Family Medicine Obstetrical Care: Partners in Providing Maternity Care and Improving Outcomes

In the state of Minnesota, Family Medicine physicians are an integral part of the primary care workforce, and the role of family physicians varies significantly in communities and practices across the state. Family physicians are ubiquitous within a variety of healthcare settings throughout the state, from urgent cares and emergency rooms to long-term care facilities, tertiary care centers to critical access hospitals. We are in rural, suburban and urban community clinics, large hospital system-based clinics, FQHCs, direct primary care practices including mobile clinics and tribal clinics. 1 We have addiction medicine and gender affirming hormone practices, we teach in our state’s medical schools and we serve in local and state government. We are also a strong presence in labor and delivery rooms and nurseries. 1 The philosophy of Family Medicine is wide-reaching and yet very specific: we care for individuals, families and communities from birth to death and everything in between. Our guiding principles include listening deeply to our patients, families and communities, balancing their needs and preferences with evidence-based medicine. Comprehensive care for the whole person is our area of expertise. The American Academy of Family Physicians (AAFP) states on their website, “Unlike other specialties that are limited to a particular organ or disease, Family Medicine integrates care for patients of all genders and every age, and advocates for the patient in a

complex health care system.” 1 As we work together as a medical community to address complex issues such as maternal morbidity and mortality and the racial disparities within these outcomes, Family Medicine physicians remain an important partner in the Twin Cities medical community. For many family physicians, obstetrical and prenatal services are an essential component of the care they provide, contributing to significant joy in practice, staving off burnout, and preserving a wider spectrum of practice. Nationally, 18% of family physician members of the AAFP report providing obstetrical care, and 32% provide newborn care in their practices. 2 In the United States, approximately onethird of pregnant women report having received care from a family physician in the previous year. 3 While more often thought to be associated with rural settings, family physicians are currently providing comprehensive obstetrical care across the Twin Cities metro area through North Memorial Health, Allina Health, Health East/Fairview/MHealth, HealthPartners/ Park Nicollet, Hennepin County Medical Center, Northpoint Health and Wellness, Northwest Family Physicians, Entira Family Clinics, United Family Medicine, and MN Community Care (formerly East Side Community Health). In the majority of cases, family physicians continue to remain on-call for their individual obstetrical patients in order to preserve continuity in the physician-patient relationship through delivery. Family physicians often see patients who are among the most vulnerable during the pregnancy and postpartum period such as women of color, Medicaid recipients, people with unstable housing or living in poverty, and people with a number of significant chronic diseases such as substance use disorders, hypertension, diabetes and other mental health conditions. 4,5 In situations where patients have very high obstetrical or medical risk, family physicians are an important touchpoint for specialist, obstetrician and maternal-fetal-medicine referrals and overall coordination of care. In a 2019 editorial in American Family Physician, Katy Kozhimannil, PhD and Andrea Westby, MD outlined how family physicians are part of the solution to reducing maternal mortality. 6 They highlighted the unique role of family physicians in addressing health risks in the postpartum period such as breastfeeding issues, postpartum depression, and intimate partner violence during newborn visits, as a Cora Walsh, MD, MScAndrea Westby, MD, FAAFP

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“one-stop-shop” for parents and children alike. Family physicians often see siblings and parents in concurrent or consecutive office visits, and this continuity is highly valued by providers and the patients who choose family medicine physicians for their maternity care. Further, as recognition grows of the importance of continued care through the 4th trimester in improving maternal outcomes, combining maternal and child access to care with the same physician may support efforts to improve these outcomes. Despite the plethora of specialty medical services available in the Twin Cities, for many urban underserved patients barriers to care may still exist in the form of transportation difficulties, financial and insurance barriers, or historically rooted mistrust of the medical system. For such patients, community clinics, continuity of care with a single physician and the capacity to address multiple medical issues within a single visit may take on even greater importance in facilitating access to care.

