AAFP-ACOG Joint Statement of Cooperative Practice and Hospital Privileges. American Academy of Family Physicians. American College of Obstetricians and Gynecologists,” American Family Physician 58, no. 1 (1998): 277–278.

VanGompel EW, Singh L, Carlock F, Rittenhouse C, Ryckman KK, Radke S. Family Medicine Presence on Labor and Delivery: Effect on Safety Culture and Cesarean Delivery. The Annals of Family Medicine. 2024;22(5):375-382.

PURPOSE Currently, 40% of counties in the United States do not have an obstetrician or midwife, and in rural areas the likelihood of childbirth being attended to by a family medicine (FM) physician is increasing. We sought to characterize the effect of the FM presence on unit culture and a key perinatal quality metric in Iowa hospital intrapartum units.

METHODS Using a cross-sectional design, we surveyed Iowa physicians, nurses, and midwives delivering intrapartum care at hospitals participating in a quality improvement initiative to decrease the incidence of cesarean delivery. We linked respondents with their hospital characteristics and outcomes data. The primary outcome was the association between FM physician, obstetrician (OB), or both disciplines’ presence on labor and delivery and hospital low-risk, primary cesarean delivery rate. Unit culture was compared by hospital type (FM-only, OB-only, or Both).

RESULTS A total of 849 clinicians from 39 hospitals completed the survey; 13 FM-only, 11 OB-only, and 15 hospitals with both. FM-only hospitals were all rural, with <1,000 annual births. Among hospitals with <1,000 annual births, births at FM-only hospitals had an adjusted 34.3% lower risk of cesarean delivery (adjusted incident rate ratio = 0.66; 95% CI, 0.52-.0.98) compared with hospitals with both. Nurses endorsed unit norms more supportive of vaginal birth and stronger safety culture at FM-only hospitals (P <.05).

CONCLUSIONS Birthing hospitals staffed exclusively by FM physicians were more likely to have lower cesarean rates and stronger nursing-rated safety culture. Both access and quality of care provide strong arguments for reinforcing the pipeline of FM physicians training in intrapartum care.

Welsh S, Salazar-Collier C, Blakeslee B, Kellar L, Maxwell RA, Whigham LD, Lee M, Lindheim SR. Comparison of obstetrician-gynecologists and family physicians regarding weight-related attitudes, communication, and bias. Obes Res Clin Pract. 2021 Jul-Aug;15(4):351-356.

Objectives: To assess physician perceptions regarding weight-related communication, quality of care, and bias in obstetrics-gynecology (OBGYN) and family physician (FP) practices.

Methods: A cross-sectional survey study based on a convenient sampling of OBGYN and FP was conducted. Physicians completed a 40-question survey assessing perceived obesity management and weight bias in caring for female patients with body mass index ≥25kg/m2.

Results: Reponses from 51 physicians (25 OBGYN and 26 FP) were received. There was no difference between specialties in satisfaction with care or level of confidence in treating patients with obesity. However, OBGYNs reported more negative perceptions of patients with obesity (mean score 19.2±3.3 vs. 15.0±4.0, p<0.001) and greater weight bias (11.8±2.0 vs. 9.7±2.5, p<0.01) compared to FPs. OBGYNs were also more likely to expect less favorable treatment outcomes (13.3±2.5 vs. 15.5±2.8. p<0.01). Physicians between 31-50 years old displayed a significantly higher perception of weight bias in their profession when compared to the reference 21-30year olds, and for each unit increase in self-reported BMI there was a 0.18 average increase in the composite score for perceived weight bias.

Conclusions: OBGYN physicians reported significantly higher levels of weight bias than FP physicians, indicating a need for improved education in OBGYN training.

Partin M, Sanchez A, Poulson J, Berg A, Parascando J, Ramirez SI. Social Inequities Between Prenatal Patients in Family Medicine and Obstetrics and Gynecology with Similar Outcomes. J Am Board Fam Med. 2021 Jan-Feb;34(1):181-188.

Introduction: Family Medicine (FM) physicians play a vital role in caring for vulnerable populations across diverse practice settings. The significant decline in FM physicians performing deliveries compounds the estimated shortage of 9000 prenatal care providers expected by 2030.This study investigated the social risk profile, as characterized by social determinants of health, of patients receiving prenatal care from FM versus Obstetrics and Gynecology (OB/Gyn) providers.

