Re: The Numbers Quandary in Family Medicine Obstetrics

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.