It's no secret that the number of family physicians who provide maternity care, including delivering babies, is declining in the United States, and that fact undermines the promise of comprehensive "cradle-to-grave" care that is foundational to the specialty of family medicine.
In fact, 2012 research(www.jabfm.org) published in the Journal of the American Board of Family Medicine shows that the percentage of FPs who provide maternity care dropped from 23.3 percent in 2000 to just 9.7 percent in 2010.
The puzzle, as observed by authors of a current study(journals.stfm.org) published online in Family Medicine on March 8, is that a good chunk of family medicine residents -- some 23 percent of those included in 2014 survey data from the American Board of Family Medicine -- said when they applied for their initial certification that they intended to provide such services.
But just 9 percent reported providing deliveries when recertifying one to 10 years into practice.
Authors of the new article, titled "Characteristics of Graduating Family Medicine Residents Who Intend to Practice Maternity Care," say they explore "for the first time, the individual and residency program characteristics associated with intent to provide maternity care."
- The number of U.S. family physicians who provide maternity care is declining.
- Researchers investigated the intent of graduating family medicine residents to provide such care and then linked residents to their programs to explore the associations of residency-level characteristics with intentions to provide maternity care.
- In univariate analysis, individual characteristics associated with intent to provide this care include being female and graduating from an allopathic medical school; residency characteristics include additional months of required maternity care rotations and existence of a residency-based maternity care fellowship.
They note, "If intent to practice maternity care could translate into actual practice, these efforts may increase family medicine scope of practice, increase access to maternity care, decrease costs and improve health outcomes."
Researcher Wendy Barr, M.D., M.P.H., program director at the Lawrence Family Medicine Residency in Lawrence, Mass., specializes in health care related to maternal and child health, and has delivered more than 450 babies in her family medicine career.
In addition, she's been an instructor for the AAFP's Family-Centered Maternity Care Live Course and the Advanced Life Support in Obstetrics (ALSO) Live Course, and currently serves as an ALSO advisory faculty member.
In an interview with AAFP News, Barr spoke to the importance of providing maternity care in family medicine.
"We are at a crossroads as a specialty as to whether maternity care continues to be part of the services that patients can expect from their family physician," said Barr.
"No other specialty in medicine cares for all of a woman's most common health care needs, which include care for common acute and chronic illnesses, and her reproductive health, including pregnancy."
Barr said the research team was concerned about the decreasing number of U.S. family physicians who provide maternity care, "particularly at a time when access to maternity care, especially in rural areas and inner-city underserved populations, is also decreasing."
Based on data collected from 2014-2016 graduating family medicine residents -- obtained from the American Board of Family Medicine certification examination demographic questionnaire -- researchers determined that of 9,541 graduating residents, 22.7 percent intended to provide obstetrical delivery services and 51.2 percent intended to provide prenatal care.
Researchers then linked applicants to their residency programs "to explore the associations of residency-level characteristics with intentions to provide maternity care."
Program characteristics were primarily obtained from the AAFP's Residency Directory with additional information gathered from directories associated with teaching health centers (THCs) and rural training tracks.
In univariate analysis, individual characteristics associated with intent to provide obstetrical deliveries included
- being female,
- graduating from an allopathic medical school,
- carrying an educational debt between $25,000 and $149,999, and
- taking part in a loan repayment program.
Authors noted that, with the exception of educational debt, the same associations held true for intent to offer prenatal care.
Residency characteristics associated with intent to provide deliveries and prenatal care included
- funding as a THC,
- training based in a federally qualified health center (FQHC),
- additional months of required maternity care rotations,
- existence of a residency-based maternity care fellowship, and
- a larger residency class size.
Furthermore, said the authors, "increased number of beds and the presence of a rural training track were associated with intent to provide deliveries but not prenatal care."
Authors also identified regional patterns; for instance, higher proportions of residents graduating from programs in the Midwest or West intended to provide obstetric deliveries and prenatal care.
In addition, there were wide variations regionally regarding intent to provide obstetric deliveries -- from 3.9 percent of Mississippi residency graduates to 70.3 percent of those in Alaska.
Prenatal care intent ranged from 27.3 percent of West Virginia graduates to 83.8 percent in Alaska.
In an adjusted, multivariate analysis, researchers found no individual statistically significant relationship between intent to provide obstetric deliveries and training in an FQHC.
Authors pointed out that "the only nongeographic residency-level variable associated with both increased intent to provide deliveries and prenatal care was increased months of required maternity care rotation."
Researchers concluded that "if family medicine as a specialty values the continued provision of maternity care, efforts may need to be taken to encourage residency programs to require increased maternity care exposure."
Continuing the Conversation
Barr provided additional comments about the work completed by the team of seven researchers; that conversation is captured in this brief Q&A.
Q: Were there any unexpected findings?
A: We were surprised that graduates from rural training tracks were not more likely to intend to provide maternity care, especially given the high level of need for this service in rural communities.
Q: What statistics jump off the page?
A: At the time of graduation, more family physicians (22.7 percent) intend to provide deliveries compared to our current national rate (9 percent), and half of all graduates intend to provide prenatal care.
There is significant geographic variation for the intention to practice maternity care -- with some of the highest-needs areas of our country having the worst maternal/child health outcomes and also showing the lowest percentage of family physicians intending to provide maternity care.
Q: What do you want family physicians to take away from this study?
A: There is a higher percentage of family physicians graduating who intend to provide maternity care compared to current practice patterns. And there are characteristics of residency programs that encourage this, as outlined in the study results.
Q: What are the next steps in this area of research?
A: We need to follow these graduates out into practice to see if they practice maternity care as they intend, and if they don't, we need to investigate what barriers exist that prevent family physicians from providing maternity care.
In addition, we plan to take a deeper look at characteristics of residency training programs associated with graduates practicing maternity care.
Related AAFP News Coverage
Leader Voices Blog; AAFP Delivering on Maternity Care Training, Resources
More From AAFP
Family-Centered Maternity Care Live Course