Drop in FPs Providing Obstetric Care Alarms Researchers

Pregnant Women, Infants in Rural Communities at Risk

July 02, 2017 02:48 pm Sheri Porter

Family physicians often tout family medicine's broad scope of practice -- that cradle-to-grave patient care continuum that sets the specialty apart from all others.

AAFP Past President Robert Wergin, M.D., of Milford, Neb., shown in this photo with two of his patients -- a mother and her newborn -- enjoys delivering babies in his small rural Nebraska town.

That's why new research from the Washington-based Robert Graham Center for Policy Studies in Family Medicine and Primary Care that shows a precipitous drop in the percentage of family physicians providing obstetric care is particularly alarming(www.graham-center.org).

Specifically, in study results published in the June 15 issue of American Family Physician, researchers noted that the percentage of family physicians who practice high-volume obstetrics -- defined as more than 50 deliveries a year --dropped by nearly 50 percent between 2009 and 2016.

Researchers based their conclusions on 13 years of data culled from registration questionnaires completed by family physicians who sat for the American Board of Family Medicine's Family Medicine Certification Examination between 2003 and 2016. For this study, authors examined results from 95,750 completed questionnaires.

Story Highlights
  • New research from the Graham Center for Policy Studies in Family Medicine and Primary Care shows an alarming drop in the percentage of family physicians who provide obstetric care.
  • The percentage of family physicians who practice high-volume obstetrics -- defined as more than 50 deliveries a year -- dropped by nearly 50 percent between 2009 and 2016.
  • According to the researchers, the downward trend is cause for concern that access to care for pregnant women -- especially those in rural communities -- may be dwindling.

Researchers based their conclusions on 13 years of data culled from registration questionnaires completed by family physicians who sat for the American Board of Family Medicine's Family Medicine Certification Examination between 2003 and 2016. For this study, authors examined results from 95,750 completed questionnaires.

Whereas previous studies documented a steady decrease in the percentage of family physicians providing low-volume (one to 25 deliveries per year) and medium-volume (26 to 50 deliveries per year) obstetric care between 2000 to 2010, the percentage providing high-volume obstetrics remained relatively constant, hovering at about 2 percent.

In their study, Graham Center researchers found that from 2003 to 2009, the percentage of family physicians engaged in high-volume obstetric care held fairly steady at 2.3 percent to 2.1 percent, respectively. But by 2016, that percentage had dropped by nearly half -- to just 1.1 percent of total family medicine respondents

The study's authors pointed out that the American Congress of Obstetricians and Gynecologists has predicted a shortage of some 9,000 obstetricians by 2030.

"This combination of a decrease in family physicians attending deliveries and shortage of obstetricians leads to concern for reduced access to care for pregnant women, especially those in rural areas," wrote the authors.

Family Physician's Perspective

Lead study author Tyler Barreto, M.D., is completing a policy fellowship at the Graham Center. Barreto completed her residency training at the Grand Rapids (Mich.) Family Medicine Residency in 2016. Her schedule there was heavy on obstetrics.

She told AAFP News she's a native Midwesterner -- born and reared in a small town in Indiana.

"My family doctor delivered me," said Barreto. "So when I went into family medicine, I expected it to be full scope, including obstetrics."

She said the downward slide in the percentage of family physicians providing obstetrics -- along with the projected shortage of OB/Gyns "has serious repercussions for patients."

Barreto noted the increase in maternal morbidity and mortality rates, particularly in rural America where studies have shown that rural hospitals -- many with labor and delivery units run by family physicians -- are closing.

"When that happens, women are forced to travel farther and farther for care, which can lead to complications if a woman in labor can't get emergently to a labor and delivery-capable hospital," said Barreto.

"There are no obstetricians in many rural areas. Patients count on their family doctor to deliver their babies," she said. And if barriers exist that prevent family physicians from offering obstetrics, that creates an access-to-care problem.

She said family physicians who want to provide obstetric care to their communities need to take a stronger stance in addressing barriers to providing that care.

Next Steps

The study authors offered some possible routes to help curb the growing shortage of physicians providing obstetrics. They suggested

  • discussing changes to physician call schedules to counteract lifestyle issues,
  • addressing payment barriers,
  • easing credentialing roadblocks, and
  • creating payment and practice incentives to encourage family physicians to provide obstetric care.

Barreto said another Graham Center study is underway to try to discover what happens to the 25 percent of new family physicians who plan on doing obstetrics when they complete residency but then don't follow through.

Where's the disconnect?

"I don't know, so that's one of things we'd like to look at further," said Barreto, noting that credentialing issues, higher malpractice rates or a number of other things could be responsible.

"I know from other studies that we've done that there is a lot of continued interest in obstetrics among young family physicians," she said.

As for Barreto, when she completes her fellowship at the Graham Center, she'll be looking for a practice where caring for pregnant moms -- and delivering their babies -- will be a key component of her work.

She joked that at the end of a patient's pregnancy, family physicians "win" a baby.

"You followed the mom and whoever else is in her support system for nine months. You got them ready for this big life event, and you were there for the event, and then you follow them afterwards. You get to see that baby grow, and you're an integral part of that family.

"It's just very cool. It's true family medicine," said Barreto.

Related AAFP News Coverage
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FPs Protect Scope of Family Medicine, Address Practice Issues

(5/3/2017)

Leader Voices Blog: AAFP Delivering on Maternity Care Training, Resources
(8/17/2016)

Fresh Perspectives: Labor of Love: Maternity Care Offers Unique Chance to Partner With Patients
(11/5/2014)

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