Family Medicine as Part of the Solution to the Obstetric Care Crisis
“Womb to tomb” or “cradle to grave” are just a couple phrases used to represent the spectrum of care family physicians provide for patients across all ages and stages of life. This broad scope of practice drew many of us into the specialty as bright-eyed students eager to serve our patients. In fact, obstetric care has been a part of our specialty since its inception. Labor and delivery units are experiencing an alarming rate of closure in California – nearly 60 units have closed since 2012 with close to 30% in Los Angeles County. The closure of labor and delivery units has outpaced ability to maintain an up-to-date list of maternity hospitals on our county public health website. Although the term “maternity care deserts” typically paints a picture of a rural farmtown, our patients will soon find themselves in a version of a maternity care desert even in a bustling metropolitan like Los Angeles. South LA saw the closure of two units at Centinela Hospital Medical Center and Memorial Hospital of Gardena Medical Center, leaving a gap in communities with some of the highest proportion of Black Californians in the state. On average in the US, people in urban areas travel an average of 15 minutes to a birthing hospital which seems laughable if you’re anywhere in LA at 5 pm on a weekday. Our particular predicament in LA County won’t raise flags nationally by current definitions of maternity care deserts that look at the number of obstetric care providers per county, hospital and birth centers offering obstetric care, and proportion of reproductive age women without health insurance. However, our patients will feel a very real impact as they travel farther and farther within our sprawling county for obstetric care, especially in our underserved communities that have been most impacted by these closures.
The 2022 March of Dimes Maternity Care Deserts Report affirmed that family physicians are “an integral part of the maternity care workforce.” Maternal outcomes are similar for OB-GYN physicians and family physicians. Family physicians care for patients with an increased burden of social risk without compromise to care. Family physicians go where others will not, providing care in 93.5% of U.S. counties.
The AAFP Position Paper “Striving for Birth Equity: Family Medicine’s Role in Overcoming Disparities in Maternal Morbidity and Mortality” outlines key actions family physicians, educators, and policy makers can take to impact these issues. In California (and LA), we are lucky to have addressed a couple of these points:
- SB 464, the California Dignity in Pregnancy and Childbirth Act, and AB 2319 are steps towards addressing implicit bias training for healthcare providers and
- California expanded Medicaid postpartum coverage to 12 months as part of the American Rescue Plan Act with this extension taking effect 2022
However, ongoing challenges exist including insufficient reimbursement rates from insurance providers for pregnancy and birth care which will likely be exacerbated by Medicaid cuts when about 40% of all births in the state are covered by MediCal. Advocacy to propel alternative payment models or other changes to reimbursement rates for pregnancy care are needed to make labor and delivery units sustainable for health systems.
Additionally, fewer family physicians report delivering babies – a number that has dropped precipitously over the decades from 45% to 7%. Meanwhile, there will be a shortage of 12,000 to 15,000 OB-GYNs by 2050. While family physicians reporting burnout has increased to 51%, early career family physicians providing a broader scope of practice (such as obstetrics) reported significantly lower rates of burnout. With now 23 ACGME-approved family medicine residency programs in Los Angeles County, we are charged with finding means to train family physicians in an urban environment who will be capable of providing obstetric care in their communities. With this density of training programs in our county that rivals or outpaces the number of programs in many states (while many residency faculty fall into the above pattern of declining delivery practice), collaboration as educators will be instrumental in retaining and enhancing pregnancy care training for our trainees. The creation of a new residency network under LAAFP can help facilitate this work while centering patient and community outcomes.
Finally, regardless of our training of family physicians who are capable of providing obstetric care, this becomes obsolete if family physicians are not able to find jobs that allow them to provide obstetric care including deliveries. The AAFP has assembled a family medicine privileging advisory group to begin this foundational work (and family physicians can contribute by filling out the privileging and credentialing survey). At a local level we need our health systems to understand that family medicine includes pregnancy (and pediatric) to enable family-centered care. Our family medicine graduates seeking positions can make clear to recruiters and health systems the broad scope of training for which they have been trained. Our health systems’ and facilities’ privileging should reflect the AAFP-ACOG Joint Statement on Cooperative Practice and Hospital Privileges that asserts “privileges should be granted based on training, experience and demonstrated current competence,” regardless of specialty.
Full spectrum family-centered care family medicine uplifts patients’ perspectives in collaboration with a diverse pregnancy workforce that includes family physicians, OB-GYNs, midwives, nurses, doulas, lactation consultants, educators, and mental health professionals. Family physicians can play a pivotal role in addressing disparities in care in our communities.