Methods: Retrospective chart review of patients receiving prenatal care between 2015 to 2018 at Penn State Health Hershey Medical Center comparing social determinants of health between FM and OB/Gyn.

Results: A total of 487 patient charts were reviewed with final analysis completed on 215 charts from each cohort. When compared with OB/Gyn, prenatal patients cared for by FM were more likely to be younger (27 vs 29 years old; P < .0001), African American (28% vs 8%; P < .0001), single (52% vs 37%; P < .01), have high school or less education (67% vs 49%; P < .01), use Medicaid (46% vs 23%; P < .0001), and use tobacco during pregnancy (17% vs 8%; P < .01). In addition, FM patients had a lower rate of total Cesarean-sections (C-section), including primary and repeat, when compared with OB/Gyn (23% vs 32%; P = .04).

Conclusions: Our work demonstrates that when compared with OB/Gyn at our institution, FM physicians provide care to a cohort of patients with an increased burden of social risk without compromise to care as evidenced by a lower C-section rate and similar gestational age at delivery.

Iobst SE, Storr CL, Bingham D, Zhu S, Johantgen M. Variation of intrapartum care and cesarean rates among practitioners attending births of low-risk, nulliparous women. Birth. 2020 Jun;47(2):227-236.

Background: Variation in hospital cesarean birth rates across the United States is likely because of differences in practitioner practice patterns. Yet, few studies conducted in the last twenty years have examined the relationships between practitioner characteristics and the use of intrapartum interventions and cesarean birth. The objective of this study was to examine associations among practitioner characteristics and the use of amniotomy, epidural, oxytocin augmentation, and cesarean birth in low-risk women with spontaneous onset of labor.

Methods: A secondary analysis was performed using data collected by the Consortium on Safe Labor. The sample included nulliparous term singleton vertex (NTSV) births with spontaneous onset of labor (n = 13 196) from 2002 to 2007 across eight hospitals. Generalized linear mixed models were conducted to examine outcomes.

Results: The cesarean birth rate ranged from 7.2% to 18.9% across hospitals and from 0% to 53.3% across physicians. Practice type (P < .05) and specialty type (P < .0001) were associated with physician cesarean birth rates. Compared with obstetrician/gynecologists, midwives were nearly twice as likely to use no intrapartum interventions (relative risk 1.80 [CI 95 1.45-2.24]) and 26% less likely to use amniotomy-epidural-oxytocin (0.74 [0.62-0.89]). Family practice physicians had a 21% lower likelihood of using amniotomy-epidural-oxytocin (0.79 [0.67-0.94]) and a 53% lower likelihood of performing cesarean births (0.47 [0.35-0.63]).

Conclusions: Wide variation in hospital and physician cesarean birth rates was observed in this sample of low-risk, nulliparous women. Practitioner practice type and specialty were significantly associated with the use of intrapartum interventions. Interprofessional practitioner education could be one strategy to reduce variation of intrapartum care and cesarean birth.

Powell J, Skinner C, Lavender D, Avery D, Leeper J. Obstetric Care by Family Physicians and Infant Mortality in Rural Alabama. J Am Board Fam Med. 2018 Jul-Aug;31(4):542-549.

Background: The closure of obstetrics (OB) units at rural hospitals is thought to have implications for access to prenatal care (PNC) and infant mortality rate (IMR). The objective of this study was to determine whether local availability of PNC and OB services, specifically as provided by family physicians (FPs), would be associated with a lower IMR in 1 rural Alabama county.

Methods: Data from 1986 to 2013 from Pickens County was compared with data from 2 sets of control counties: Clarke/Monroe (full OB care) and Coosa/Conecuh (no local OB care).

Results: From 1986 to 1991 (no local OB services; period 1), Pickens County’s IMR was 17.9, which fell to 7.2 from 1993 to 2001 (with local services; period 2). After the county’s OB unit closed, IMR rose to 16.0 from 2005 to 2013 (period 3). In Clarke/Monroe (continuous OB service), the IMR fell from 14.5 to 9.9 from period 1 to period 3. Coosa/Conecuh (no OB service) exhibited a consistent IMR ranging from 10.9 to 14.4.

Conclusion: OB services provided by FPs in Pickens County resulted in improvement of the county’s IMR. Local PNC was associated with a lower IMR.

Prasad S, Hung P, Henning-Smith C, Casey M, Kozhimannil K. Rural Hospital Employment of Physicians and Use of Cesareans and Nonindicated Labor Induction. J Rural Health. 2018 Feb;34 Suppl 1:s13-s20.

