The past 30 years have witnessed a trend toward increasing disparity in overall physician distribution.1 A maldistribution of the overall physician workforce has been widely studied, and a shortage of physicians in rural areas is of particular concern regardless of the overall supply.2,3 The disproportionately higher concentration of physicians in metropolitan areas has continued despite federal financial policies and incentives aimed at attracting more to rural areas.1 This trend is even more striking for younger physicians, among whom lifestyle may play a larger role in career decisions.4
Developing benchmarks or ideal ratios of obstetrician–gynecologists (ob-gyns) to the adult woman population is challenging, given the highly specialized nature of many physicians' practices and the tendency to cluster around hospitals in urban centers. Standards do exist, however. The 1980 Graduate Medical Education National Accreditation Council report recommended that in 1990 there should be 1 ob-gyn per 10,146 general population (or 2.5 per 10,000 women) as a minimum requirement.5 In 2004, the health care research and consulting firm Solucient issued a national report recommending a minimum of 1 ob-gyn per 4,000 general population (or 6.3 per 10,000 women), which would vary according to counties within each census region.6 Jacoby et al reported in 1998 that by 2010 there would be 2.7 ob-gyns per 10,000 women.7
The American Congress of Obstetricians and Gynecologists (ACOG) and its membership are committed to facilitating access to women's health care.8 It is estimated that 93–95% of all ob-gyns are ACOG members.9 The locations where they practice must be understood first to develop policies that best address healthcare delivery to women. Although there is the strong perception that more ob-gyns practice in metropolitan than in rural areas, there are no published data in our specialty exploring physician workforce distribution throughout the United States. The objective of this observational study was to assess the distribution of ACOG members in practice at county, state, and ACOG district levels in 2010.
MATERIALS AND METHODS
This investigation was approved by the Human Research Review Committee (HRRC 11–328) at the University of New Mexico and the ACOG institutional review board. Data about ob-gyns were gathered from the 2010 ACOG membership roster. No physician's name was identified. Only Fellows and Junior Fellows in general ob-gyn practice who identified their practice type as involving direct patient care were included in this analysis. Addresses were reported as being their practice site (or less commonly, their home location). Physicians were excluded from the analysis if they reported being in residency training or being retired.
We sought the most current population and health service data from standard national resources. Parameters and data resources are listed in Table 1. We defined an adult as being any person age 15 years or older, and reproductive-aged as 15–44 years old. Population characteristics came from the U.S. Census County Characteristics File for 2010.10 Counties were defined by Federal Information Processing Standards codes, districts by ACOG, and rural–urban locations using the U.S. Office of Management and Budget's statistical area definitions.11
County-level measures of health services infrastructure and utilization came from the American Hospital Association Annual Survey 2005, as reported in the Area Resource File (http://www.arf.hrsa.gov). Critical access hospitals are small rural hospitals in relatively isolated areas that provide limited inpatient and mostly 24-hour emergency services. Counts of those hospitals came from the Flex Monitoring Team website (http://www.flexmonitoring.org/).
The primary outcome measure was the number of ACOG members (or density of ob-gyns) per 10,000 women and reproductive-aged women at the county, state, and ACOG district levels. Two directions in analyzing the data were taken because of the anticipated skewed distribution of ob-gyns. First, ob-gyn distribution was divided into two county groups (no ob-gyn compared with one or more ob-gyns). Second, the state data were categorized as the density of ACOG Fellows and Junior Fellows in practice in each state and district. Densities of the ob-gyns were mapped at county levels using uDig GIS Software (http://udig.refractions.net) and U.S. Census TIGER/Line Shapefiles (http://www.census.gov/geo/www).
In 2010, there were 127,026,926 adult women in the United States, with 62,373,964 being of reproductive age. The 33,624 ACOG members in general ob-gyn practice represented 5.0% of the total physician workforce (N=661,400). There were 15,076 (44.8%) female and 18,548 (55.2%) male ACOG members in practice. On average, female ob-gyns were 7.4 years younger than their male counterparts (46.5 compared with 53.9 years).
There were 2.65 ob-gyns per 10,000 women and 5.39 ob-gyns per 10,000 reproductive-aged women in the United States. Table 2 displays the density of ACOG Fellows and Junior Fellows in practice for each state and ACOG district. The largest number of women and ob-gyns were located in California, Texas, and New York. States with the highest number of ob-gyns per 10,000 women and per 10,000 reproductive-aged women were Connecticut, Rhode Island, Hawaii, Maryland, and Vermont. The fewest numbers of ob-gyns were located in rural states with the lowest populations (North Dakota, South Dakota, Alaska, and Wyoming). Those states with the lowest density of ob-gyns were in Arkansas, Oklahoma, North Dakota, and Iowa.
