (Greywolfe, 2014).

Career dissatisfaction is often a focus of studies that seek to determine why OB/GYN practice, and obstetric practice in particular, is becoming increasingly unpopular. One study that measured career satisfaction found that OB/GYNs had significantly lower overall career satisfaction than other primary care physicians (Kravitz et al., 2003). Malpractice premiums, medical liability and lifestyle factors are typically cited as reasons for current OB/GYNs’ discontent and deterrents for medical students choosing a specialty.

OB/GYNs are more likely than other medical doctors to be targeted in medical malpractice cases. A 2009 National Survey on Professional Liability by the American Congress of Obstetricians and Gynecologists found that 94.9% of respondents from New York State had had at least one professional liability claim filed against them during their careers; of these, 49.9% had four or more claims filed against them (ACOG, 2012). The absurdly high number of malpractice claims results in skyrocketing malpractice premium prices for OB/GYNs in New York State in the last few decades.

Compared to the malpractice premiums of other American OB/GYNs, New York’s physicians tend to pay more as a percentage of their operating costs. On average, 11% of an American OB/GYN’s operating expenses are devoted to malpractice insurance; in New York’s Rockland County, insurance accounts for 29% of an OB/GYN’s operating costs (ACOG, 2012).

The Medical Society of the State of New York (MSSNY) reports that medical liability insurance costs for OB/GYNs increased by 63-72% between 2003 and 2008, and by another 5-9% in 2010 when temporary rate freezes were removed. The Medical Liability Mutual Insurance Company (MLMIC) insures 60% of all physicians in New York State and determines its rates based on a physician’s location. The most extreme instance is the $186,772 premium assigned to Nassau and Suffolk counties’ OB/GYNs. Approximately half of New York State’s deliveries are covered by Medicaid, and physicians are currently reimbursed at the Medicaid Fee for Service rate of $1,370 per delivery. For an OB/GYN in Nassau or Suffolk to cover her malpractice

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insurance premium alone, she must deliver one baby every three days if she accepts mostly Medicaid patients. Though these doctors do earn higher salaries than doctors in more rural counties, their cost of living on Long Island is typically much higher than other parts of the state (ACOG, 2012). The stress and lost time due to malpractice lawsuits and the high price of medical liability insurance are persuasive enough for some students to choose other specialties and some doctors to discontinue their practices.

Lifestyle is also often cited as a reason for avoiding obstetrics. A survey of fourth year medical students at the Indiana University School of Medicine demonstrates how much students are influenced by lifestyle. When the respondents of the survey were asked what the most important factor was in choosing a specialty other than OB/GYN, close to 40% cited “lifestyle” (Gariti et al., 2005). Some medical specialties offer doctors flexibility in their schedules; obstetrics does not. It is time-consuming and very unpredictable. In addition to long hours, OB/GYNs are often on-call and must work at erratic times as births can occur at any time of the day. The pressure from the high stakes of the job is stressful; obstetricians care for two patients rather than just one and poor results can be disastrous for families (Friedman, 2005). For medical students who want to have leisure and personal time, obstetrics is not an attractive specialty.

The State University of New York (SUNY) Center for Health Workforce Studies found that between 2000 and 2004, the overall number of OB/GYN physicians decreased. The most concerning finding was that the number of OB/GYNs in upstate areas that are already considered underserved declined significantly more than birth rates, while certain urban areas experienced increased numbers of OB/GYNs (SUNY, 2005).

3. Model

According to the previously mentioned SUNY report and much of the other literature on this topic, regional shortages and spatial disparities of physicians are thought to be major threats to public health. I will use information from New York State to explore this hypothesis by analyzing the relationship between the number of OB/GYNs per females ages 15 to 44 in a county and birth outcomes.

Due to New York State’s unique developed environment, which ranges from small rural communities to the United States’ most populated city, I expect to find significant disparities in the number of OB/GYNs in each county. Weighted for population, I suspect that cities and urban areas will have more OB/GYNs than rural and less densely populated counties.

