"Family doctors can deliver babies?" That's a common reaction I get when chatting with people (whether non-medical friends or medical students). And my answer is always an adamant "YES!"
But the reality now is that fewer and fewer family physicians are choosing to provide maternity care as part of their scope of practice. The most recently presented data shows that, as of 2010, only 10% of family physicians provide maternity care - down from 23% in 2000 (1). "So what?", you may ask. We have enough OB/GYNs in this country - they can do prenatal care and deliver babies. We don't need family doctors to do that.
The problem is that OB/GYNs are not well distributed across the country. Take a look at the county map below - all the red counties are the counties without a single OB/GYN doctor. That's like 50% of counties in the USA.
(2)[Note the graph shows the number of OB/GYN doctors per 10,000 women, not the absolute number.]
Generally, family doctors are the ones who provide in these "red" counties, most of which are rural areas. In fact, family doctors disproportionately provide maternity care to Medicaid and underserved patients. Without family doctors, those in these areas would not receive adequate care.
In July 2012, new family medicine residency requirements will be implemented for FM residents. Currently, all residents must perform 40 deliveries during the course of their residency training. About 50% of programs do not meet these guidelines. As such, in July 2012, a two-tiered system will be created: an exposure track and a competency track. The exposure track will require 20 deliveries and the competency track will require 80 deliveries (3).
To many, this sounds like the death knoll of family physicians' participation in the provision of maternity care. Some residency programs will choose to only offer the exposure track while many residents unsure if they want to practice maternity care will select into exposure tracks. To students choosing between family medicine and OB/GYN, family medicine may no longer offer enough obstetric exposure to draw these students. Likewise, family medicine without obstetric care loses one of its distinguishing features from med-ped residencies. Most importantly, however, pregnancy is an essential part of and often a defining moment in a woman's life. Without maternity care, family medicine can no longer claim to provide the full continuum of comprehensive care.
We need to explore the reasons why family doctors no longer provide maternity care. Is it lifestyle? Malpractice costs? Lack of institutional support and hospital privileges? Then we have to actively evaluate whether these new residency requirements for maternity care are training the next generation of family physicians we need to best serve our nation's patients. If we don't do this, our next generation of women needing maternity care in rural and underserved areas will not have a doctor to provide their prenatal care or deliver their babies.
(1) Tong S et al. Predictors of Maternity Care Provision Among Family Physicians. Data presented at the North American Primary Care Research Group, November 12, 2011.
(2) American College of Obstetricians and Gynecologists. The Obstetrician-Gynecologist Workforce in the United States. Facts, Figures and Implications. 2011.
(3) AFMRD Presidents' Welcome. November 1, 2011.
The map in this article is not correct if the statics indicate the number of ob/gyn doctors is measured by "1" being "one doctor". The county in which I live (Lancaster county, PA) is listed as having 1.2-2 ob/gyn practitioners. That is simply not the case. This county contains four hospitals that all operate maternity/labor & delivery/newborn facilities (Heart of Lancaster Hospital, Lancaster General Hospital, Ephrata Hospital, Regional Medical Center Hospital). Plus one of these hospitals operates a separate facility (Women & Babies Hospital) satellite. There are MANY ob/gyn doctors who practice in this county . . . plus midwives and other types of related services. It is not difficult to find doctors for pregnant women . . . I know this first hand as I was able to easily find a doctor who specialized in high risk pregnancies and births. The hospitals, as well, are very competitive and offer beautiful facilities for pregnant women as well as a full array of classes . . . everything from childbirth, lamaze, prenatal yoga & meditation, organic food preparation for babies, and classes for women with specialized medical issues. There is truly well organized and well delivered medical practices, facilities, and programs available for pregnant women, infants, and families in Lancaster county. As one could guess, Lancaster county is also plentiful in family doctor practices. It's really not difficult to find medical services in this county.
ReplyDeleteI went to the website from which this map originated and discovered lots of references to government lobbying. As a teacher, I am well aware of the need to lobby for government support of such matters. However, statistics should be accurate. Misrepresenting statistics, when publicized, can have the effect of losing public support for these causes . . . as we all well know, loss of public support can mean a loss of federal and state funding. I would encourage the American College of Obstetricians and Gynecologists to be accurate when presenting statistics as prenatal care/labor/deliver/infant care is truly important.
I also noticed that there are counties in PA that are colored red . . . indicating that there is no ob/gyn doctor practicing in those counties. What the map does not indicate is that many of these counties in red include counties where population centers are low, mostly for geographical reasons. The people living in these counties probably do have access to ob/gyn care in a nearby county and there's a pretty good chance that it's more convenient. After all, it's not easy to build commercial facilities in areas where people don't live. It's not easy or logical to build medical in areas where the geography is mostly rocky forests.
Simply presenting information in this manner doesn't always give people the real picture of what medical services are needed. Perhaps it would be better to develop a formula for calculating the need for ob/gyn doctors/midwife services. This formula could include total population, doctors available, as well as the average age of the population and average size of families living in these areas.
As we all know, generalizing large statistics in the field of medicine doesn't always make for economical medical services.
Renae,
ReplyDeleteThank you for your comment. I checked the report where I got the map from and I had inadvertently misrepresented the map when I posted it. The dark red counties do in fact represent counties where there are no OB/GYN doctors. However, the map shows the number of OB/GYN doctors per 10,000 women. I have corrected this in the post.
Since ACOG is doing this data analysis, they are only looking at OB/GYNs who are members of ACOG (which is according to their report 93-95% of all OB/GYN doctors). Of course, this does not include family doctors or mid-level practitioners (such as midwives or nurse practitioners). In terms of mid-level practitioners, reports that I have seen consistently put them at providing ~5% of all care for women.
For full statistical transparency, while 49% of all US counties do not have a OB/GYN doctor, only 9.5 million Americans live in these counties. However, the point is in many of these predominantly rural counties, it may be difficult to travel to another nearby county to access maternity care services.
If you are really interested in this area, I would be happy to send you a copy of the ACOG report and to keep you updated as I do further analyses on the distribution of family doctors across the counties.
ReplyDeleteYou can contact us at: futureoffamilymedicine@gmail.com
I have always believed FM residencies should offer a non-OB track as an alternative while still providing emphasis on women's care issues. The major problem (I think ) with FM practitioners doing OB is that, when something goes wrong, they are judged not by a group of their peers, but by OB doctors who don't appreciate the foray into their specialty. This is an odd reaction, since they are usually unwilling to practice in such rural areas so I don't get the attitude. I would have preferred more training in critical care as opposed to OB since I moved to being a hospitalist after doing a year in the clinic trenches.
ReplyDelete