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Family medicine-maternity care: A romantic idea facing an uncertain future

There is a romance to the notion of family medicine-maternity care (FM-MC). Of being cared for throughout your life by the same person who cared for you even before you entered the world, who was there to deliver you, who knows you and your medical history intimately. Maybe that doctor will even deliver your baby, too.

But times are changing. These days, with midwifery and obstetrics at the public forefront of childbirth, the family medicine-maternity care physician’s future is uncertain. 

A generalist in the field of medicine, most family physicians offer supportive care up to 20 weeks gestational age and then hand off care to an obstetrician or midwife. However, there are some passionate family physicians who also offer full-scope care. Particularly in rural locations, family physicians are an integral service during pregnancy and birth. 

But where midwife care is growing (particularly in Ontario), and obstetrical care remains a staple of care in pregnancy, the number of family physicians who offer maternity care is declining, and the FM-MC is often not an option most birthers even realize is offered.  

So what is happening to the family-medicine maternity-care provider? One of the first challenges facing this profession is recruitment of interested residents. As a family medicine resident, when I bring up the subject to my fellow residents, most of the time I am answered with loud groans.

Lifestyle is, of course, an important factor. Babies don’t operate on schedules. The on-call demands are not to be dismissed and have gotten worse with the dwindling number of FM-MC providers.

“Home call is very challenging, and (it’s) not for me,” says Victoria Zhang, a family medicine resident at St. Michael’s Hospital who decidedly does not want to pursue pregnancy care. “I found it very difficult to separate work from my home life while on call, and especially found it hard to leave home on short notice to assess a patient in (labour and delivery).”

Adequate training is also frequently cited as a concern – because family medicine physicians are generalists, there is a vast area of knowledge that must be covered through specified training that has to be sought out during residency. You have to want to learn pregnancy care. Which can be a challenge. Qualitative research has shown that the learning environment can be harsh and the hierarchy of learners can interfere with a family medicine resident’s learning.

It turns out though, that even with these drawbacks, there are residents who do intend to practice maternity care.

“Residents are interested in FMOB,” says Milena Forte, an FM-MC provider and assistant professor in the Department of Family and Community Medicine at the University of Toronto. “(The stats we have) tell us that across the country, over the last five years, three times as many grads intend to provide intrapartum care as are currently providing it.”

But these residents don’t seem to be turning their knowledge into FM-MC practices. In B.C., specifically, research led by Lindsay Hedden has shown that in spite of investments in training programs and increased financial incentives for pregnancy care in family medicine, the number of providers who offer such care continues to decline. This is part of a longer trend: The percentage of family physicians offering obstetrical care through family planning to birth declined to 10.5 per cent in 2010 from 20 per cent in 1997.

There is little research explaining why this is so – perhaps it is a perceived lack of opportunity; perhaps there are challenges in the practice of obstetrical care that cause providers to go in other directions.

However, Hedden’s research suggests that inter-professional team-based primary care might be a way to encourage physicians to provide obstetrical care.

The family medicine-maternity care physician’s future is uncertain. 

Consider the Maternity Centre of Hamilton. It was created as a pilot project based on recommendations from a multitude of family physicians and patients as well as an advisory committee of academics from family medicine, obstetrics, midwifery and nurse practitioners. At first, it included 11 family medicine obstetricians, a nurse practitioner, a social worker, a lactation consultant, a public health nurse, and a receptionist – and has grown from there. Both providers and patients report high satisfaction.

Another concern for FM-MC providers is the lack of public knowledge. “People don’t know about us,” says Tali Bogler, an FM-MC provider at St Michael’s Hospital and one of the minds behind the popular and invaluable Instagram @pandemicpregnancyguide, along with Sheila Wijayasinghe and obstetrician Eliane Shore.

Bogler is trying to recruit residents and patients to the table. “It’s an issue that’s not being spoken about a lot,” she says of the public’s lack of awareness, adding that family physicians who provide obstetric care often have to advocate for themselves to their colleagues and colleagues’ patients.

Bogler reports that FM-MC providers are often associated with academic sites and referrals are mostly from within their own health teams, though they do accept external ones as well. But overall, birthers don’t seem to know that this service exists. Indeed, in interviewing several women for this article, just one had a family physician as her pregnancy care provider, and that was only because she is a family physician herself and sought out an FM-MC even before getting pregnant.

Bogler and Forte speculate that the solution may lie in branding.

“Family medicine doctors tend to just quietly do our thing but when people hear what we have to offer – they want it,” Forte says, adding that getting the word out to patients is an important part of the future of FM-MC. “It is time for FM-MC to highlight our brand-value proposition.”

Bogler highlights the value of FM-MC as “the most holistic approach,” encompassing care through all parts of the life cycle beyond just the time of pregnancy. Also, she adds, no one is pregnant in a health vacuum. Health issues entirely unrelated to pregnancy arise even while a patient is receiving prenatal care. An FM-MC can offer support for that itchy rash, the infected eye, the mental health concerns that can arise during pregnancy, even the five-year-old’s fever.

FM-MC’s philosophy of care is about blending medical expertise and understanding of patient’s psychosocial factors as well as patient values and providing care that aligns with it all, Bogler says. “The birthing parent is a dyad -– not just a parent, not just a baby, and we can provide ongoing care for them both,” she says. 

And these advantages still exist even when patients are referred from their usual family physician to a FM-MC provider. In interviews, several women said they wouldn’t consider seeing a family medicine provider for maternity care if their own family physician didn’t offer it – if they need to meet a new provider, why not go straight to an obstetrician? But FM-MC practitioners have that holistic approach and generalist knowledge to bring to the table and demonstrate equivalent outcomes and fewer C-sections in low-risk births compared to obstetricians.

“Some birthers are afraid of being over-medicalized with obstetrics and some birthers are afraid of working with midwives,” says Tarana Wheelwright, a doula who practices in Winnipeg and has supported more than 300 births. “FM-MC can be an excellent middle ground (between midwifery and obstetrics). It all depends on a birther’s goals of care.”

Wheelwright focuses on making sure birthers are given opportunities to make conscious and informed choices, a sentiment echoed by the Canadian Association of Midwives. She says that when birthers can make informed choices, we can reduce the trauma that sometimes comes with birth and empower birthers. And one of the first choices in a pregnancy is who the care provider will be.

Adding to its importance is that FM-MC is a vital source of care in rural locations. In sparsely populated areas that cannot support a specialist clinic, family doctors are the touchstone for care and a gateway to specialist care. But despite data that shows local intrapartum care results in better outcomes, access to physicians is limited and more and more birthers are required to travel significant distances. And social barriers, both monetary and emotional, can be high. Increasing the number of family physicians who practice obstetrics (and who are appropriately culturally trained) and fostering a wide community of providers who can offer them support would help address this issue.  

The family medicine-maternity care provider may be an old, romantic idea. But there is a way to reframe it through groups and communities of providers sharing the demands of constant availability.

You may not be delivered by the same person who delivered your mother but you can receive excellent care from a physician who supports and treats you and your new bundle of joy in a holistic manner. 

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Peggy Hamilton

Contributor

Peggy is a second year family medicine resident at the University of Toronto.

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