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LetterCorrespondence

Re: The Numbers Quandary in Family Medicine Obstetrics

Tyler Barreto, Aimee R. Eden, Andrew Bazemore and Lars E. Peterson
The Journal of the American Board of Family Medicine January 2018, 31 (1) 168; DOI: https://doi.org/10.3122/jabfm.2018.01.170410
Tyler Barreto
UT Health San Antonio, San Antonio, TX
MD
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Aimee R. Eden
American Board of Family Medicine, Lexington, KY
PhD, MPH
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Andrew Bazemore
Robert Graham Center, Washington, DC
MD, MPH
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Lars E. Peterson
American Board of Family Medicine, Lexington, KY
MD, PhD
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To the Editor: Worth1 brings up some important points including outcomes and training. As described, there are several studies that demonstrate equivalent outcomes between family physicians and obstetricians. Worth voices concern about the paucity in outcomes literature based on various limitations. Of the 3 recent studies cited, 1 is in Canada, which, while there are clear health care differences, presumably the patients and procedures are not so different that we must exclude it.2 The other 2 articles cited had over 14,000 patients and found a significantly lower cesarean-section rate among patients delivered by family physicians with all other outcomes equivalent whether delivery was attended by a family physician or obstetrician.3,4 These studies support previous research documenting equivalent outcomes, and leave us wondering how many times does equivalency in outcomes need to be demonstrated. However, with recent changes in family medicine training requirements, we do agree that there is a need for new studies to assess how these changes may affect outcomes in obstetric care.

Regarding training standards, family medicine is a broad field with many competing interests. Decades of work conducted by the family medicine community, Accreditation Council for Graduate Medical Education (ACGME), and Family Medicine Residency Review Committee (RRC) has been done to ensure competency is achieved in each of the Family Medicine domains of practice, including obstetrics. Despite the lowered ACGME obstetric requirements, more intensive training in obstetrics via electives, mentoring, or fellowship is available for physicians interested in increasing their obstetric experience.

Our finding that 23% of recent graduates want to include obstetric deliveries is encouraging both for believers in the full spectrum of family medicine and for patients who are facing higher maternal and infant morbidity.5,6 A study of over 2.6 million births in California found that rural women who were able to deliver in a rural hospital had decreased rates of morbidity and mortality.7 However, rural hospitals continue to close labor and delivery units.8 If a local family physician provided obstetric care at a local hospital, women would not have to travel such distances and may see improvement in outcomes.

We agree that all patients deserve nothing less than highly qualified, competent physicians. Our concern is not simply that the numbers of family physicians delivering babies is decreasing. Our concern is that at a time of national shortage of obstetric care, there are 2000 family physicians who intended to provide obstetric care after graduating and are being prevented by barriers that have nothing to do with their training or competence. We might improve maternal and infant morbidity if the family physicians who are interested and competent in obstetric care are able to provide that care.

References

  1. 1.↵
    1. Worth A
    . The numbers quandary in family medicine obstetrics. J Am Board Fam Med 2018;31:167.
    OpenUrlFREE Full Text
  2. 2.↵
    1. Aubrey-Bassler K,
    2. Cullen RM,
    3. Simms A,
    4. et al
    . Outcomes of deliveries by family physicians or obstetricians: A population-based cohort study using an instrumental variable. CMAJ 2015;187:1125–32.
    OpenUrlAbstract/FREE Full Text
  3. 3.↵
    1. Avery DM,
    2. Graettinger KR,
    3. Waits S,
    4. Parton JM
    . Comparison of delivery procedure rates among obstetrician/gynecologists and family physicians practicing obstetrics. Am J Clin Med 2013;10:17–20.
    OpenUrl
  4. 4.↵
    1. Avery DM,
    2. Waits S,
    3. Parton JM
    . Comparison of Delivery Related Complications among Obstetrician/Gynecologists and Family Physicians Practicing Obstetrics. Accepted for publication in. Am J Clin Med 2013;10:11–25.
    OpenUrl
  5. 5.↵
    1. Barreto TW,
    2. Eden AR,
    3. Petterson S,
    4. Bazemore AW,
    5. Peterson LE
    . Intention versus reality: Family medicine residency graduates' intention to practice obstetrics. J Am Board Fam Med 2017;30:405–6.
    OpenUrlAbstract/FREE Full Text
  6. 6.↵
    Centers for Disease Control and Prevention. Severe maternal morbidity in the United States. Available from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html. Accessed September 28, 2017.
  7. 7.↵
    1. Hughes S,
    2. Zweifler JA,
    3. Garza A,
    4. Stanich MA
    . Trends in rural and urban deliveries and vaginal births: California 1998–2002. J Rural Health 2008;24:416–22.
    OpenUrlPubMed
  8. 8.↵
    1. Hung P,
    2. Henning-Smith CE,
    3. Casey MM,
    4. Kozhimannil KB
    . Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004–14. Health Aff (Millwood) 2017;36:1663–71.
    OpenUrlAbstract/FREE Full Text
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The Journal of the American Board of Family     Medicine: 31 (1)
The Journal of the American Board of Family Medicine
Vol. 31, Issue 1
January-February 2018
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Re: The Numbers Quandary in Family Medicine Obstetrics
Tyler Barreto, Aimee R. Eden, Andrew Bazemore, Lars E. Peterson
The Journal of the American Board of Family Medicine Jan 2018, 31 (1) 168; DOI: 10.3122/jabfm.2018.01.170410

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Re: The Numbers Quandary in Family Medicine Obstetrics
Tyler Barreto, Aimee R. Eden, Andrew Bazemore, Lars E. Peterson
The Journal of the American Board of Family Medicine Jan 2018, 31 (1) 168; DOI: 10.3122/jabfm.2018.01.170410
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