The World Health Organization cites maternal and child health outcomes among the most fundamental indicators to assess health status and health care infrastructure. I predict that fewer OB/GYNs in a particular county limits access to care for women who live in that area; therefore, I anticipate finding poorer birth outcomes in counties with lower numbers of OB/GYNs per capita. Poor birth outcomes are defined by the infant mortality rate (DEATH), low birthweight births per 1,000 births (WGHT), and the number of certain defects per 1,000 births (DEFECT). I also control for certain variables that can act as potential determinants of infant health. In addition to the number of OB/GYNs per capita (OB/GYN), the variables used are abortions per 1,000 births (ABT), median household income (Y), the number of births to mothers over the age

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of 40 per 1,000 births (MFP), the percent of births financially covered by Medicaid or private insurance (INSU), the adult obesity rate (OBESE), and the adult smoking rate (SMOKE).  My basic specifications are the following:  

DEATH = β1 + OBGYNβ2 + ABTβ3 + SMOKEβ4 + MFPβ5 +Yβ6 + INSURβ7 + OBESEβ8

WGHT = β1 + OBGYNβ2 + ABTβ3 + SMOKEβ4 + MFPβ5 +Yβ6 + INSURβ7 + OBESEβ8

DEFECT = β1 + OBGYNβ2 + ABTβ3 + SMOKEβ4 + MFPβ5 +Yβ6 + INSURβ7 + OBESEβ8

Abortions per 1,000 births are considered because they may affect the number of unhealthy infants born in particular counties. Understanding of genetics and increasing use of medical technology allow doctors and women to monitor infant development, and birth defects can be detected and diagnosed fairly early during pregnancy. Upon learning of birth defects, some women may choose to terminate their pregnancies; meanwhile, women living in more conservative or religious communities may be less likely to do so. As a result, some counties may show lower levels of defects because unhealthy pregnancies are not brought to term.

The adult smoking rate is also included in this analysis because smoking during pregnancy has been linked to a variety of infant health problems. Smoking can cause an array of problems with the placenta, an infant’s source of food and oxygen during pregnancy. Some babies born to smokers are born prematurely, causing them to have a low birthweight and a higher chance of having certain birth defects like cleft lip or cleft palate. Some infants born to smokers die because of these complications (“Tobacco”, 2014).

Similarly, the adult obesity rate is taken into account because it has been linked with pregnancy complications. Studies suggest that women who are overweight before becoming pregnant have a higher chance of giving birth to infants with health problems (“Complications”, 2014).

Age is also a major risk factor in child bearing, so I consider births to women over the age of forty as well. Women who conceive in their 40s are more likely than younger women to have a baby with certain chromosomal abnormalities or a baby that is born with a low birthweight (Mayo, 2014). Again, these complications can lead to infant death in some cases.

Health insurance coverage and median household income must also be included because they indicate whether or not a woman can receive proper prenatal care. Despite the passage of the Affordable Care Act, many Americans remain uninsured because the law allows citizens to opt out of purchasing insurance by paying a fine (Kaiser, 2013). Income also plays a role because even with insurance, some women may forego seeing a doctor to avoid travel expenses and high co-pays. A woman’s ability to remain healthy during pregnancy by having good nutrition and taking dietary supplements can also be dependent on her income and may affect the health of her child.

4. Data

The United States Census Bureau collects information about the nation’s people and economy. New York’s State population data and projections from the Census was found through

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the New York State Department of Labor. The data contains 2009 civilian population estimates organized by demographics, including a breakdown by age and sex by county. I narrowed the data to focus on women of childbearing age. Childbearing age in this report is defined as ages 15 to 44 because these are the ages that the National Center for Health Statistics typically uses to determine fertility rates.

To determine how OB/GYNs are dispersed throughout New York State, I obtained each reported OB/GYN’s zip code from HealthGrades.com. HealthGrades provides consumers with information to make informed decisions about their medical care. Physicians also use HealthGrades to represent their practice online and to make them more discoverable (HealthGrades, 2014). Though the New York State Department of Health offers information through a Physician Profile website called nydoctorprofile.com, I found that HealthGrades.com is the superior source for the information I was looking for. Many physicians that were listed on nydoctorprofile.com were currently practicing out of state or did not have the location of their main practice listed at all; meanwhile, HealthGrades.com clearly listed each doctor’s current practice address. Using the doctors’ zip codes, I was able to sort them by county.