Objective: Workforce issues constrain obstetric care services in rural US hospitals, and one strategy hospitals use is to employ physicians to provide obstetric care. However, little is known about the relationship between hospital employment of maternity care physicians and use of obstetric care procedures in rural hospitals. We examined the association between obstetric physician employment and use of cesareans and nonindicated labor induction.

Study Design: We conducted a cross-sectional analysis of a telephone survey of all 306 rural hospitals providing obstetric care in 9 states from November 2013 to March 2014 and linked the survey data (N = 263, 86% response rate) to all-payer childbirth data on maternity care utilization from 2013 Statewide Inpatient Database (SID) hospital discharge data.

Methods: Using logistic regression models, we assessed the proportion of a hospital’s maternity care physicians employed by the hospital and estimated its association with utilization of low-risk and nonindicated cesareans, and nonindicated labor induction.

Results: Rural hospitals that employed family physicians but not obstetricians had lower cesarean rates among low-risk pregnancies. Rural hospitals that employed only obstetricians did not show a relationship between employment and procedure utilization. Across hospitals with both obstetricians and family physicians, a 10% higher proportion of obstetricians employed was associated with 4.6% higher low-risk cesarean rates (4.6% [0.7%-8.4%]), while no significant relationship was found for the proportion of family physicians employed by a hospital.

Conclusions: In rural US hospitals, associations between physician employment and obstetric procedure use differed by physician mix and the types of physicians employed.

Aubrey-Bassler K, Cullen RM, Simms A, et al. Outcomes of deliveries by family physicians or obstetricians: a population-based cohort study using an instrumental variable. CMAJ. 2015;187(15):1125-1132.

Previous research has suggested that obstetric outcomes are similar for deliveries by family physicians and obstetricians, but many of these studies were small, and none of them adjusted for unmeasured selection bias. We compared obstetric outcomes between these provider types using an econometric method designed to adjust for unobserved confounding.

Methods: We performed a retrospective population-based cohort study of all Canadian (except Quebec) hospital births with delivery by family physicians and obstetricians at more than 20 weeks gestational age, with birth weight greater than 500 g, between Apr. 1, 2006, and Mar. 31, 2009. The primary outcomes were the relative risks of in-hospital perinatal death and a composite of maternal mortality and major morbidity assessed with multivariable logistic regression and instrumental variable–adjusted multivariable regression.

Results: After exclusions, there were 3600 perinatal deaths and 14 394 cases of maternal morbidity among 799 823 infants and 793 053 mothers at 390 hospitals. For deliveries by family physicians v. obstetricians, the relative risk of perinatal mortality was 0.98 (95% confidence interval [CI] 0.85–1.14) and of maternal morbidity was 0.81 (95% CI 0.70–0.94) according to logistic regression. The respective relative risks were 0.97 (95% CI 0.58–1.64) and 1.13 (95% CI 0.65–1.95) according to instrumental variable methods.

Interpretation: After adjusting for both observed and unobserved confounders, we found a similar risk of perinatal mortality and adverse maternal outcome for obstetric deliveries by family physicians and obstetricians. Whether there are differences between these groups for other outcomes remains to be seen.

Walters D, Gupta A, Nam AE, Lake J, Martino F, Coyte PC. A Cost-Effectiveness Analysis of Low-Risk Deliveries: A Comparison of Midwives, Family Physicians and Obstetricians. Healthc Policy. 2015 Aug;11(1):61-75.

Objective: To investigate the cost-effectiveness of in-hospital obstetrical care by obstetricians (OBs), family physicians (FPs) and midwives (MWs) for delivery of low-risk obstetrical patients.

Methods: Cost-effectiveness analysis from the Ministry of Health perspective using a retrospective cohort study. The time horizon was from hospital admission of a low-risk pregnant patient to the discharge of the mother and infant. Costing data included human resource, intervention and hospital case-mix costs. Interventions measured were induction or augmentation of labour with oxytocin, epidural use, forceps or vacuum delivery and caesarean section. The outcome measured was avoidance of transfer to a neonatal intensive care unit (NICU). Model results were tested using various types of sensitivity analyses.

