Is maternity care still part of the family medicine continuum?

"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.