Abstract
Introduction Maldistribution of maternity care (MC) providers in the U.S. limits access to full spectrum MC services. Obstetricians are concentrated in urban areas with many rural areas reliant on family physicians (FP) to provide MC, yet fewer FPs are providing MC. The objective of this study was to understand the challenges FPs face in gaining skills in and providing advanced MC. Methods We conducted qualitative semi-structured interviews with 51 purposively sampled key stakeholders in family medicine MC (21 family medicine-OB fellowship directors, 19 past fellows, and 10 family medicine residency directors of programs with advanced MC training). Interviews were recorded, transcribed, and analyzed using an inductive approach to qualitative content analysis. Results Three primary challenges for FPs providing advanced MC emerged from the interviews. Training: most family medicine residency programs do not provide sufficient surgical OB training, so fellowship training is an important alternative for FPs to acquire such skills. Credentialing: obtaining hospital privileges to perform cesarean sections is unpredictable and highly variable by institution. Professional relationships: “turf battles” with other MC providers can limit FPs’ ability to provide care commensurate with their level of training. Discussion As the predominant provider of MC in rural and underserved areas, FPs need to be supported to provide advanced MC services. Possible strategies to accomplish this include: enhanced family medicine training in MC; policy changes to address credentialing inconsistencies; and improved team-based care for pregnant women to ensure that every woman has access to high quality MC.
Similar content being viewed by others
References
ACOG. (2014). Committee Opinion No. 586: Health disparities in rural women. Obstetrics and Gynecology, 123, 384–388. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Disparities-in-Rural-Women. Accessed 1 July 2016.
AAFP. (1987). Family physicians and obstetrics: A professional liability study. Kansas City, Mo.
AAFP. (2012). Maternal/Child Care (Obstetrics/Perinatal Care). AAFP Policies. http://www.aafp.org/about/policies/all/maternal-child.html. Accessed 1 July 2016.
AAFP and ACOG. (2014). AAFP-ACOG Joint Statement on Cooperative Practice and Hospital Privileges. AAFP Policies. http://www.aafp.org/about/policies/all/aafp-acog.html. Accessed 1 July 2016.
Abenhaim, H. A., Welt, M., Sabbah, R., & Audibert, F. (2007). Obstetrician or family physician: Are vaginal deliveries managed differently? Journal of Obstetrics and Gynaecology Canada, 29(10), 801–805.
Aubrey-Bassler, K., Cullen, R. M., Simms, A., Asghari, S., Crane, J., Wang, P. P., & Godwin, M. (2015). Outcomes of deliveries by family physicians or obstetricians: A population-based cohort study using an instrumental variable. Canadian Medical Association Journal, 187(15), 1125–1132.
Avery, D., Graettinger, K. R., Waits, S., & Parton, J. M. (2014). Comparison of delivery procedure rates among obstetrician/gynecologists and family physicians practicing obstetrics. American Journal of Clinical Medicine, 10(1), 16–25.
Avery, D., Marshall, E., Hooper, D. E., & Parton, J. M. (2013). University of alabama family medicine obstetrics fellowship: Results and outcomes, 1986–2011. Journal of Family Medicine Obstetrics, 7(1), 23–31.
Barreto, T. W., Eden, A. R., Petterson, S., Bazemore, A. W., & Peterson, L. E. (2017). Intention versus reality: Family medicine residency graduates’ intention to practice obstetrics. Journal of the American Board of Family Medicine, 40(4), 405–406.
Berman, D. R., Johnson, T. R., Apgar, B. S., & Schwenk, T. L. (2000). Model of family medicine and obstetrics-gynecology collaboration in obstetric care at the University Of Michigan. Obstetrics & Gynecology, 96(2), 308–313.
Boss, D. J., Timbrook, R. E., & Group, F. W. M. E. R. (2001). Clinical obstetric outcomes related to continuity in prenatal care. The Journal of the American Board of Family Practice, 14(6), 418–423.
Bredfeldt, R., Sutherland, J., & Wesley, R. (1988). Obstetrics in family medicine: Effects on physician work load, income, and age of practice population. Family Medicine, 21(4), 279–282.
Brown, D. R., Brewster, C. D., Karides, M., & Lukas, L. A. (2011). The phenomenon of collaboration: A phenomenologic study of collaboration between family medicine and obstetrics and gynecology departments at an academic medical center. The Qualitative Report, 16(3), 657.
Buckle, D. (1994). Obstetrical practice after a family medicine residency. Canadian Family Physician, 40, 261.
Deutchman, M. E., Sills, D., & Connor, P. D. (1995). Perinatal outcomes: A comparison between family physicians and obstetricians. The Journal of the American Board of Family Practice, 8(6), 440–447.
Eden, A. R., & Peterson, L. E. (2017). Impact of potential accreditation and certification in family medicine maternity care. Family Medicine, 49(1), 14–21.
Glaser, B. G., & Strauss, A. L. (2009). The discovery of grounded theory: Strategies for qualitative research. Piscataway, NJ: Transaction Publishers.
Helton, M., Skinner, B., & Denniston, C. (2003). A maternal and child health curriculum for family practice residents: Results of an intervention at the University of North Carolina. Family Medicine, 35(3), 174–180.
Homan, F. F., Olson, A. L., & Johnson, D. J. (2013). A comparison of cesarean delivery outcomes for rural family physicians and obstetricians. The Journal of the American Board of Family Medicine, 26(4), 366–372.
Hueston, W. J., Applegate, J. A., Mansfield, C. J., King, D. E., & McClaflin, R. R. (1995). Practice variations between family physicians and obstetricians in the management of low-risk pregnancies. Journal of Family Practice, 40(4), 345–352.