The United States Department of Health and Human Services Health Resources and Services Administration has developed a shortage designation criteria to determine if a geographic area is a Health Professional Shortage Area (HPSA). Primary Care HPSAs are based on a physician to population ratio of 1 to 3,500, meaning that an area is considered to have a doctor shortage when there are 3,500 or more people per primary care physician. It is essential to note that there is no universally accepted definition of physician shortage as community needs and the number of additional services such as nurse practitioners and physician assistants differ, but the 1:3,500 physician to population relationship that I use is the long standing ratio used to identify high need areas (HRSA, 2014).

Based on this ratio, the number of OB/GYNs per county, and the number of women ages 15 to 44 in each county, ten of New York’s counties have critical shortages of OB/GYNs: Delaware, Columbia, Genesee, Livingston, Oswego, Schoharie, Schuyler, Seneca, Washington, and Yates. Of these, Delaware, Seneca, and Washington counties have no OB/GYNs at all. Meanwhile, larger cities like Manhattan had 7.54 OB/GYNs per 3500 females.

Infant mortality and low birthweight rates were acquired from the New York State Department of Health Vital Records Office. The Vital Records Office files all certificates on births and deaths that occur in New York State and makes these statistics available to the public through a series of annual vital statistics tables. A death is considered an infant mortality when the child is under the age of one. Infants are considered low birthweight when they weigh less than 2,500 grams upon birth. Data from years 2000-2007 is used; because of the small populations of some counties, it is necessary to average the data over a longer period of time to get a large enough sample size. Throughout this time period, Hamilton had an extremely high number of low birthweight births relative to the other counties, leading me to remove it from my regression analysis.

The New York State Department of Health Congenital Malformations Registry archives cases of children born in New York State diagnosed before the age of two with any structural, functional, or biochemical abnormality. The recorded defects are specifically genetic or induced during gestation and are not due to birthing events. Like with infant mortality and low

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birthweight, I collected information on several common birth defects from years 2000-2007 to get a large enough sample size. The defects I use can occur due to environmental factors and are often preventable. For instance, the Centers for Disease Control and Prevention suggests that women take adequate amounts of a B vitamin called folic acid to prevent neural tube defects such as spina bifida and anencephaly. Folic acid can be purchased over the counter, but doctors can prescribe prenatal vitamins that contain higher dosages (OWH, 2012). I was also certain to use birth defects that are considered harmful. Though heart defects in infants are common, many structural abnormalities require little to no medical attention, even through adulthood (Mayo, 2014). Interestingly, large hospitals often screen for such defects more frequently. Data including congenital heart defects may inaccurately demonstrate that certain areas have more birth defects, even though many of those defects are actually harmless. For this reason, I exclude some of the most common birth defects such as atrial and ventricular septal defects.

I also obtained data for the variables that I believe could act as determinants of infant health. The number of births by mothers over the age of 40, financial coverage of births, the adult obesity rate, the number of abortions per 1000 births, and adult smoking rates for years 2000-2007 was found through the New York State Department of Health’s Vital Statistics Office and averaged. Median household income for the years between 2006 and 2010 was obtained from the U.S. Census Bureau’s American Community Survey.

Table 1: Summary Statistics of Key Variables

Variable Mean Median Std. Dev Min Max N

DEATH 6.210685484 6.2875 1.108036604 4.2875 9.3875 62

WGHT (w/ Hamilton)

76.2431166 72.89117171 26.42764086 58.81851815 271.8333912 62

WGHT (w/o Hamilton)

73.03672 72.5683 7.874999 58.81852 96.69472 61

DEFECT 2.177949 2.10252 0.842987 0 4.483706 62

OB/GYN 2.243911 1.960011 1.476565 0 7.543599 62

Y 52288.39 48215 12438.99 34264 93613 62

INSU 0.93582 0.960644 0.06973 0.634345 0.990694 62

OBESE 0.269452 0.2755 0.046908 0.15 0.375 62

MFP 0.297998 0.270876 0.112332 0.131952 0.665002 62

ABT 268.7329 240.87 154.403 60.19 938.74 62

SMOKE 0.19871 0.19 0.054336 0.09 0.31 62

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5. Analysis

5.1 Infant Mortality

Table 2: Regression on DEATH Results

Variable B Std. Error Beta T Sig. (Constant) 12.026 2.147 5.601 .000 OBGYN -.043 .096 -.058 -.452 .653

Y -6.157E-005 .000 -.691 -3.808 .000 INSU -.039 .019 -.243 -2.055 .045

OBESE -.006 .036 -.025 -.160 .874 MFP .032 .020 .321 1.544 .128 ABT -.001 .001 -.080 -.603 .549

SMOKE .024 .030 .120 .825 .413

Median household income, the percentage of the population that is insured, and the percentage of births to mothers over the age of 40 all play a statistically significant role in the number of infant deaths per 1,000 live births.

