FOUR MINNESOTA FAMILY PHYSICIANS SHARE ABOUT THE IMPORTANCE OF FAMILY MEDICINE OBSTETRICS AND THE NEED FOR MORE SUPPORT
by Emie Buege, MAFP Communications & Marketing
Family physicians play an important role in access to maternity care, especially in underserved areas. In 2022, a study published in the journal Birth (1) looked at the impact of family physicians on rural maternity care. Of the 185 hospitals surveyed across 10 states, the authors reported that 67% of babies were delivered by family physicians and, in 27% of those facilities, family physicians were the only physicians delivering babies.
Despite their vital role in providing maternity care, recent survey data has shown that only 6.7% of practicing family doctors are performing deliveries (2).
The requirement for the number of infant deliveries for family medicine residents has also decreased (in the last decade), resulting in trainees not often getting the exposure and acquiring the skills needed to perform deliveries in their future practices.
These declines, coupled with the increase in maternal mortality in the U.S., loss of OB care in rural hospitals where family physicians are more likely to attend births compared to other specialists and a Minnesota Academy of Family Physicians (MAFP) member-adopted resolution to advocate for expanded obstetrical skills training and credentialing, led to the creation of the MAFP Family Medicine Obstetrics (OB) Workgroup in 2022.
Among its goals, the workgroup aims to help medical students and family medicine residents see the possibilities for OB care in their future practices as well as to advocate for the support family physicians need to be able to practice OB.
We interviewed four family physicians from across Minnesota about their experiences providing OB care:
- Karlyn Armbruster, MD (Sleepy Eye Medical Center, Sleepy Eye)
- Betsy Gilbertson, MD (Allina Health West St. Paul Clinic, St. Paul)
- Lee Haggenjos, MD (CentraCare – Willmar Lakeland Clinic, Willmar)
- Cybill Oragwu, MD (CentraCare – Long Prairie Clinic and Hospital, Long Prairie)
DESCRIBE THE OB PART OF YOUR PRACTICE.
Armbruster: I have worked at Sleepy Eye Medical Center for the past 11 years, providing OB services and broad-spectrum family medicine care. Sleepy Eye Medical Center is owned by the city of Sleepy Eye and completely unaffiliated, a rarity these days! The city itself has a population of about 3,500 people. We have a 15-bed critical access hospital with an emergency room, surgical services and two OB suites. Four of our five physicians provide OB care and perform vaginal deliveries. Two of us additionally do Cesarean sections: me and my husband Adam, who is a family physician practicing OB. All four of us deliver our own patients, meaning that we are always on call for our own OB panels.
Gilbertson: I am a family medicine OB provider working in a large health care system. I have an outpatient practice in West St. Paul, where I care for a diverse group of patients (often in collaboration with OB and perinatology colleagues), and I attend deliveries at United Hospital in St. Paul.
Haggenjos: I provide OB care, including attending deliveries and vacuum-assisted deliveries, in a diverse, rural setting with a large immigrant population, including Somali-speaking, Spanish-speaking and Karen-speaking patients. I personally care for many Spanish-speaking patients, given my language abilities. Our practice was a physician-owned group that is now part of CentraCare.
Oragwu: I provide prenatal care at a rural health clinic and do vaginal deliveries at a critical access hospital, both at the same site. Another family physician in my clinic provides C-section services whenever my patients need to have one. Given that my practice is in a rural location and far from tertiary care, I usually consult with high-risk obstetricians and perinatologists when needed.
WHY IS IT IMPORTANT FOR YOU TO PRACTICE OB?
Armbruster: The ability for our facility to provide OB care allows patients to deliver close to home, which is very important to them. Not only is it more convenient and more desirable for a mother to receive care from a team she knows and trusts, but it is also much safer (in most cases). I find a lot of joy in providing OB care too, and it helps to keep my practice varied and fresh. It also supports our small medical center in that young families are drawn in and stay with us long term. Not only is this a benefit to our facility, but also our town.
Gilbertson: Pregnancy can be joyful, but it can also be an incredibly vulnerable time, especially for patients experiencing complications or loss, or those who haven’t felt well-supported by the medical establishment. I think all birthing people deserve to feel safe and supported as they navigate such a major life and health event. Being able to be with patients during this time—to be a pillar of support and a source of reliable information; to be a familiar, loving presence when they are uncertain; to witness their strength—is one of the greatest privileges of my practice.
Haggenjos: I find the work meaningful in the continuity it provides with patients across prenatal, labor and delivery and postnatal care. It’s a humbling privilege to care for patients in such a frequently profound part of life.
Oragwu: Not only does OB help me maintain a broad scope of practice, it helps me provide a better quality of care for my patients through every stage of their lives. As a family physician, I can care for pregnant patients and still address and continue their other health concerns and treatments without having to refer them to another primary care physician.
With the rise in maternal mortality, providing continuity of care before, during and after pregnancy is important. I often care for pregnant patients and their newborns. So, whenever I see the newborn, I often see the parent, as well, and check in on their well-being, blood pressure and other things that, if I were seeing either party [separately], would not necessarily be addressed. As a result, on numerous occasions, I have been able to diagnose and address postpartum preeclampsia, postpartum depression, lactation and feeding difficulties and poor weight gain all during the same visit.
Providing OB care is crucial to not only maintaining our scope of practice for future generations but also fulfilling the core values of our specialty, and it is important to improving the health of the public, especially in underserved communities where, oftentimes, only family physicians choose to practice.
