Declining Trends in the Provision of Prenatal Care Visits by Family Physicians

To the Editor

It was with great interest that we read the recent article by Cohen and Coco [1] regarding the declining provision of maternity care services by family physicians across the United States. This decline parallels the general decline in interest in family medicine and we feel it is directly proportional to two primary factors:

1. Professional jousting. This phenomenon is a unique and sad product of the medical education system. Students interested in primary care are frequently dissuaded from pursuing that career path by staff and resident physicians in other disciplines who bombard them with negative comments regarding their chosen field. “You’re too smart to be a Family Physician” is a mantra often heard by students during their clinical years. It is unclear what other professional disciplines tolerate this blatant lack of respect in their educational pipeline. The (un)intended consequence of such professional jousting has been the steady erosion of interested and qualified candidates in all fields of primary care--family medicine, general internal medicine, general pediatrics and general surgery. A similar phenomenon and mantra is common, particularly within tertiary facilities: “Family physicians (or midwives) have no business delivering babies.” While there is certainly no outcomes-based data to back this statement, family physicians are clearly voting with their feet when it comes to providing maternity care services.

2. Economic reality. Students often graduate medical school with six- figure debts. It is no surprise, therefore, when they seek greener pastures economically [2]. Similarly, current malpractice requirements make the provision of maternity care very difficult for physicians in community family medicine practices. Until there is some modicum of payment reform (and/or tort reform), the exodus of family physicians from the world of maternity care will most likely continue.

There is, however, one relative exception to this rule—the Uniformed Services—a population not reflected in the database used in Cohen and Coco’s study. The provision of maternity care services by family physicians within the Uniformed Services remains robust. A majority of family physicians in the uniformed services retain their obstetric credentials and actively deliver prenatal care. At facilities where family physicians provide routine prenatal care, operative delivery rates remain much lower than national averages with equivalent neonatal outcomes [3]. In reflecting upon the reasons why many uniformed family physicians remain active in the maternity care arena, the answer (for us) is obvious: 1. outstanding professional relations and 2. Fewer economic pressures.

Within the armed forces, there is an unspoken credo of camaraderie and service. Rather than competing for individual gain, the goal is team success. In the end, everyone wins—physicians, hospitals and (most importantly) patients.

References:
1. Cohen D, Coco A. Declining trends in the provision of prenatal care visits by Family Physicians. Ann Fam Med 2009; 7: 128-133.
2. Ebell MH. Future salary and US residency fill rate revisited. JAMA 2008; 300(10): 1131-1132.
3. Jaditz T, Bickett T, Foster L, et al. Examples of practice variation across Navy Military Treatment Facilities. CNA Report N00014-05-D-0500. Arlington, VA. 2008.

Mark B. Stephens, MD, Associate Professor, Department of Family Medicine, Uniformed Services University, Bethesda, MD
Pamela M. Williams, MD, Assistant Professor, Department of Family Medicine, Uniformed Services University, Bethesda, MD

The opinions are those of the authors--they do not represent official policy of the Department of Defense, the Navy Bureau of Medicine and Surgery, the Deparment of the Navy, the Department of the Air Force or the Uniformed Services University.

Competing interests:   None declared

Dr. Lin makes a compelling argument that further studies are needed examining the impact of the declining trend in prenatal care by family physicians. Studies demonstrating the cost-effectiveness and increased value of FP-provided maternity care may indeed substantiate the argument for ongoing maternity care training in family medicine. However, there are some inherent difficulties in structuring such an analysis. Unlike other analyses of usual sources of care, a large number of family physicians may rely on their obstetrical colleagues for assistance in managing obstetrical conditions both during prenatal care and delivery, making it difficult to determine the impact of care by specialty on outcomes, cost, or value. In addition obstetricians caring for patients with higher-risk conditions or requiring surgical procedures would expectedly result in higher medical expenditures, making the interpretation of such findings less clear.

There may be greater value in future studies exploring the impact that this decline by family physicians may have on access to prenatal care, particularly in rural communities where no other providers may exist and women may be forced to travel in order to obtain prenatal or delivery care. As discussed in the current article, ongoing attrition of FP prenatal care services will undoubtedly have major public health implications. Research to demonstrate the specific consequence of this attrition may be the single most effective way to inform future health policy and training and ultimately the case for supporting ongoing maternity care by family physicians.

Competing interests:   None declared

Competing interests:   None declared