Health insurance likely affects infant mortality because they determine whether or not some women utilize health care. Health insurance may ensure women can access expensive, insurance-based acute interventions during pregnancy and after birth, such as surgeries to correct life-threatening birth defects. Despite the passage of the ACA, many people remain uninsured, and high co-pays can deter patients from visiting physicians’ offices; as a result, regular checkups during pregnancy may still be unaffordable for some women and correctable problems may go undetected. Low incomes may also prevent some women from eating proper diets and remaining healthy throughout pregnancy. Both the lack of access to care and inability to take care of oneself through pregnancy could lead to unhealthy births that result in infant deaths.

The percentage of births to mothers over the age of 40 also has a slight effect on infant mortality. Women who conceive in their 40s are more likely than younger women to have a baby with certain chromosomal abnormalities that could lead to infant death.

5.2 Birth Defects

Table 3: Regression on DEFECT Results

Variable B Std. Error Beta T Sig. (Constant) 3.270 1.751 1.867 .067 OBGYN -.073 .078 -.129 -.942 .350

Y -3.524E-006 .000 -.052 -.267 .790 INSU .002 .015 .020 .161 .873

OBESE -.031 .030 -.175 -1.054 .297

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MFP -.023 .017 -.307 -1.379 .174 ABT -.001 .001 -.111 -.777 .441

SMOKE .036 .024 .234 1.505 .138

No variables in this regression appear very statistically significant. While some birth defects can be caused by environmental or behavioral factors, most are caused by genetics. The adult smoking rate indicates some significance, which is likely because particular defects like cleft palate that are included in my aggregate birth defects per 1,000 births are more closely linked to smoking than, say, gastroschisis. If I looked for correlations between specific birth defects rather than looking at them as a collective number, there might be more significant links.

5.3 Low Birthweight

Table 4: Regression on WGHT Results

Variable B Std. Error Beta T Sig. (Constant) 75.806 13.385 5.664 .000 OBGYN 1.912 .604 .356 3.167 .003

Y .000 .000 .177 1.014 .315 INSU -.204 .117 -.182 -1.734 .089

OBESE -.043 .228 -.026 -.190 .850 MFP -.231 .139 -.326 -1.664 .102 ABT .036 .006 .704 5.619 .000

SMOKE .229 .186 .158 1.230 .224

Insurance is somewhat significant to the prevalence of low birthweight births. When women have the means to visit their doctors for regular checkups during pregnancy, pregnancies can be monitored and physicians can intervene by offering strategies to manage risky pregnancies.

On the other hand, not all intervention may be beneficial; alarmingly, a strong positive correlation exists between the number of OB/GYNs and low birth weight births. In other words, this analysis suggests that the more OB/GYN physicians a county has, the more low birthweight births occur in that county. This finding is opposite of what I suspected and is very troubling. One explanation is that increased medical intervention can be harmful to an extent.

Another possible explanation is that although there may be more OB/GYNs in a county, they may not be available to all pregnant women. Although the ACA mandates that individuals obtain health insurance, expanded access to health insurance does not necessarily mean expanded access to health care. Through the ACA, the number of uninsured Americans has fallen from 46 million to 41 million. However, 60% of these insurance gains are the result of Medicaid enrollment, and having Medicaid is not guaranteed access to care. Compared to private insurance, Medicaid pays physicians very little, so they are less likely to accept and treat Medicaid patients. One study found that Medicaid patients are six times more likely to be denied

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an appointment with a specialist than people with private insurance, and those who are accepted wait 42 days on average to see a doctor—two times longer than private insurance carriers (Bisgaier and Rhodes, 2011).

According to this regression, as the number of births to mothers over the age of 40 increases, the number of low birthweight births per 1,000 births decreases. This finding contradicts the literature that asserts that it can be dangerous for middle-aged women to bear children. These numbers could be the result of social and cultural change. Today’s women are more educated and career-driven than any throughout history. It is not socially unacceptable or particularly unusual for a woman to wait longer to settle down and start a family. As a result, there may be more births to women over the age of 40, but these women may have better financial ability to maintain healthy pregnancies thanks to careers with higher incomes and health insurance benefits.