Klein, M. C., Kaczorowski, J., Tomkinson, J., Hearps, S., Baradaran, N., Brant, R., & Group, M. C. R. (2011). Family physicians who provide intrapartum care and those who do not: Very different ways of viewing childbirth. Canadian Family Physician, 57(4), e139-e147.
Koppula, S., Brown, J. B., & Jordan, J. M. (2012). Experiences of family medicine residents in primary care obstetrics training. Family Medicine, 44(3), 178–182.
Kozhimannil, K., Casey, M., Hung, P., Prasad, S., & Moscovice, I. (2014). The obstetric care workforce in critical access hospitals (CAHs) and Rural Non-CAHs. Minneapolis, MN: University of Minnesota Rural Health Research Center.
Kruse, J., Phillips, D., & Wesley, R. (1989). A comparison of the attitudes of obstetricians and family physicians toward obstetric practice, training, and hospital privileges of family physicians. Family Medicine, 22(3), 219–225.
Larimore, W. L., & Sapolsky, B. S. (1995). Maternity care in family medicine: Economics and malpractice. Journal of Family Practice, 40(2), 153–161.
Magee, S. R., Radlinski, H., & Nothnagle, M. (2015). Maternal-child health fellowship: Maintaining the rigor of family medicine obstetrics. Family Medicine, 47(1), 48–50.
McCaleb, H. S., & Wheat, J. R. (2013). The advantages and disadvantages for a rural family physician practicing obstetrical care. Journal of Family Medicine Obstetrics, 7(1).
Mehl, L., Bruce, C., & Renner, J. (1976). Importance of obstetrics in a comprehensive family practice. The Journal of Family Practice, 3(4), 385–389.
Pecci, C. C., Hines, T. C., Williams, C. T., & Culpepper, L. (2012). How we built our team: Collaborating with partners to strengthen skills in pregnancy, delivery, and newborn care. The Journal of the American Board of Family Medicine, 25(4), 511–521.
Pecci, C. C., Leeman, L., & Wilkinson, J. (2008). Family medicine obstetrics fellowship graduates: Training and post-fellowship experience. Family Medicine, 40(5), 326.
Peterson, L. E., Blackburn, B., Phillips, R. L. Jr., & Puffer, J. C. (2014). Structure and characteristics of family medicine maternity care fellowships. Family Medicine, 46(5), 354–359.
Ratcliffe, S. D., Newman, S. R., Stone, M. B., Sakornbut, E., Wolkomir, M., & Thiese, S. M. (2002). Obstetric care in family practice residencies: A 5-year follow-up survey. The Journal of the American Board of Family Practice, 15(1), 20–24.
Rayburn, W. F., Klagholz, J. C., Murray-Krezan, C., Dowell, L. E., & Strunk, A. L. (2012). Distribution of American Congress of Obstetricians and Gynecologists fellows and junior fellows in practice in the United States. Obstetrics & Gynecology, 119(5), 1017–1022.
Rayburn, W. F., Petterson, S. M., & Phillips, R. L. (2014). Trends in family physicians performing deliveries, 2003–2010. Birth, 41(1), 26–32.
Reime, B., Klein, M. C., Kelly, A., Duxbury, N., Saxell, L., Liston, R., & Wong, V. (2004). Do maternity care provider groups have different attitudes towards birth? BJOG: An International Journal of Obstetrics & Gynaecology, 111(12), 1388–1393.
Rodney, W., Martinez, C., Collins, M., Laurence, G., Pean, C., & Stallings, J. (2010). OB fellowship outcomes 1992–2010: Where do they go, who stops delivering, and why? Family Medicine, 42(10), 712–716.
Smits, A. K., King, V. J., Rdesinski, R. E., Dodson, L. G., & Saultz, J. W. (2009). Change in Oregon maternity care workforce after malpractice premium subsidy implementation. Health services research, 44(4), 1253–1270.
Sutter, M. B., Prasad, R., Roberts, M. B., & Magee, S. R. (2015). Teaching maternity care in family medicine residencies: What factors predict graduate continuation of obstetrics? A 2013 CERA program directors study. Family Medicine, 47(6), 459–465.
Tietze, P., Gaskins, S., & McGinnis, M. (1988). Attrition from obstetrical practice among family practice residency graduates. The Journal of Family Practice, 26(2), 204–205.
Tong, S. T., Makaroff, L. A., Xierali, I. M., Puffer, J. C., Newton, W. P., & Bazemore, A. W. (2013). Family physicians in the maternity care workforce: Factors influencing declining trends. Maternal and Child Health Journal, 17(9), 1576–1581.
Tucker, W., Diaz, V., Carek, P. J., & Geesey, M. E. (2007). Influence of residency training on procedures performed by South Carolina family medicine graduates. Family Medicine, 39(10), 724.
Young, R. (2017). Maternity care services provided by family physicians in rural hospitals. Journal of the American Board of Family Medicine, 30(1), 71–77.
Young, R., Webb, A., Lackan, N., & Marchand, L. (2008). Family medicine residency educational characteristics and career satisfaction in recent graduates. Family Medicine, 40(7), 484.
Acknowledgements
We would like to thank Anneli Cochrane-Horn (AC) for data analysis assistance and Elizabeth Hansen for managing references and editing. We thank Robert Phillips, MD, for providing feedback on the manuscript and ensuring our interpretations were accurate. We greatly appreciate the time and thoughtful responses of the family physicians who participated in the interviews.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Eden, A.R., Peterson, L.E. Challenges Faced by Family Physicians Providing Advanced Maternity Care. Matern Child Health J 22, 932–940 (2018). https://doi.org/10.1007/s10995-018-2469-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10995-018-2469-2