Abstract
Of family physicians who perform cesarean sections, more than half do so in rural communities and 38.6% provide cesarean sections in counties without any obstetrician/gynecologists. As policymakers in the United States struggle with a widening landscape of ‘obstetrical deserts,’ efforts to adequately train a family physician workforce prepared to provide cesarean sections could help maintain access to local obstetric services in rural communities and reduce perinatal morbidity and mortality.
- Cesarean Section
- Family Physicians
- Health Workforce
- Maternal Health Services
- Obstetrics
- Pregnancy
- Rural Health
Having local obstetric services in rural communities is associated with lower perinatal morbidity and mortality and decreased health care utilization and cost.1,2 While approximately 28 million reproductive-age women in the United States live in rural communities, over half of rural counties do not have an obstetrician/gynecologist.3 Since providing hospital-based obstetric services is often dependent on having cesarean section capacity, family physicians (FPs) who perform cesarean sections have an important role in maintaining obstetric care access in rural communities.4
We used data from the 2017 and 2018 American Board of Family Medicine’s Family Medicine Certification Examination registration questionnaire for FPs seeking to continue their certification.5 Completed 3 to 4 months before the examination date as a required component of registration, the questionnaire asked FPs whether they provided obstetric deliveries and, if yes, whether they performed cesarean section deliveries as primary surgeon. FPs’ practice locations were geocoded and matched with county level data on obstetrician/gynecologist availability from the Area Health Resources Files.6 We classified rurality based on the Rural-Urban Continuum Codes, which further divided rural areas based on population size. The American Academy of Family Physicians Institutional Review Board approved this study.
The response rate was 100%. In our sample of 17,171 FPs, 6.7% (n = 1144) provided any obstetric deliveries and 1.6% (n = 267) provided cesarean section deliveries as the primary surgeon. Of FPs who perform cesarean sections as primary surgeon, 57.3% (n = 153) did so in a rural county and 38.6% (n = 103) did so in a county without any obstetrician/gynecologists (Table 1).
Family Physicians Who Provide Cesarean Sections as Primary Surgeon (N [%]) from the 2017 and 2018 American Board of Family Medicine’s Family Medicine Certification Examination Registration Questionnaire*
We found that a substantial proportion of FPs who perform cesarean sections do so in rural counties and in counties without an obstetrician/gynecologist. The current decreasing trends in the proportion of FPs who provide any obstetric services may result in decreased access to obstetric care services in rural areas.7 Maintaining and potentially augmenting the rural FP obstetric workforce will require increasing FP preparedness to provide cesarean sections by supporting obstetric fellowship training in family medicine, providing retraining opportunities for practicing FPs and promoting policies that facilitate obstetric credentialing of FPs with adequate training.4 These efforts could reverse the trend of closing obstetric units in rural hospitals8 and help improve obstetric outcomes in rural communities.
Notes
This article was externally peer reviewed.
Conflict of interests: STT is employed by the Agency for Healthcare Research and Quality but contributed to this article in his personal capacity. The opinions expressed are the author’s own and do not reflect the view of the Agency for Healthcare Research and Quality, the Department of Health and Human Services or the Federal government. ARE, ZJM, AWB, and LEP are employed by the American Board of Family Medicine.
Funding: None.
To see this article online, please go to: http://jabfm.org/content/34/1/10.full.
- Received for publication April 9, 2020.
- Revision received June 16, 2020.
- Accepted for publication June 18, 2020.
