Why Aren't We Using Family Medicine to Help Confront the Maternal Mortality Crisis in the United States?

Abstract

The maternal mortality rate in the United States (US) has steadily risen since 2000. The 2021 CDC numbers show the overall rate of maternal deaths increased to 32.9/100,000 live births, making the US maternal mortality rate more than 10 times that of other high-income countries. If you are Black, that rate is a staggering 69.9/100,000 live births [1, 2]. For perspective: having a higher education tends to be protective in health and mortality, but for Black women with a college education, a 60% greater risk for pregnancy-related death exists compared to white or Hispanic women with less than a high school diploma. In fact, a Black, college-educated woman is five times more likely to die from pregnancy-related complications than a white college-educated woman [3]. Clearly, what's being done isn't working.

In the US, obstetrical care is provided by three groups of clinicians. Family Medicine physicians offer comprehensive care for families that can include pregnancy, childbirth, and newborn care. Some provide prenatal care until 28 weeks then transfer patients to colleagues for the third trimester and delivery. Others manage low-risk pregnancies including deliveries as part of their practice. A third subset undergoes fellowship training; an extra year of expertise in managing medically complex obstetric patients, including managing insulin-dependent diabetes and twins, and acquiring surgical skills for procedures like Cesarean births, D&Cs, and tubal ligations. The American Academy of Family Physicians recognizes 57 Family Medicine OB fellowships across the US. For our discussion, “FMOBs” are synonymous with “Family Medicine with Obstetrics,” and refer to any family physicians who deliver babies.

Obstetrics and Gynecology (OB/Gyn), defined by the American College of Obstetrics and Gynecology as dedicated to the comprehensive medical and surgical care of women, is most commonly associated with attending deliveries. They provide the majority of obstetrical care in the United States and may collaborate with Advanced Practice Nurses. Their fellowships include reproductive endocrinology, and Maternal Fetal Medicine, providing very high-risk prenatal care. OB/Gyns rarely provide newborn care.

Midwives often collaborate within OB/Gyn practices, providing a more holistic approach to pregnancy and delivery. They are often chosen by patients seeking an alternative to physician-led prenatal care. Midwives' scope includes pregnancy, childbirth, postpartum care, and newborn care up through 6 weeks. Outside of pregnancy, their care also primarily focuses on women's health.

The reasons behind the rising maternal mortality rate are multifaceted but access to care is one of the main contributors. In Relocation of Obstetrician-Gynecologist in the United States, 2005–2015, Xierali et al. [4] examine the trend of OB/Gyns moving to predominantly large, metropolitan, less impoverished areas, creating “maternity care deserts” and growing demand for alternative maternity care models. Unfortunately, those most affected have higher social risk i.e. those from minoritized or impoverished communities, challenged by navigating complex hospital systems and advocating for themselves, or who are not fluent in English. In Family Physicians Providing Obstetrics Care in Maternity Care Deserts, the authors discuss the March of Dimes' definition of maternity care deserts: “counties that have no hospitals providing obstetric care and no practicing OB/Gyns or certified nurse midwives (CNMs),” and its exclusion of thousands of Family Physicians providing maternity care to those very areas [5]. Without Family physicians, some 400,000 women in 2021 would have gone without care in their counties. Family physicians are the sole maternity care clinicians in over 180 counties designated as maternity care deserts. Excluding them from the Health Resources and Services Administration's definition of maternity care target areas could lead to under-resourcing areas with the highest need [5].

In Social Inequities between Prenatal Patients in Family Medicine and Obstetrics and Gynecology with Similar Outcomes, Partin et al. [6] highlight benefits of FMOB care. They show that while FMOB patients had more social risk factors, they had fewer cesarean births and their rates of preterm and low birth-weight babies were comparable to the OB/Gyn patient cohort—more likely white, educated, married non-smokers with private insurance [6]. Despite having a population expected to have higher rates of preterm and low birth weight babies, the FMOB and OB/GYN groups had similar outcomes [6]. Other studies note that OB care from Family Medicine, particularly for vulnerable populations [6], leads to lower cesarean birth rates, higher rates of spontaneous vaginal deliveries, and vaginal births after cesarean (VBACs), both linked to fewer complications overall [7]. Another study examining community-based continuity of care, (perfect for FMOBs), found continuity of care critical in reducing health inequities and improving maternal and neonatal outcomes, especially for those with more social risk factors [8]. Nevertheless, the number of Family Physicians providing obstetric care is dwindling.

Why? The answer is complex and multifaceted. According to the ABFM 2021 National Graduate Survey, only 13% included OB post-residency; of the remaining 87%, 60% weren't interested in OB, 16% felt inadequately trained, 12% cited challenges with privileging and 40% said delivering babies wasn't available in their practice [9]. In raw numbers, the 40% equals 541 more Family Medicine physicians providing OB care and increasing access from 2021 alone.

The most often cited reason is “lifestyle considerations” [10] The practice of FMOB is often made unnecessarily challenging by organizational constraints and inaccurate perceptions of productivity. Solutions include minor schedule changes and less binary thinking to facilitate office procedures, hospital rounding, and overnight call. A group of independent physicians in northwestern Ontario covered OB call 1 month a year for their collective call group; they followed the women due during their month for prenatal and intrapartum services. Patient satisfaction was 100% and physicians reported improved satisfaction as well; this change enabled them to continue providing obstetric care [11]. The assumption in articles seems to be that “lifestyle considerations” equals call. However, decreased barriers to Family physicians practicing obstetrics creates a larger pool of FMOBs, decreasing overall call burden while increasing access for patients.

