A CDC Vital Signs report(www.cdc.gov) on pregnancy-related deaths presents some sobering statistics before offering common-sense advice: "Make sure pregnant women receive quality care during pregnancy and after."
Family physicians already answer exactly that call. But empowering them to help solve a crisis in which some 700 American women die each year because of pregnancy complications requires a dual commitment from lawmakers: Better understand health disparities, and improve access to care.
It also demands acknowledgement that rural and underserved communities face a related crisis of access to care -- a lesson brought into stark relief by the COVID-19 emergency.
The Academy delivered these messages to lawmakers this month in a detailed response to a Senate Finance Committee request for information on improving the nation's maternal morbidity and mortality rates.
"Physician medical care should be accessible for all who need it," said the April 3 letter,(2 page PDF) which was signed by AAFP Board Chair John Cullen, M.D., of Valdez, Alaska.
- In an April 3 letter to the Senate Finance Committee, the AAFP noted that some 25% of all U.S. women do not receive the recommended number of prenatal visits.
- The health disparities at the root of that and other factors that increase U.S. maternal mortality "could be addressed by increasing primary care access," the AAFP wrote.
- Promoting nonphysician clinicians at the expense of physician-led team care to ease the strain would be "counterproductive," the letter said.
With approximately 25% of all U.S. women not receiving the recommended number of prenatal visits -- rising to 32% of black women and 41% of American Indian or Alaska Native women -- the need to close gaps in care and coverage(www.americanprogress.org) is obvious, added the letter. It was sent to Sens. Charles Grassley, R-Iowa, and Ron Wyden, D-Ore., the chair and ranking member, respectively, of the Senate Finance Committee.
Although maternal outcomes have generally improved for women in most developed countries, "the U.S. maternal mortality rate is worsening," the AAFP said. The letter noted that the U.S. rate was 17 deaths per 100,000 births in 1990 but had increased to 26 deaths per 100,000 births in 2015.(www.mhtf.org) "During that same period, global maternal health rates fell by 44%."
The numbers are even worse for women of color. As that same CDC Vital Signs report indicates, black and American Indian and Alaska Native women are "about three times as likely to die from a pregnancy-related cause" as white women.
(These troubling trends helped to spur the 2018 creation of the AAFP's maternal mortality task force.)
Disparities in pregnancy outcomes also exist between women in rural areas and those in urban areas,(www.acog.org) the Academy pointed out. "With the increasing rates of closure of rural hospitals and obstetric units, pregnant women must travel long distances for maternity care and have worse outcomes."
More than half of all rural U.S. counties -- counties that are home to 2.4 million women of reproductive age -- had no hospital obstetric services and faced primary care physician shortages, the letter said, citing a 2017 study published in Health Affairs.(www.healthaffairs.org)
Meanwhile, "more than one-half of rural hospitals with obstetrics units depend on family physicians to attend births, and family physicians continue to attend the majority of births in small hospitals," the Academy said. "Twenty-eight percent of rural family physicians continue to provide obstetrical services."
As Cullen wrote in a 2018 Leader Voices Blog post, "Family physicians are the best choice to provide obstetrical care in small communities."
This is why, the letter said, "the Academy's programmatic and legislative priorities include retaining obstetric care professionals, supporting maternity care education, increasing the supply of family physicians, reducing health care disparities, improving access to care and addressing social factors that impact health."
The Academy went on to detail a number of recommendations, including:
Maximizing the use of physician-led teams: "If we are to reduce maternal mortality, we must have high-functioning maternity care teams capable of recognizing and handling obstetrical emergencies," the letter advised. "Promoting nonphysician clinicians at the expense of such highly functional teams will be counterproductive."
As examples, the letter pointed to
- patient-centered medical homes and other team-based care models;
- the Strong Start for Mothers and Newborns Initiative, a discontinued federal program for which the Academy advocated;(hcp-lan.org) and
- Medicaid medical homes.
Improving coverage and care standards: "Patients with a usual source of care, which is fundamental among primary care physicians, have fewer expensive emergency room visits and unnecessary procedures than those without it," the Academy wrote. With primary care as the baseline, then, the letter called for
- reducing health care barriers for those with high-deductible health plans through passage of the Primary Care Patient Protection Act (S. 2793);
- expanding postpartum Medicaid coverage through passage of the Helping Medicaid Offer Maternity Health Services Act (H.R. 4996);
- increasing Medicaid primary care reimbursements to at least the Medicare rate;
- investing in quality-improvement initiatives such as the Alliance for Innovation on Maternal Health Program;(safehealthcareforeverywoman.org) and
- establishing a standardized system for evaluating hospital obstetric care, such as one proposed(www.acog.org) by the American College of Obstetricians and Gynecologists.
Addressing health disparities: "The AAFP believes many health disparities could be addressed by increasing primary care access and supporting programs that address the social factors that impact individuals' health," said the letter, noting that 5 million U.S. women live in obstetric deserts.(newsmomsneed.marchofdimes.org)
The majority of women facing pregnancy complications are women of color, the Academy wrote -- a fact stemming from decades of structural, systemwide inequities, institutionalized racism and the unconscious biases of health care professionals.
To combat this, the Academy recommended
- educating physicians about implicit bias and strategies to address it to support culturally appropriate, patient-centered care and reduce health disparities;
- increasing the number of diverse family medicine physicians who provide obstetric care in rural and other underserved areas by reducing their liability insurance premiums;
- retaining primary care physicians through loan repayment and other incentives;
- enhancing the primary care workforce with initiatives such as the highly effective Teaching Health Center Graduate Medical Education Program; and
- passing the Rural Physician Workforce Production Act of 2019 (S. 289).
Streamlining data collection and evaluation: The Academy said it continued to support the Rural Maternal and Obstetric Modernization of Services Act (S. 2373), among other efforts to improve outcomes and quality.
Supporting social services for mothers and children: The federal government should provide adequate funding for programs addressing social determinants of health, the AAFP said, including home visiting,(mchb.hrsa.gov) which more than 30 states cover through Medicaid.
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