The density of ob-gyns was highest in metropolitan areas and declined in counties designated as micropolitan and rural. Approximately half (1,550, 49%) of the total 3,143 U.S. counties lacked an ob-gyn. Figure 1 displays those counties in which there was no ACOG Fellow or Junior Fellow in active practice. Whereas all states had at least one county without an ob-gyn, those states with the highest proportion of counties without an ob-gyn were especially located in central and mountain west states (58.6% of counties in ACOG Districts VI, VII, and VIII). In contrast, only 4.1% of the counties in Districts I, II, and III did not have an ob-gyn.
Counties without hospitals providing inpatient maternity services were unlikely to have an ob-gyn. Nearly all such counties were classified as being health provider shortage areas. In addition, 48.8% of the 1,550 counties without an ob-gyn had hospitals designated as critical access hospitals.
A total of 10.1 million women (8.2% of all adult women) resided in counties without an ob-gyn. Table 3 differentiates between characteristics of women living in counties where there was either none or at least one ACOG Fellow or Junior Fellow in practice. Those counties contained residents with older average ages, lower per-capita incomes, and slightly higher proportions living below the Federal poverty level. A migration out of the county by the resident population was more likely to be in counties without an ACOG member.
The distribution of ob-gyns is tied to the adult female population, considering that maintenance of a practice depends on a minimum patient volume, which also supports a hospital offering maternity and certain surgical services. This study thoroughly assesses the geographic characteristics of ACOG Fellows and Junior Fellows in practice at the county and state levels. Findings in the present uncontrolled descriptive study show that the distribution of ACOG members in the United States is very uneven. This creates problems for women in certain locales to access obstetric, certain surgical, and perhaps preventive care services. A substantial number of American women must travel to the next county or beyond to receive the necessary services from their ob-gyn.
Our findings confirm previously published research that physicians in general congregate to areas where supply is already high.7 Like physicians in other health care specialties, ob-gyns tend to be clustered around metropolitan areas.2 – 4 Density of ob-gyns was lower in nonmetropolitan counties, and about half of all U.S. counties had no ACOG members in practice. We found that this affected more than 10 million women who resided in those counties. Visual representation of those counties without an ACOG member is particularly striking, showing large areas of certain states in the central and mountain west United States.
The concentration of ob-gyns in metropolitan areas is high despite financial incentives aimed at attracting physicians to rural areas.4,12 There is a clear trend toward Junior Fellows, on completion of residency training, to join larger groups located in more urban areas.13 Practice sites may be driven by the need for sufficient operational infrastructure, referral patterns with a fuller array of services, and growth of group practices to share calls and assist with increasingly diverse surgeries. Furthermore, the changing demands and preferences of younger, mostly female ob-gyns are becoming clear, with more control over schedule and work hours, and many stop practicing obstetrics at an earlier age.9,14 A growing stream of research suggests that amenities, work-life balance, and lifestyle considerations are important elements in the ability to recruit new physician graduates.
Continued concerns about medical professional liability likely influences not only practice patterns but also practice locations.15 – 18 Discontinuing obstetric care at a younger professional age and restricting practices as mandated by insurers are not new to any one region but have been reported in many states. These trends would challenge rural hospitals to maintain obstetric services and recruit and retain ob-gyns.19 Meeting the needs of women in underserved areas, and perhaps reducing maternal morbidity and mortality, requires governing bodies to develop, test, and implement provider compensation models.
Models of collaborative health care delivery continue to evolve, especially to address those regions with an inadequate supply of ob-gyns.20 The emergence of qualified non–ob-gyn clinicians who provide care has appeal. Ob-gyns should recognize the national trends in the number of active nurse practitioners, certified nurse-midwives, physician assistants, and primary care physicians (family physicians and general internists) receiving additional postgraduate training in women's health care. Furthermore, retraining ob-gyns who wish to either re-enter the workforce or work part-time rather than to retire also requires closer attention.
Another means for correcting the maldistribution of ob-gyns is to increase the number of residency positions.21,22 More federal funding for the additional graduate education of non–primary care resident physicians is highly improbable. Furthermore, simply increasing the ob-gyn physician workforce is a blunt instrument to address regional shortages. These actions, built on nationwide demographic and gross domestic product projections, do not account for local physician distribution. Although increasing the number of resident graduates in ob-gyn seems appealing, it may exacerbate the current disparity in distribution between urban and rural areas.12
In conclusion, this investigation is a first step to elucidate the current status of the ACOG Fellow and Junior Fellow in practice based on ob-gyn to population ratios, a calculation that is not completely sensitive to regional differences in patient demands and to physician practice patterns. ACOG is ideally placed to assume more of a leadership role by further exploring the issues discussed in this article. ACOG member demographics, the need for work-life balance, the role of coordinated care in the health care delivery system, training capacities at all stages of education, roles of nonphysician clinicians, and trends in retirement have a direct bearing on the future distribution for ob-gyns. Addressing future workforce needs also requires consideration of more part-time work, medical advances, and changing payment systems. Increased awareness about physician distribution and creative innovations in programs proven to be effective in enhancing a more uniform geographic distribution of women's health care services must be promoted.
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