WHAT CHALLENGES HAVE YOU EXPERIENCED IN PROVIDING OB CARE?
Armbruster: Availability and competency of support staff, including nursing, surgical and anesthesia staff, and C-section coverage. Since my husband and I are the only two providing C-sections at our medical center, our time away is planned carefully, and sometimes influences the way a laboring patient is managed. Unfortunately, there are fewer and fewer family physicians with C-section training and interest.
Gilbertson: Effectively being “on call” for my own patients much of the time is hard, especially as I’ve grown my family. I am still working to find the right balance between honoring my commitment to continuity of care and making space for family and self. I am lucky to have a supportive partner and to work in a supportive call pool, but I have definitely considered giving up my OB practice multiple times. For now, the connection and satisfaction that comes from following patients through this special part of their lives keeps me going.
Haggenjos: Finding appropriate training opportunities, including electives to prepare for practice, and finding mentors who share similar goals.
Oragwu: Poor support, e.g., not having enough colleagues to share call with and inadequate training in C-sections; health systems not giving family physicians OB privileges and limiting scope of practice; and reimbursing family physicians at lower rates for providing the same services as other specialists.
WHAT SUPPORT DO FAMILY PHYSICIANS NEED TO PROVIDE OB CARE?
Armbruster: Easily accessible referral centers to provide support to us as well as an adequate number of well-trained nurses.
Haggenjos: To maintain OB within a family medicine practice, family physicians need institutional recognition of their role, including recruitment and marketing; continuing medical education; emergency preparedness training, both at the site of practice and from provider associations; and support and a collegial practice setting with other non-family-medicine providers who also attend births.
Oragwu: I believe that [support] starts as far back as medical school. Medical students should be made aware that family physicians practice OB and offered opportunities for shadowing and mentoring from their first year of medical school through residency. Residency programs and institutions need to prioritize OB training for family medicine trainees alongside OB-GYN trainees, and health systems and hospitals should offer OB privileges to family physicians based on standardized measures and/or experience. Increasing continuing education opportunities for family medicine OB, including surgical OB, is also important, as well as considering collaborations between OB-GYN and family physicians.
WHAT SHOULD STUDENTS/RESIDENTS KNOW ABOUT FAMILY MEDICINE OB?
Armbruster: There is nothing quite like following an expectant mother through her pregnancy, providing care for her through labor and bearing witness to such an important event for her family. Additionally, we almost always follow the baby and provide pediatric care as well. It is such a gratifying thing to be able to do—a physician who has a good rapport with a family is best able to provide the most customized care for mom and baby.
Gilbertson: Seriously, is there a better job? It maximizes all of the greatest things about family medicine: meaningful and longitudinal connections with patients, medical complexity and constant learning, procedural skill and opportunities to advocate for safe, respectful care for all patients.
Haggenjos: Family medicine OB is deeply rewarding and still possible to find in academic and private practice, and there are family physicians, in practice, who are eager to serve as mentors.
Oragwu: It is a great way to establish care with a younger generation. Our patients depend on us! I cannot count how many times I confirmed a pregnancy during a patient visit and the patient’s face lit up when I told them that I could manage their pregnancy and deliver their newborn. It creates another level of trust with patients and, as most family physicians plan on remaining in their communities for as long as they can, you may end up delivering more than one generation in families that you care for.
HOW CAN THE MAFP SUPPORT FAMILY MEDICINE OB?
Armbruster: Increase continuing education opportunities on prenatal and OB care as well as postpartum and newborn care and help create/encourage more opportunities for medical students and residents to learn and provide OB care from a family medicine perspective.
Gilbertson: Provide opportunities for mentoring for medical students and residents with interest in an OB practice and continuing education and networking for practicing physicians. In terms of addressing the crisis of pregnancy-associated mortality, advocate for policies that address racism in and outside of health care structures and that support birthing people and families, like paid leave, lactation support and adequate, durable access to quality care, including comprehensive reproductive health options.
Haggenjos: Advocate for further investment in training, recruitment and support for family medicine OB, as well offer CME and recertification in preparing for emergencies, like Advanced Life Support in Obstetrics (ALSO®) courses.
Oragwu: Family physicians are more likely (than other primary care specialists) to practice in rural, underserved communities, which also happen to have higher rates of maternal mortality. If more family doctors practice OB, that will have an important impact in decreasing overall rates of maternal mortality in the U.S.
The MAFP can help advocate for family medicine OB by:
- Speaking to health systems and hospitals about credentialing family medicine OB, citing best practices set by the American Academy of Family Physicians and American College of Obstetricians and Gynecologists.
- Talking to legislators about policies that are limiting scope of practice as well as the need to increase reimbursement rates, especially for Medicaid programs.
- Encouraging family medicine residency programs to improve their OB focus by hiring more faculty that provide obstetrical services and compensating them with incentives for doing so, as it requires more skill and training.
- Educating medical students and residents on the importance and benefits of OB to their comprehensive education and practice.
- Creating mentoring networks for medical students, residents and practicing family physicians.
REFERENCES
- Deutchman M, Macaluso F, Bray E, Evans D, et al. The impact of family physicians in rural maternity care. Birth. 2022;49(2):220-32.
- Loeven Michael. Credentialing family physicians who provide maternity care. Am Fam Physician. 2022;105(5):456-457.
Want to get involved in the MAFP’s advocacy efforts around family medicine OB? Email office@mafp.org.