“For me, the opportunity to provide a family with a continuity of care—starting before pregnancy, through prenatal to birth, and then including infancy and childhood—allows me to have a deep impact on their long-term health and wellbeing. The moment of childbirth is so central to that journey. Being in the delivery room and helping them bring their child into the world creates such a powerful, trusting bond between me and the family. I feel that it enables me to be an even more effective guide and advocate for them down the road.”—Nancy Struthers, MD; Physician Lead for Family Medicine Obstetrics at Allina Health, East Metro Region. In addition to clinical risks, family physicians have a role in addressing social determinants of health. Family Medicine clinics often have robust care coordination and referral systems for addressing social needs such as food insecurity, housing instability, financial difficulties, insurance lapses and community support. Family physicians are also known in the medical and public spheres for their dedicated activism and advocacy on behalf of patients and communities. Family Medicine residency training incorporates routine prenatal care and births as a standard, although some family physicians also choose to do an Obstetrics Fellowship to gain further experience in interventional obstetric care such as surgical training in Cesarean section. There are 46 Board of Certification in Family Medicine Obstetrics (BCFMO)-recognized Family Medicine-Obstetrics fellowships in the United States, including two in Minnesota. 7 Additionally, the AAFP annually hosts a high quality and highly popular CME course called Family Centered Maternity Care, ® and it developed the Advanced Life Support in Obstetrics (ALSO ® ) course and certification, which focuses on preparing participants for obstetrical and medical emergencies in a team-based approach. As the field of obstetrical care continues to evolve, challenges have emerged that have resulted in fewer numbers of family physicians continuing obstetrical care as a component of their practice, perhaps most notably in rural areas where the need for obstetrical providers is often greatest. 4 The AAFP Obstetrics Member Interest Group identified the following challenges to Family Medicine OB care and target areas of advocacy: 8 • Improving access to job and proctorship opportunities for AAFP members practicing maternity care and rural medicine • Removing barriers to physician credentialing in rural and physician shortage areas • Supporting fair reimbursement for maternity care services in rural areas • Ensuring hospital operative and non-operative obstetric privileges for family physicians In both urban and rural settings, Family Medicine physicians providing obstetrical care continue to fill an important clinical role whether due to patient barriers to accessing other models of obstetrical care or patient preference for a Family Medicine model of care. It is critical that we continue to address challenges to Family Medicine physicians incorporating obstetrics into their practice, to maintain Family Medicine physicians as partners with OB/GYN, midwifery, maternal fetal medicine, nursing and community health in improving maternal health outcomes in the Twin Cities and across the state. The cross disciplinary care we offer within the Twin Cities and as partners working together makes us a stronger medical community for our patients.

Andrea Westby, MD, FAAFP, Assistant Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, and full spectrum Family Medicine faculty at North Memorial Family Medicine Residency program. She can be reached at: westby@umn.edu.

Cora Walsh, MD, MSc, Family Physician with Obstetrics, Allina Health, West St. Paul Clinic. She can be reached at: cora.walsh@ allina.com.

References 1. American Academy of Family Physicians, Get to Know the Academy, “Family Medicine Specialty”. https://www.aafp.org/about/the-aafp/ family-medicine-specialty.html. Accessed Jan 24, 2020. 2. American Academy of Family Physicians, Get to Know the Academy, “Family Medicine Facts”, statistics from 2018 member survey, Accessed Jan 24, 2020. https://www.aafp.org/about/ the-aafp/family-medicine-specialty/facts/table-11(rev).html. 3. Kozhimannil KB, Fontaine P. Care from family physicians reported by pregnant women in the United States. Ann Fam Med. 2013;11(4):350–354. 4. ACOG Committee opinion no. 586: Health disparities in rural women. Obstet Gynecol. 2014;123(2 pt 1):384–388. 5. Gregory DS, Wu V, Tuladhar P. The pregnant patient: managing common acute medical problems. Am Fam Physician. 2018;98(9):595–602. 6. Kozhimannil KB, Westby A. What Family Physicians Can Do to Reduce Maternal Mortality. Am Fam Physician. 2019 Oct 15;100(8):460-461. 7. American Board of Medical Specialties, “Board of Certification in Family Medicine Obstetrics (BCFMO)-recognized Family Medicine-Obstetrics fellowships”. https://www.abpsus.org/family-medicine-obstetrics-fellowship-programs. Accessed Jan 24, 2020. 8. American Academy of Family Physicians, Member Interest Groups, Obstetrics MIG. Accessed Jan 24, 2020.