Another interesting finding is a slightly positive correlation between the number of abortions in a county and the number of low birthweight births. Again, this result is surprising, but it could indicate socioeconomic factors that are not included in this regression, such as the prevalence of single parent headed households and out-of-wedlock pregnancies. Many women may have abortions because of their financial inability to raise a child alone. Meanwhile, those single mothers who do carry their pregnancies to term may produce low birthweight children because they lacked the financial and health support of another person throughout pregnancy.

6. Discussion

According to these regression analysis results, the availability of physicians is not very influential to infant health. There are multiple reasons why I did not see the expected correlation between local presence of OB/GYNs and birth outcomes. A limitation of this study is that I am currently unable to determine how many of the reported OB/GYNs actually practice obstetrics. The literature explains that many OB/GYNs do not practice obstetrics; many recent medical school graduates have subspecialized in other aspects of women’s health and about 5% of OB/GYNs nationally have dropped obstetrics (Greywolfe, 2014).

An additional restraint to this study is that I am unable to determine how many hours each doctor works. The number of hours worked by physicians, especially between the sexes, can differ considerably. While OB/GYN was once a male-dominated specialty, more women are entering the field: in 2001, 70.3% of residency spots were filled by women (Lewin, 2001). A more diversified choice of physicians is desirable for patients; however, female physicians on average work significantly fewer hours than their male colleagues because they reportedly devote more time to other responsibilities. This, combined with a stagnant number of medical schools and residency spots, has led to the same number of physicians as years ago working fewer hours for a larger population (Lobosky, 2012). I did not track the working hours of each reported OB/GYN, which could have given me an incomplete picture of the availability of doctors. As a result of these limitations, this study may not contain an accurate assessment of the obstetric care available in each county. I am uncertain of how the results may shift given this information.

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The previous limitations aside, another possible explanation for the lack of connection between OB/GYN physicians and birth outcomes is the increasing role of other medical professionals in our health care system. More hospitals are shifting from using strictly physician care for certain treatments to allocating more responsibility to other professionals like physician assistants (PAs) and nurse practitioners (NPs) (Beck, 2014). These professionals are trained to provide comprehensive care to patients; for example, PAs are able to perform physical exams, diagnose and treat illnesses, order tests, recommend directions for preventative care, aid physicians during surgery, and write prescriptions. Many PAs work in settings in which they provide OB/GYN services to women: 2.3% of PAs work in OB/GYN practices and 26% work in family practices. A survey of the Association of Physician Assistants in Obstetrics and Gynecology found that members did report that they often assist patients in family planning and prenatal care (AAPA, 2010).

In addition to PAs and NPs, midwives are also trained to provide obstetric care by helping women maintain healthy pregnancies, delivering infants, and monitoring recoveries in the postpartum period. Though midwife care is not as common in the United States as it is in other countries, many births are attended by midwives. Genesee County has only 0.8684 OB/GYN physicians per 3500 females according to the data I collected; however, its hospital that provides maternity care, United Memorial Medical Center, reported that 321 out of its 651 births in 2012 were attended by a midwife (NYSDOH, 2012). Similarly, the data reports that Livingston County had only 0.9503 OB/GYN physicians per 3500 females, but 64 of 268 births at Nicholas H. Noyes Memorial Hospital were attended by a midwife (NYSDOH, 2012). Though these areas may have a small number of OB/GYN physicians, it is evident that other professionals capable of providing obstetric care are present. Birth outcomes in New York State may not be related to the number of OB/GYNs because other health professionals are available to provide adequate access to care. If the presence of other medical professionals like PAs, NPs, and midwives in OB/GYN practices does lead to more desirable birth outcomes, policy should aim to increase the number of students entering these fields.

Aside from more information about individual OB/GYNs’ practices and the presence other clinical professionals, there are a number of other variables that could be added to this analysis. The inclusion of factors such as the percentage of college educated mothers and the prevalence of single parent headed households may offer further explanation for poor birth outcomes.

