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March 8, 2017

Review finds some rural hospitals turn away women in labor

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At least 20 rural hospitals in recent years have been found in violation of a federal law that requires hospitals with an ED to treat patients who are in labor when they arrive, Julie Lasson writes in a ProPublica review of federal inspection reports.

Background: The Emergency Medical Treatment and Labor Act

Under the federal Emergency Medical Treatment and Labor Act (EMTALA), hospitals with EDs must treat patients who arrive in labor and care for the patients at least until they deliver the placenta, Lasson reports. 

According to Lasson, Congress passed the law largely to ensure that EDs could not deny treatment to patients if they are not able to pay for the services. The law's labor-specific provisions sought to address an increasing number of hospitals, particularly those in rural areas, that had started eliminating obstetrics care because of costs and provider shortages, Lasson reports.

EMTALA violations

Despite the law, some hospitals in recent years have turned away patients in labor, Lasson reports.

According to ProPublica's review of federal inspection reports, at least 20 rural hospitals in the United States have been found in violation of EMTALA in the past five years. In several instances, women in labor faced serious complications after being denied care or were misdiagnosed at facilities that lacked obstetrics specialists. For instance, the federal government in October 2013 cited and fined a hospital in Willows, California, for failing to recognize that a pregnant woman had preeclampsia.

In addition, some EDs that denied treatment to women in labor did not help transfer the patients elsewhere, Lasson reports. For example, one woman who was denied care at a Georgia hospital had to call 911 outside of the hospital because the hospital did not transfer her elsewhere for care.  

Larry Weiss—a physician, lawyer, and professor of emergency medicine at the University of Maryland—said, "It is hard to understand the legal requirements in an emergency room and many physicians have a mental block when it comes to the law. But ignorance of the law is no excuse."

Responding the issue

According to Lasson, some rural hospitals that faced EMTALA violations have made a deliberate effort to improve. For instance, Harlan County Health in Alma, Nebraska, faced an EMTALA citation in 2011 after an ED staffer told the boyfriend of a woman in labor that the hospital did not do deliveries, which prompted the couple to leave. The hospital reported the problem and hired a consultant to update its policies, according to Manuela Wolf, Harlan's current CEO. In addition, Wolf said the hospital now trains its staff on EMTALA and bought new equipment to use in emergencies. The hospital also has a telemedicine system that allows it to contact practitioners elsewhere for guidance.

However, not every facility has taken such a concerted approach, Lasson reports. For example, federal investigators when assessing a Texas-based hospital for a July 2012 EMTALA violation found the center turned away emergency deliveries more than once, even though staff members were aware of EMTALA.

Some experts say hospitals, including those that lack obstetrics units, need to do more to meet their duty to provide care to women in labor.

Shailey Prasad, an associate professor at the Department of Family Medicine and Community Health at the University of Minnesota, explained that active labor can be hard to diagnose and the process can last for hours. She said physicians in rural areas who do not frequently perform deliveries should use simulations to help maintain their skills so they can deliver in emergency situations (Lasson, ProPublica, 3/3).

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