RE: Family Medicine Obstetrics: Answering the Call

An underused, evidence-based option for almost all FPs to provide the maternity care that America needs

Drs. Barr and DeMarco are to be commended on their recent editorial, “Family Medicine Obstetrics: Answering the Call;”(1) however, their call for designing “new training models … to not only focus on patient care skills in pregnancy care but also the critical skills for leading and being included in interprofessional teams needed to provide comprehensive pregnancy care,” left out a potential critical component of such care that could be practiced by most of the 88% of family medicine graduates who are not attending births.(2) This is especially important given alarming association of increasing maternal and infant mortality in areas with decreased availability of family physicians providing maternity care, whether in rural or inner-city America, a concern that’s been only growing over the last 30 years.(3,4) Yet, in most of these areas, we family physicians are already practicing.(5-7)
This begs the question, why not train all our residents to provide an old model of basic, practical, economical, life-saving (or mothers and babies), and proven maternity care that is successfully practiced by family and general physicians across the globe? It goes by various monikers, such as “shared ante-natal care” or “shared maternity care,” but I’ll just call it, as I did 25 years ago, “shared care.”(8)
In shared care systems, the pregnant patient’s family physician provides prenatal and postpartum care in partnership with the health professional who will attend the i-hospital birth. During my practice years when I attended the birth of over 1,500 babies while practicing family-centered maternity care,(9-10) My practice partners and I would have some mothers that wanted their birth to be attended by a midwife or an obstetrician. In those cases, we didn’t “give up the patient,” rather, we offered shared care. I can’t remember a single woman turning it down.
Shared care can be done by almost any family physician in our country and can benefit the patient, her unborn baby, her family, society in general, and her family physician. Shared care not only could be, but should be, “an improved paradigm for women’s health.”(11) Upon what was this still-ignored recommendation based upon? Both a small U.S. study and multiple international studies.
I published the U.S. study in 1995 and compared family physicians in Florida who attended deliveries (the “OB group”) with those who did not attend deliveries (the “non-OB group”).(12) Within the non-OB group was a subgroup who practiced shared care (the “Shared care group”). For every benefit the OB group reported (e.g., increased income, satisfaction, practice diversity, numbers of complete families in the practice, and reduced malpractice risk compared with the non-OB group), the shared-care group reported the same benefits. The degree of benefit for the shared-care group was always close to or equal to that of the OB group.
I observed, “The time just before and during a pregnancy is one of the most important times in a young family’s life, and physicians in our specialty who refer these families to other healthcare professionals for maternity care often find the family does not bring the baby back to the family physicians’ practice.”(12) In other words, family physicians not providing shared care were less likely to provide care for the babies their patients deliver.
The study concluded, “Therefore, family physicians who do not want to or who cannot attend deliveries but who do want to increase their practice satisfaction, diversity, and income, while lowering their risk of malpractice suit, should consider providing shared maternity care. In addition, family practice residencies and family medicine departments may wish to consider modeling, researching, and teaching shared maternity care to those residents and family physicians who prefer not to deliver babies or who will practice in outpatient environments.
Multiple international studies have also highlighted the benefits of shared care. Thirty years ago, shared care was studied in a randomized, controlled manner in Scotland and found to be safe and effective.(13) Australians reported that at least 80 percent of pregnant women benefited from shared care.(14) By the early 1990s, shared care had been shown safe and effective in such diverse countries as Australia, England, Scotland, Denmark, Finland, India, Saudi Arabia, Zaire, Zimbabwe, and most of continental Europe.(15)
By 2000, research of shared care revealed a large number of advantages to the patient, the family physician, and the health care system, including: (1) reduced antenatal costs;(14) (2) improved continuity of care;(14) (3) improved perinatal and maternal outcomes, improved communication between women and health care providers, and improved patient satisfaction;(16); (4) reduced perinatal death rates;(16) (5) increased satisfaction among general practitioners;(16) (6) reduced workload in overcrowded hospital antenatal clinics;(16) (7) reduced travel time and waiting time for pregnant women and their families, easier access to antenatal care along with increased continuity of care(16); and (8) reduction in maternity care admissions and length of stay.(17) Wow! If I could invent a prenatal vitamin that did all that, I’d make a million dollars!
