Care From Family Physicians Reported by Pregnant Women in the United States

INTRODUCTION

Family physicians are important providers of care for reproductive-age women, and the breadth of the specialty includes care before, during, and after pregnancy.^1,2 Primary care, family planning, preconception, and prenatal care contribute to the health and well-being of women during the perinatal period and beyond.³

The proportion of women’s preventive health visits conducted by family physicians remained stable from 1995 to 2007, accounting for 20% of such visits overall and 28% in nonmetropolitan areas.⁴ The role of family physicians as providers of maternity-related care, however, has steadily declined.^5,6 Family physicians provided 12% of prenatal visits in 1995 to 1996 and only 6% in 2003 to 2004.⁵ In 2006, 7% of women had a family physician attend their delivery.⁷ As of 2009, there were notable regional differences in maternity care, with family physicians in the North Central and Pacific regions more likely provide hospital obstetrics (22% and 33%, respectively) compared with family physicians in the Mid- and South Atlantic (5% and 8%, respectively).⁸

Women receive medical care from many types of clinicians during the perinatal period, including family physicians, obstetrician-gynecologists, midwives, other specialists, and midlevel clinicians. The extant literature contains descriptions of trends in provision of prenatal and intrapartum care by family physicians but does not quantify the number of pregnant women who have family doctors. This analysis describes the proportion of family physicians providing medical care of any sort to pregnant women in the United States and examines trends over time and by geographic region.

METHODS

RESULTS

Slightly more than one-third of pregnant women in our aggregated 10-year sample reported care from a family physician during the prior year (Table 1). Approximately one-fourth were Hispanic and 13% were black; one-third were under age 25 years. The majority of pregnant women receiving care from family physicians had a high school education or less, and one-half were working. Seventeen percent were low-income; 10% were uninsured, 30% had Medicaid, and 55% had private coverage. Results from logistic regression models are shown on the right side of Table 1 as adjusted odds ratios (AORs) and 95% confidence intervals. There were no significant changes in annual trends in family physician care (AOR = 1.006). Although 34.4% of pregnant women reported care from family physicians, just 3.8% saw family physicians alone (Table 2). The majority (64.8%) of pregnant women reported care from multiple clinicians during the past year. The proportion of pregnant women reporting care from family physicians and other clinicians remained steady over time (results not shown).

Although overall trends in family physician care were steady, there were significant regional differences. We found an increasing trend in family physician care in the North Central region (6.7% annual increase), steady trends in the Northeast and West, and a decline in the South (4.7% annual decrease). Figure 1 displays these findings using model-based predicted probabilities from the 2000–2009 study period, extrapolated by region from 2010 to 2015 and assuming unchanging trends in care for the “average” woman: aged 27 years, white, married, working, US-born citizen with a high school education. In this model, by 2015, more than 60% of all pregnant women in the North Central region will have consulted a family physician for her medical care during the prior year.

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Figure 1

Predicted probability that an average pregnant woman (aged 27 years, white, married, working, US-born citizen with high school education) reports having seen a family physician in the prior year, by US region.

DISCUSSION

Even though provision of maternity care by family physicians has decreased during the past decade, a substantial and steady proportion of pregnant women (34.4%) received care from a family physician, underscoring the importance of family physicians as providers of clinical services for childbearing women, before and during pregnancy.³ Family physicians need to be familiar with preconception care and with the physiologic changes and common complications of pregnancy, even if they are not the clinician solely or primarily responsible for prenatal care.

In the United States, women typically seek care from multiple clinicians to meet their medical needs.^15–18 This study confirms that pregnant women see multiple clinicians during the perinatal period. Because clinical circumstances may necessitate specialized care, and patients may shift among clinicians, care coordination is a clear need for pregnant women¹⁹ and has been shown to improve outcomes, especially for underserved women.^20,21 One strategy that holds promise for improving care coordination is the patient-centered medical home model (PCMH) advocated by the American Academy of Family Physicians and other professional societies. PCMH models have yet to be widely implemented for maternity care, but have met with early successes in other clinical areas.^22,23 Clinical maternity outcomes have historically been similar among low-risk patients of family physicians, midwives, and obstetricians, and emerging evidence suggests that midwifery models of care may improve outcomes for low-risk women.^24–26 Collaborative practice models have recently generated enthusiasm for improving care coordination and meeting maternity-related health care needs.^27,28 Most collaborative models in the United States have combined midwifery and obstetric practices, and—indeed—pregnant women increasingly report care from such a combination of clinicians.²⁹ Collaborative maternity practices that include family physicians and other clinicians have met with early success and may warrant further exploration.^30,31 Additional research is needed to evaluate choices, outcomes, costs, and women’s satisfaction with care in various care delivery models.

Although future investigations may shed light on best practices, it is important that all pregnant women have access to care. Our analysis revealed that 7.8% of pregnant women reported that they had not seen a clinician during the past year (Table 2). Our findings regarding regional differences raise questions about ongoing changes in the family physician’s scope of practice, particularly in the South, where pregnant women are reporting decreases in care from family physicians. Factors associated with family medicine specialty choice include female sex, rural background, and an interest in obstetric care,^32,33 which may help to cultivate the family physician workforce in places with greatest needs.

The analysis has important limitations. The survey did not ask about the status or gestational age of the pregnancy, delivery attendant, or about timing or reasons for visits with different types of clinicians, so we are unable to determine whether women consulted family physicians for preconception care, general primary care, prenatal care, or other health services. No information on clinician practice models was collected in the survey. Finally, our proxy definition for family physician care is limited by the survey questions and may possibly have misclassified general practitioners or internal medicine physicians who also see pediatric patients as family physicians.

Given that pregnant women were likely to report care from multiple clinicians, coordinating preconception, prenatal, and postpartum care is essential to ensure that relevant health information is shared, screenings and necessary follow-up are provided, and high-quality care is delivered to women through the reproductive years and beyond.