Graham Center One-Pager

Family Physicians' Declining Contribution to Prenatal Care in the United States

A substantial decline in prenatal care by family physicians has occurred over the past 20 years in all geographic regions of the country. Even so, during the past two decades, family physicians and general practitioners (FP/GPs) have provided more than 2 million prenatal visits per year. As the field re-explores future scope, it should consider the erosion of the provision of prenatal care, its effect on the U.S. population and the specialty, and possibilities for revitalization of prenatal care in residency curricula and practice.

We analyzed National Ambulatory Medical Care Survey (NAMCS) data spanning 1980 to 1999 identifying all prenatal visits performed by physicians. To create comparison periods consisting of an equal number of annual surveys using all NAMCS data available over the past 20 years, data were aggregated for seven surveys before 1993 (early period) and seven surveys after 1992 (later period).

Overall, 27.4 million live births occurred in the early period and 27.5 million live births occurred in the later period. However, from the early period to the later period, there was a decrease in the total number of prenatal visits performed by all physicians in the country and a decrease in the number of visits per FP/GP and obstetrician. Total prenatal visits by all medical specialties decreased from 192 million in the early period to 182 million in the later period, with the loss of visits occurring largely in areas outside of Metropolitan Statistical Areas (non-MSAs). The accompanying table focuses on the two specialties that, together, provided almost all physician-delivered prenatal visits to U.S. women in the two periods. FP/GPs provided 33.2 million visits (17.3 percent of all prenatal visits) in the early period; this contribution dropped to 18.6 million visits (10.2 percent) in the later period. Most strikingly, the number of prenatal visits by FP/GPs in non-MSAs decreased by 50 percent. FP/GP visits decreased in all regions, including the Midwest, where the greatest drop occurred in the number of visits over time. In the Midwest, FP/GPs delivered 15.5 million visits in the early period and 6.1 million visits in the later period.

Prenatal Visits Provided by FP/GPs and OBs in Two Seven-Year Periods Region FP visits in early period* in millions (% of total visits in regions) FP visits in later period† in millions OB visits in early period* in millions OB visits in later period† in millions MSA‡ 10.0 (8.4%) 11.8 (7.7%) 104.3 (88%) 136.2 (88.6%) Non-MSA§ 17.7 (38.7%) 6.8 (23.7%) 25.7 (56.2%) 21.4 (74.6%) Northeast 1.6 (5%) 1.0 (3.8%) 29.1 (91.2%) 24.2 (91%) Midwest 15.5 (28.8%) 6.1 (13.6%) 37.1 (68.8%) 37.5 (83.5%) South 8.6 (15.2%) 6.4 (9.7%) 46.0 (81.1%) 58.7 (88.5%) West 7.4 (14.9%) 4.9 (11%) 40.8 (82.4%) 37.2 (83.4%) Total visits 33.2 (17.3%) 18.6 (10.2%) 152.9 (79.6%) 157.5 (86.4%) FP = family physician; GP = general practitioner; OB = obstetrician; MSA = metropolitan statistical area. *--Seven annual surveys between 1980 and 1992 (1980, 1981, 1985, 1989-1992). †--Seven annual surveys between 1993 and 1999. ‡--MSA is a county or group of contiguous counties that contains at least one city with a population of >=50,000 or a Census Bureau-defined urbanized area of at least 50,000 with a metropolitan population of >=100,000. §--Non-MSA is a county that does not meet the above criteria. NOTE: MSA plus non-MSA does not equal 100 percent because of missing National Ambulatory Medical Care Survey data.

These results support the general impression that the contribution of FP/GPs to prenatal care has declined over time. Plausible explanations for these changes include increases in nonphysician providers, changes in specialist workforce, or poor access to prenatal services. Nevertheless, FP/GPs continue to make an important contribution to prenatal care, especially in non-MSAs. It is unclear whether rural regions would be adequately served if family physicians abdicated prenatal care, because evidence suggests that these areas are vulnerable to FP/GP service withdrawal.

Adapted from Graham Center One-Pager #14. Guirguis-Blake J, Fryer GE, Deutchman M, Green LA, Dovey SM, Phillips RL. Family physicians' declining contribution to prenatal care in the United States. November 2002. Available at: www.aafppolicy.org/x387.xml. From the Robert Graham Center: Policy Studies in Family Practice and Primary Care, 1350 Connecticut Ave., NW, Suite 950, Washington, DC 20036 (telephone: 202-986-5708; fax: 202-986-7034; e-mail: policy@aafp.org).