Obstetrics in family medicine: can it survive?

For the 30 years family practice has formally been accepted as a primary specialty, it has had a defined scope of practice that includes all conditions and both sexes. Pregnancy is among the most common conditions and is often the first involving young families with the health care system in a meaningful way. The medical literature and government reports have documented the importance of family physicians in obstetrics, particularly in rural areas where these physicians represent the majority of obstetric providers. The loss of these providers in rural areas has been associated with adverse effects of birth outcomes. Despite compelling reasons to provide obstetric care, nearly 4 of 5 family physicians are no longer doing so. In 1978, 46% of family physicians reported having privileges for routine deliveries; that rate declined to 41% in 1987, to 26.1% in May 1993, and to 22.4% in May 2000. The numbers also reflect considerable declines for family physicians who practice obstetrics in rural areas. In 1993, 38.6% of rural family physicians had hospital privileges for routine deliveries; in 2000 only 25.5% had these privileges. Why is family physician participation vanishing from a core component of family health care in which, from a rural public health standpoint, family physicians play such a critical role? Clearly multiple factors, many of which have been beyond the control of the individual family physician, have contributed to this decline. Throughout the past 25 years issues related to malpractice litigation and liability coverage have made it difficult for family physicians to provide obstetric care. In 1989 the Institute of Medicine reported that 9 national studies and 23 state studies cited liability concerns as primary reasons for the loss of obstetric providers. This report concluded that although it was not clear the cost of liability premiums constituted a serious economic burden to obstetric providers, the burden was greater for family physicians than for obstetricians. For instance, in 1992 the average increase in premium for a family physician in California to include obstetrics in his or her practice was approximately $13,000, or 162% of what family physicians had to pay who did not provide this service to their patients. More recent studies have suggested that issues other than malpractice are important in family physicians’ decisions regarding obstetrics. Denied hospital privileges, lack of adequate specialty backup, adequate training, and other factors have been cited as reasons for family physicians not delivering babies. According to recent data from the American Academy of Family Physicians, however, most family physicians who are not delivering babies cite “not desiring” to do so as their reason. Studies on what is responsible for these physicians’ lack of desire to deliver babies report a variety of reasons, including lifestyle issues as a major factor. Why do some areas of practice seem optional whereas others do not? Clearly some decision making when choosing a specialty is based on expectations, expectations that have developed during training. In 1994, Greenberg and Hochheiser reported that 72% of secondand third-year residents from a sample of 30 residency programs throughout the country were planning to include obstetrics in their practices. This level of interest increased dramatically compared with previous studies on residents’ intentions and was considerably higher than the percentage of family physicians delivering babies at that time. They concluded that their results might have indicated a resurgence in obstetrics care. Between the time of that survey and May 2000, the date from which the last statistics are available, however, more than 17,000 new residents graduated, and the percentage of family physicians delivSubmitted 4 December 2001. From the Office of the Dean, Regional Outreach, Telehealth and Continuing Medical Education, University of California, Davis. Address reprint requests to Thomas S. Nesbitt, MD, MPH, Office of the Dean, Regional Outreach, Telehealth and Continuing Medical Education, UC Davis Health System, 2315 Stockton Blvd, Sacramento, CA 95817.