Opinion

Accessing pregnancy care in Canada: Family physicians as part of the solution

Despite numerous proposed solutions and collaborative initiatives, government and policymakers have yet to make unified efforts to address the inequity in perinatal care across Canada.

Many women and child-bearing individuals, especially those from equity-deserving groups or living in rural and remote communities, continue to face challenges in accessing perinatal care. As a result, concerned Canadians and health-care providers are calling for action. The time is now to leverage the skills of all our perinatal care providers, to support safe and socially accountable care for all Canadians. We propose that this means recognizing the role family physicians can play in perinatal care.

Pregnancy care is offered by a wide range of health-care providers, all of whom make unique contributions to the continuum of care. Most will recognize obstetricians and midwives as obvious options. However, while family physicians have long provided perinatal (including birthing) care, and despite the fact 34 per cent of pregnant Canadians identified a family physician as their main prenatal care provider in a Public Health Agency of Canada survey, many remain unaware of this option. A soon to be published Canadian survey of more than 2,800 pregnant and recent parents found that 23 per cent of participants did not know family physicians could deliver babies. However, a 2022 College of Family Physicians of Canada publication shows that approximately 8-10 per cent of its members provide this care, which adds up to a lot given the large number of family physicians across the country. In fact, in some parts of Canada, including both rural and urban communities, family medicine obstetrics providers (FMOBs) are the default provider for most births; in other regions, access to FMOB care is limited in part, because of region-specific variability in practice patterns and institutional policies.

While patients with high-risk pregnancies (such as those with a complex past obstetrical or medical history or carrying multiples) undoubtedly benefit from the specialized care our obstetrician colleagues provide, most pregnancies can also be cared for by family physicians and registered midwives if triaged appropriately. A recent study in British Columbia reported positive perinatal outcomes for patients with low- to moderate-risk pregnancies who had either a family physician or midwife as their most responsible provider during their hospital stay. For instance, when compared to those who received care by an obstetrician, those with a family physician or midwife had lower rates of caesarean section and higher rates of spontaneous vaginal birth and vaginal birth after caesarean as well as higher rates of breast- or chest-feeding. These positive outcomes may also represent a selection bias, indicating that midwives and FMOBs appropriately triage patients and ensure those for whom they offer care fit with their skill set and scope of practice.

Most pregnancies can be cared for by family physicians and registered midwives if triaged appropriately.

Health-care providers can have a significant influence on patients’ decisions on choosing a perinatal care provider. A 2011 study found that 90 per cent of Canadian women who were pregnant with their first child stated they would change their birthing plans if recommended to do so by their provider. However, in the soon-to-be published Canadian study mentioned earlier, only 16 per cent of respondents noted that their provider discussed options for pregnancy care providers with them, and of those, only a minority discussed FMOBs as an option.

Autonomy and communication are key elements of respectful maternity care. Collaborative decision-making allows patients greater opportunity to choose someone that best suits their medical and psychosocial needs and fits their values. By educating patients about all their options, including a referral to an FMOB when appropriate, we can ensure that pregnant individuals make informed decisions about their care early on. This is important, as a positive relationship between patient and provider enhances trust and has been shown to improve patient satisfaction, adherence to care and health outcomes.

Family physicians providing perinatal care can also enhance resource stewardship. Drawing from a broad scope of training, family physicians are well-positioned to concurrently address non-pregnancy related issues, optimize health-care resource utilization and relieve burden on specialists. As primary care providers, family physicians are attuned to the social determinants of health; many work within specialized programs that provide pregnancy care to patients from equity-deserving groups in their communities. Choosing an FMOB may mean the provider is already known to the patient and/or closer to home, thus enhancing continuity of care and allowing pregnant individuals to benefit from the support of their communities. Finally, family physicians are a common entry point for early pregnancy care, an area recently identified as sorely in need of support.

It is unlikely that any one type of provider will serve the needs of all pregnant Canadians. Thus, interprofessional strategies are ultimately needed to ensure perinatal care appropriate to each patient and community. Building awareness of family physicians as perinatal care providers enhances respectful and value-based pregnancy care and eases pressure on the health-care system. As we look to improve healthcare access and quality of care for all pregnant people, we can leverage each providers’ strengths and work collaboratively towards this end.

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Authors

Sanja Kostov

Contributor

Sanja Kostov, MD, CCFP, is a family physician and FMOB provider at the Royal Alexandra Hospital in Edmonton. She is an Assistant Professor and Program Director of the Enhanced Skills FMOB Residency Program with the Department of Family Medicine, University of Alberta, and the vice-chair of the College of Family Physicians’ Maternity and Newborn Care Member Interest Group.

Kanya Rajendra

Contributor

Kanya Rajendra BHSc, MD(C), Temerty Faculty of Medicine, University of Toronto.

Milena Forte

Contributor

Milena Forte, MD, CCFP, FCFP, is a family physician and FMOB provider at Mount Sinai Hospital in Toronto. She is an Associate Professor and Family Medicine Maternity Care Lead at the Temerty Faculty of Medicine, University of Toronto, and the chair of the College of Family Physicians’ Maternity and Newborn Care Member Interest Group.

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