Findings: The mean maternal age by provider groups was 29.7 for OBs, 29.8 for FPs and 31.2 for MWs – a statistically higher mean for the MW group. The MW deliveries had lower costs and better outcomes than FPs and OBs. FPs also dominated OB.s The differences in cost per delivery were small, but slightly lower in MW ($5,102) and FP ($5,116) than in OB ($5,188). Avoidance of transfer to an NICU was highest for MW at 94.0% (95% CI: 91.0-97.0), compared with 90.2% for FP (95% CI: 88.2-92.2) and 89.6% for OB (95% CI: 88.6-90.6). The cost-effectiveness of the MW group is diminished by increases in compensation, and the cost-effectiveness of the FP group is sensitive to changes in intervention rates and costs.

Conclusions: The MW strategy was the most cost-effective in this hospital setting. Given data limitations to further examine patient characteristics between groups, the overall conservative findings of this study support investments and better integration for MWs in the current system.

Avery DM, Waits S, Parton JM. Comparison of Delivery-Related Complications Among Obstetrician-Gynecologists and Family Physicians Practicing Obstetrics. Published online 2014:5.

Delivery-related complications and maternal postpartum outcomes of family physicians practicing obstetrics and obstetrician-gynecologists have been studied for four decades. Previous studies have shown no difference in the outcomes of family physicians practicing obstetrics compared to obstetrician-gynecologists in low-risk pregnancies. However, there is very little information in the literature regarding maternal outcomes under the care of family physicians when high-risk pregnancies are considered. This study compares the delivery-related complications among family physicians practicing obstetrics and obstetrician-gynecologists when high-risk pregnancies are included without any risk adjustment.

Methods: Nineteen common delivery complications were selected and assessed from medical records of 14,586 patients at a regional community medical center with totals for family physicians practicing obstetrics and obstetrician-gynecologists.

Results: Family physicians practicing obstetrics and obstetrician-gynecologists have similar rates of uterine rupture during labor, uterine inversion, pelvic hematomas, stillbirths, neonatal deaths, babies with Apgar scores less than 6 at 5 minutes, pulmonary emboli, placenta accreta, maternal deaths, perineal hematomas, urinary bladder and urethral injuries, and birth trauma. Family physicians had more fourth-degree extensions of episiotomies, lacerations of the cervix and postpartum hemorrhage. Conclusions: Family physicians practicing obstetrics have comparable delivery-related complications as obstetrician-gynecologists with the same outcomes.

Avery DM, Graettinger KR, Waits S, Parton JM. Comparison of delivery procedure rates among obstetrician/gynecologists and family physicians practicing obstetrics. Am J Clin Med. Published online 2013.

Background: Delivery rates and maternal postpartum outcomes comparing obstetrician-gynecologists (OB/GYNs) and family physicians practicing obstetrics have been studied for the last four decades. Family physicians who practice obstetrics and perform cesarean sections have lower rates of cesarean section, use of forceps, and labor inductions in low risk pregnancies. Family physicians have higher rates of spontaneous vaginal delivery, vaginal birth after cesarean section (VBAC), and vacuum-assisted delivery. There is very little information in the literature regarding maternal outcomes and mode of delivery of patients under the care of family physicians when high-risk pregnancies are included. Methods: Data were gathered from medical records of 14,576 deliveries at a regional community medical center regarding total numbers of overall, primary and repeat cesarean sections, VBAC, instrumental delivery, induction of labor, postoperative cesarean section length of stay, transfusion, evacuation of perineal hematomas, and peripartal hysterectomy following cesarean section including high-risk pregnancies. The number of deliveries included all that were performed between January 1, 2003, through December 31, 2011, regardless of provider.

Results: The overall, primary and repeat cesarean section rates of family physicians practicing high-risk obstetrics compared to obstetrician-gynecologists were lower. The VBAC, instrumental delivery, and transfusion rates were higher for family physicians. Postoperative cesarean section length of stay, evacuation of perineal hematomas, and peripartal hysterectomies were similar for both groups. Conclusions: Family physicians and obstetrician-gynecologists deliver comparable maternity care and both can practice obstetrics including high-risk pregnancies.

Homan FF, Olson AL, Johnson DJ. A Comparison of Cesarean Delivery Outcomes for Rural Family Physicians and Obstetricians. The Journal of the American Board of Family Medicine. 2013;26(4):366-372.

Purpose: Despite declining access to obstetrical care in many regions, family physicians often have difficulty obtaining Cesarean delivery privileges. We compared outcomes of Cesarean deliveries performed by family physicians (FPs) and obstetricians (OBs). The last such study done was more than 15 years ago.