Another possibility is that the quantity of services provided is irrelevant because certain birth outcomes are inevitable. While I aimed to use birth outcomes that can occur due to environmental factors and could be considered preventable, genetics are an important determinant of infant health (Lobo & Zhaurova, 2008). The significance of the percentage of births to mothers over the age of 40 and its increased risk for abnormalities in two of the three regressions supports this conclusion. In these cases, the number of OB/GYN physicians in a given area is unimportant. No amount of prenatal care can change genetic makeup and prevent certain chromosomal abnormalities. If genetics do play the most important role in birth outcomes, policy should be geared toward encouraging further genetic research rather than offering incentives for students to specialize in OB/GYN.

On the other hand, genetics do not explain the disparity between birth outcomes in the United States and other wealthy nations. The Organization for Economic Co-Operation and

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Development (OECD) tracks health outcomes and expenditures of developed countries. New York’s infant mortality rate is about the same as the national average, but year after year the United States has higher levels of infant mortality than many other wealthy countries; the United States’ infant mortality rate is 6.1 deaths per 1,000 births while the OECD average is 4.0 deaths per 1,000 births (Health Statistics, 2014). This data infers that there must be some other significant difference between the way our and other developed countries’ health care systems deliver OB/GYN care. The regression analyses in this study suggest that health insurance may play a large role in this difference. Further comparative research into the health care procedures, health insurance systems, and OB/GYN care strategies of other developed countries could shed more light on this disparity.

7. Concluding Remarks

The purpose of this paper is to ask if OB/GYN shortages and disparities lead to undesirable birth outcomes in New York State. After collecting data and running regression analyses, the results do not uphold the concerns described in other research on physician shortages. Though much of the literature I have cited frets about problems and major repercussions associated with national physician spatial disparities, this particular study concludes that local availability of OB/GYN physicians is generally unimportant to birth outcomes in New York. Birth defects appear to be largely genetic while infant mortalities and low birthweight births seem to be more closely tied with health insurance than with the presence of physicians.

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8. References

“About Us.” HealthGrades. Accessed June 26, 2014. http://www.healthgrades.com/about.

“Analysis of the Current Medical Liability Climate in New York State.” The American Congress

of Obstetricians and Gynecologists. March 2012. Accessed July 2, 2014.

http://mail.ny.acog.org/website/MedLiabilityRptFinal.pdf.

Anderson, Britta L., Ralph W. Hale, Edward Salsberg, and Jay Schulkin. “Outlook for the future

of the obstetrician-gynecologist workforce.” American Journal of Obstetrics and

Gynecology 199, 88 (2008): 1-8.

Beck, Melinda. “At VHA, Nurses, Doctors Clash on Oversight.” The Wall Street Journal.

January 26, 2014. Accessed August 13, 2014. http://online.wsj.com/news/articles/S

B10001424052702304856504579340603947983912

Bisgaier, Joanna and Karin V. Rhodes. “Auditing Access to Specialty Care for Children with

Public Insurance.” The New England Journal of Medicine 364 (2011): 2324-2333.

“Changing Practice Patterns of OB/GYNs in New York.” University at Albany School of Public

Health, Center for Health Workforce Studies. April 2006. Accessed June 27, 2014.

http://chws.albany.edu/archive/uploads/2012/07/obgynny2006.pdf.

“Common Types of Congenital Heart Defects.” The Mayo Clinic. Accessed July 2, 2014.

http://www.mayoclinic.org/diseases-conditions/congenital-heart

defects/multimedia/congenital -heart-defects/sls-20076059?s=1.

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“Folic Acid Fact Sheet,” Office of Women’s Health, July 16, 2012, accessed August 12, 2014,

http://womenshealth.gov/publications/our-publications/fact-sheet/folic-acid.html.

Friedman, Alexander. “Wanted: Workaholics to Become Obstetricians.” The New York Times.

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9. Acknowledgements

I would like to acknowledge and extend my heartfelt gratitude to the following people who made the completion of this research possible:

Thank you to Dr. James Booker, my faculty adviser, for his tireless assistance and the invaluable advice he offered each week for the duration of this project. I must sincerely thank Dr. Lois Daly as well for her research guidance and inspiration for the subject of this paper. I would also like to express my appreciation for all the professors who have taught me about health care policy in the last four years in the pursuit of my Bachelor’s degree.

I very gratefully acknowledge the support and generosity of the Siena College Center for Undergraduate Research and Creative Activity.

Finally, thank you to my family and friends for their support and encouragement.