Another reason quoted is the escalating cost of obstetrical malpractice coverage. Larimore et al. [12] found that family physicians practicing OB have fewer obstetrical and non-obstetrical malpractice claims/lawsuits. This, plus the overall lower pricetag of liability coverage (vs. OB/Gyn), offsets any additional cost of FM doing obstetrics. It may still be cost-prohibitive in private practice, but for multispecialty organizations, FMOBs are a lower-cost alternative for obstetrics as well as primary care on the whole. One organization, citing a desire to safely staff their labor and delivery unit 24 hours a day with physicians, used FMOBs as the second physicians, noting that even for an extra $1.2 million, their savings were considerable compared to adding a second Ob/Gyn [13]. Studies show that FMOBs have equivalent outcomes when providing high-risk maternity care and performing procedures such as cesarean births [7, 14, 15].

The last reason could be considered two sides of the same coin: insufficient training and organizational barriers to credentialing. Not having FMOBs limits the exposure of Family medicine residents to obstetrics in the context of the Family physician's practice, leaving them to be taught by OB/Gyns who may not appreciate the scope of Family Medicine and limit their involvement with complex patients. Residents can also experience overt hostility during their OB rotations [16]. These experiences contribute to a decreased likelihood of including OB in their post-residency practices [16]. A joint statement by American Academy of Family Physicians and American College of Obstetricians and Gynecologists says “the assignment of hospital privileges is a local responsibility, and privileges should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, to assure the provision of high-quality patient care [17].” Specialty-based privileges perpetuate false narratives of Family Medicine's inadequacy and impose unnecessary obstacles to the success of FMOBs. This interspecialty discrimination also signals a fractious relationship between OB/Gyn and FMOBs, warning that, even if privileged, they may find themselves alone—without support or collegiality from other obstetric clinicians [18, 19].

There are very few articles outlining collaborative practice between Family Medicine and OB/Gyn or Midwives, most are over a decade old. One 2003 study referenced, found only 45% of OB/Gyns supported Family physicians attending deliveries [20]. This small study highlights how inaccurate perceptions can hinder collaboration between Family Physicians and OB/Gyns; those OB/Gyns supportive of FMOBs were more likely to have worked with them. Studies on successful interspecialty collaboration in obstetrics emphasize the need for mutual respect and appreciation for each group's contributions, recommending elimination of barriers to collaborative interprofessional practice by addressing factors that facilitate intrapartum care [21].

So, while the popular narrative is that Family Physicians leave OB post-residency due to lack of interest or a desire for an “easier” lifestyle, the truth is, we often aren't afforded a choice. Family Physicians are abandoning obstetrics because, despite the benefits, space isn't provided for the successful integration of obstetrics into our practice unless we go to rural hospitals where there is less demand for specialities, areas requiring the practice of our full scope.

The shift toward siloed systems of care, operational challenges and workplace and leadership bias toward specialization are important contributors to the increasingly narrowed scope of Family Medicine [22]. As organizations expand and practice flexibility is further constrained, some physicians are looking to alternative models like direct primary care or returning to private practice. FQHCs (federally qualified health centers) could be another path. FQHCs provide care to medically underserved patients and marginalized populations, often who have significant social risk factors complicating their health. FMOBs passionate about providing maternity care to marginalized populations are uniquely suited to serve in these settings. Studies demonstrate group prenatal care in community settings decrease rates of preterm and low birth weight babies and improve overall health equity. The Moms2B program, a community-based group support initiative for pregnancy and parenting, has reduced pregnancy complications and infant mortality [23]. By integrating more FMOBs into FQHCs, we can provide a unified approach to prenatal and pediatric care that improves cost-efficiency and decreases adverse outcomes. The potential benefits of FQHCs are substantial. They present a unique opportunity to make a profound difference in the lives of those often sidelined by healthcare systems that overlook complex societal issues as key contributors to health. Having physician leaders dedicated to reducing health disparities and enhancing staff well-being, could transform FQHCs into care powerhouses for marginalized communities, potentially outperforming large multispecialty groups.

As a Black female Family physician in obstetrics, I've encountered multiple barriers to prevent me from doing what I believe I was called to do. For over 20 years, I have provided prenatal, intrapartum, and postpartum care to predominantly Black and brown patients. I have delivered sisters for sistas and chiquillas for primas and cuñadas alike. I am their PCP. To this day, I still mourn the one patient I lost. For me, continuity of care throughout the lives of my patients—this is what Family Medicine is all about; my passion and pride for obstetrics accentuates the paradox of lamenting the maternal mortality crisis while simultaneously overlooking the critical role of Family Medicine in resolving it.

Effectively addressing maternal mortality in the United States requires including FMOB in developing solutions. Our collective commitment to first, “do no harm,” must be the guiding principle in serving all patients. Early prenatal care and continuity of care is linked to superior outcomes for mothers and infants, yet policies that decrease access persist. It is crucial to eliminate obstacles that prevent family physicians from delivering obstetric care to communities, both urban and rural. The exclusion of Family Medicine from obstetrics reduces access to care, potentially leading to preventable maternal and fetal deaths.

Finally, we need more African American family physicians entering these spaces to enrich our profession and to better serve communities that face persistent underfunding and stigmatization. A recent study in JAMA found that communities with a higher than average number of Black primary care physicians (Family Medicine, Pediatricians, and Internal Medicine) had longer life expectancies and decreased all-cause mortality for Black individuals, decreasing the Black/white mortality rate disparity [24]. One month later, Caraballo et al. [25] published their study: since 2012, the gains decreasing the Black/white mortality rate disparity in the United States had plateaued; beginning in 2020, that disparity has started to increase again.

Now is the time for action. Now is the time for change.

The author declares no conflicts of interest. I acknowledge that Commentaries are normally requested by editors however, with the maternal mortality crisis being what it is, I hope to encourage those who care for birthers to look beyond the traditional clinicians who deliver and consider who is being excluded. Many thanks for your time.