Furthermore, the data show that most women in shared care prefer that their local family physician provide as much maternity care as possible,(16, 18-19) and physicians providing shared care find the care enjoyable and satisfying.(18-19) Most women believe that their family physician is competent to provide prenatal care and their confidence is an important determinant in the success of both improved outcomes and decreased costs.(20)
One journal editor opined, “When the needs for a strong primary maternity care system are so great, it makes good sense for all maternity care practitioners to support one another, to rethink their philosophies and priorities, and most important of all, to put the needs of the pregnant woman and her family first.”(21) A mentor of mine reflected, “Competition between primary and secondary caregivers does harm to both of them, but most harm to the women over whose bodies the battle is fought. Territorial preoccupation and defensive attitudes are formidable barriers to effective care.”(22)
Former U.S. Vice President, Hubert Humphrey, said, “The ultimate moral test of any government is the way it treats three groups of its citizens. First, those in the dawn of life – our children. Second, those in the shadows of life – our needy, our sick, our handicapped. Third, those in the twilight of life – our elderly.”(23) We family physicians are uniquely equipped, positioned, and able to do all three. But, as I’ve asked for the last three decades, “Will family medicine be seen as the specialty that abandoned our pregnant female patients and their unborn children?(10)
A potential strategy to avoid this seems a simple one to me: Almost all family physicians who do not attend deliveries can be trained to provide shared care to their pregnant patients who need and desire this care. To reiterate what I wrote in 1995, shared care “is for the U.S. maternity care system, in general, and for family physicians, in particular, an opportunity too grand not to grasp,”(10) adding, “Maternity care is intrinsic to the formation of the family” and “Family medicine without maternity care is not family medicine, it is just medicine.”(12)
1. Wendy B. Barr and Mario P. DeMarco. The Annals of Family Medicine September 2024, 22 (5) 367-368; DOI: https://doi.org/10.1370/afm.3176.
2. American Board of Family Medicine National Graduate Survey Reports. Accessed September 2024. https://bit.ly/3SZjUN8
3. Larimore WL, Davis A. Relationship of infant mortality to availability of care in rural Florida. J Am Board Fam Pract 1995; 8:392-9.
4. Ely DM, Driscoll AK, Mathews TJ. Infant mortality rates in rural and urban areas in the United States, 2014. NCHS Data Brief No. 285, September 2017. Centers for Disease Control and Prevention. https://tinyurl.com/8p7jn45c.
5. Bazemore A. The Robert Graham Center Update: A Primary Care Perspective on Health Care Workforce and Expenditures Presentation. Version 2.0. Updated March 9, 2009. https://tinyurl.com/wpsxr3u5.
6. Rodgers DV, Wendling AL, Saba GW, et al. Preparing Family Physicians to Care for Underserved Populations: A Historical Perspective. Fam Med 2017;49(4):304-10.
7. Fashner J, Cavanagh C, Eden A. Comparison of Maternity Care Training in Family Medicine Residencies 2013 and 2019: A CERA Program Directors Study. Fam Med. 2021;53(5):331-337. https://doi.org/10.22454/FamMed.2021.752892.
8. Larimore WL. Shared Antenatal Care: An Improved Paradigm for Women’s Health Care. (Editorial) J Fam Pract 1998 (Jan);46(1):31-33.
9. Larimore WL. Family-centered birthing: a niche for family physicians. Am Fam Physician 1993; 47:1365-6.
10. Larimore WL. Family-centered birthing: history, philosophy and need. Fam Med 1995; 27:132-8.
11. Larimore WL. Shared Antenatal Care: An Improved Paradigm for Women’s Health Care. (Editorial) J Fam Pract 1998 (Jan);46(1):31-33.
12. Larimore WL, Sapolsky BS. Maternity care in family medicine: Economics and malpractice. J Fam Pract 1995; 40:153-160
13. Tucker JS, Hall MH, Howie PW, et al. Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians. BMJ 1196; 312:554-9.
14. Halloran J, Gunn J, Young, D. Shared obstetric care: the general practitioner’s perspective. Aust NZ J Obstet Gynaecol 1992; 32:35.01.
15. Miller CA. Maternal and infant care: comparisons between western Europe and the United States. Int J Health Serv 1993; 23:655-64.
16. Ratten GJ, McDonald L. Organization and early results of a shared antenatal programme. Aust NZ J Obstet Gynaecol 1992; 32:296-300.
17. Chan FY, Pun TC, Tse LY, Lai P, Ma HK. Shared antenatal care between family health services and hospital (consultant) services for low risk women. Asia Oceania J Obstet Gynaecol 1993; 19:291-8.
18. Wood J. A review of antenatal care initiative in primary care settings. Brit J Gen Pract 1991; 41:26-30.
19. Del Mar C, Siskind V, Acworth J, Lutz K, Wyatt N. Shared antenatal care in Brisbane. Aust NZ J Obstet Gynaecol 1991; 31:305.
20. Mainous AG, David SK. Clinical competence of family physicians. Arch Fam Med 1992; 1:65-8.
21. Young D. Family physicians and maternity care: high tech or high touch? Birth 1994; 21:191-3.
22. Keirse MJNC. Interaction between primary and secondary care during pregnancy and childbirth. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford University Press, 1989:198-201.
23. Humphrey, H. An Inventory of His Speech Text Files. The Minnesota Historical Society Manuscripts Collection. Accessed September 2024. http://www2.mnhs.org/library/findaids/00442.xml.