Rural hospitals are closing their obstetric wards and stopping all obstetric services — at least those hospitals that manage to remain open at all. The tertiary care centers don’t seem to mind.Always wary of those rural hospital disasters in the middle of the night. Accepting transfers from a place where they must not have the latest technology, clearly, your little hospital must be behind the times, only subspecialty care is worth anything anyway.

After all, those family doctors should just do outpatient medicine.

Just send those obstetric patients to us. Transfer them by air if you need to — our policies and procedures will protect you if they deliver on the plane, if they seize on our watch if something happens. We will keep them safe from your Podunk little town and your backward ways. Regional care is best for all, of course. As long as the weather is OK … that is — otherwise, we hope you’ll figure it out.

Never mind your Podunk hospital has won the Top-20 Rural Hospitals Award for two years running. Never mind you run drills routinely to brush up on OB emergency skills. None of that matters when you deliver less than 100 babies a year. You aren’t experienced enough to continue, and your volume is too low, your head of your OB/nursery “department” is a family doc, not a board-certified OB/GYN. ACOG and SMFM have deemed you level 1, all have endorsed this designation, all recommend you transfer the hard ones — except the AAFP, we forgot to include them.

Never mind that your patients know and trust you, that they want a relationship with their doctor. They will learn. That never stopped our big groups anyway. Never mind the precipitous delivery, that’s what ER doctors are for — they can deal with the increased shoulder dystocia risk that occurs when the baby comes so quickly. Never mind the eclamptic seizure that happens before any severe features of the 35-week mild preeclamptic presented themselves. She was scheduled for her induction two weeks from now. She should have waited.

Never mind the patient who lives at the end of the road, surrounded by nothing but forest for a hundred miles to the west and is 30 miles from the Podunk hospital to the east. Never mind that she is newly on Suboxone, proud to be clean and sober, unable to travel the 200-plus miles to the big center without a Medicaid transport. Never mind the Medicaid transport will involve a two-hour car ride starting at 5 a.m., then a three-hour bus ride there only to see her specialist for 20 minutes and make the return trip much later the same day, when the bus schedule allows. She’ll arrive home well after midnight if the driver Medicaid lines up remembers to show. Oh, and her last baby was born one hour after arriving at the hospital. I’m sure she can relocate to our bigger town for a month before her due date, a few miles away from her dealer. Too bad she moved so remotely to get away from him in the first place. I’m sure she can find someone to care for her other three children while her boyfriend works. She is considered “high risk,” after all — too much for Podunk hospital to handle. Never mind she refused all of this and stayed in her small town until delivery — and this Podunk hospital handled her case with perfection.

It is for these patients that the small doctors continue, the Podunk hospitals strive to stay open. It is for these patients we push our boundaries. We are small and fierce, dedicated, remaining on call for nine days at times, running short staffed when just one doc stops doing obstetrics — forced to stop by his malpractice carrier because his volume was too low.

The biggest problems are that we are human and that babies sometimes have bad outcomes. Looking through the lens of hindsight, you add a gray filter of the Podunk hospital label. The big center staff can’t help but tell the patient that they would have done better delivering at their hospital, and the malpractice lawyers lick their chops. Never mind that patient had an MFM consult, twice, and recommended delivering with you.

You should have started Mag sooner and not waited to try Tylenol for her headache. You should have moved to C-section faster, you should have been more worried about the strip, you should have transferred her at 5-centimeters dilated after an eclamptic seizure — even if the OB you called told you to push the pit and said nothing about transfer, and your tiny airport runway was closed due to ice anyway. You didn’t give that obstetrician every piece of information, and she didn’t think to ask. She likely has no clue where you are or what resources you have.

So, here I remain with my Podunk hospital in our Podunk town, trying to keep our obstetric floor open against all odds. Me, a miniature Wonder Woman, armed with my sword, my patients and OB staff cowering behind me, trusting me to protect them. Our hospital opening our doors to shield them, despite the financial hardship obstetrics adds to our bottom line.

Alas, but I am less than perfect, my nurses are less than perfect, all of us are. I could really use another superhero on my side. The giants I am facing down are intimidating, to put it mildly. Malpractice lawyers loom large, waiting for the unexpected to happen, for preeclampsia, cord accidents and drugs to do their worst. Death and disability are always lurking and are only kept at bay by a united front. So, big center, will you support me? Will you provide a lifeline of advice and support in our time of need? I am on call alone, after all.

Or will you shrug when we close our doors, saying regional care is the way medicine is practiced now — that’s just how it is. It’s better medicine anyway, or so you think.

Tell that to those who live four hours away.

The author is an anonymous physician.

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