Methods: This study was a chart review of 250 consecutive Cesarean deliveries was done at 2 rural New England hospitals. At one hospital, Cesarean deliveries were performed by FPs; at the other they were done by OBs. Demographics, pregnancy risk factors, and maternal and neonatal complication rates at each site were compared.

Results: Demographics, indications for Cesarean delivery, and prenatal risk factors were comparable at both sites except there were more hypertensive patients at the FP site. There were no differences in intraoperative or infectious complications. There were fewer postoperative complications at the FP hospital, which were mostly attributable to fewer blood transfusions and readmissions. There were no differences in neonatal outcomes, although there were more deliveries of fetuses <38 weeks’ gestation at the FP site.

Conclusions: Patients did not face increased risk when Cesarean deliveries were performed by FPs rather than OBs. A larger, more geographically diverse study is needed to confirm these findings. Results could support FPs seeking privileges to perform Cesarean deliveries, thus expanding access to care for pregnant women.

Kidd M, Avery S, Duggan N, McPhail J. Family practice versus specialist care for low-risk obstetrics: examining patient satisfaction in Newfoundland and Labrador. Can Fam Physician. 2013 Oct;59(10):e456-61.

Objective: To investigate patient satisfaction with 3 models of low-risk obstetrics care: solo care by a GP, group care by GPs, and specialist care.

Design: Three-arm study comparing results of a self-administered, anonymous questionnaire.

Setting: Two academic family practices and the labour and delivery ward in St John’s, Nfld.

Participants: A total of 220 women deemed to have low-risk pregnancies; 82 women completed the questionnaire (37% response rate).

Main outcome measures: Patient satisfaction scores obtained from a modified version of the Patient Expectations and Satisfaction with Prenatal Care instrument.

Results: Low-risk maternity patients’ satisfaction with obstetric care provided by GPs in a group-care setting was equivalent to that with obstetric care provided by GPs working solo and greater than that with obstetric care provided by specialists.

Conclusion: Patients found that group care by GPs was an acceptable means of receiving obstetric services in a low-risk setting. Therefore, a group practice model might provide an attractive means for FPs to keep obstetrics within the scope of primary care.

Abenhaim HA, Welt M, Sabbah R, Audibert F. Obstetrician or family physician: are vaginal deliveries managed differently? J Obstet Gynaecol Can. 2007 Oct;29(10):801-5.

Background: In Canada, obstetricians and family physicians both provide obstetrical care. However, the effect of specialty training on obstetrical outcomes of low-risk pregnancies has not recently been evaluated. In this study we examine the role of specialty training on the management of vaginal deliveries.

Methods: We conducted a cohort study on all vaginal deliveries that took place at Sacré-Coeur Hospital between July 2000 and June 2006. We compared baseline characteristics of obstetricians and family physicians and used an unconditional logistic regression model to estimate the adjusted relative risk of undergoing different obstetrical interventions.

Results: Of a total 8807 vaginal deliveries, 1915 were conducted by eight obstetricians and 6892 were conducted by 21 family physicians. Apart from a higher rate of induction of labour in patients of obstetricians, baseline characteristics were comparable between the two groups. Overall rates of use of instruments were similar in the two groups; however, family physicians were less likely than obstetricians to perform an episiotomy (odds ratio [OR] 0.47; 95% confidence intervals [CI] 0.41-0.55) but more likely to have patients who sustained a perineal injury (OR 1.51; 95% CI 1.36-1.68). There were no differences in the incidence of third- and fourth-degree tears, and 5-minute Apgar scores were similar in both groups.

Conclusion: Obstetricians and family physicians differ in the performance of episiotomies, and their patients differ in the resulting type of perineal injury. Instrument use and neonatal outcomes were similar in both groups. Major maternal and neonatal morbidity are unlikely to differ whether women with low-risk pregnancies are delivered by an obstetrician or a family physician.

Coco A. How often do physicians address other medical problems while providing prenatal care? Ann Fam Med. 2009 Mar-Apr;7(2):134-8.

Purpose: It is unknown to what extent physicians address multiple problems while providing prenatal care. The objective of this study was to determine the percentage of prenatal encounters with 1 or more secondary and tertiary nonobstetric diagnoses and compare rates between family physicians and obstetricians.

Methods: Using the National Ambulatory Medical Care Survey, 1995-2004, I analyzed prenatal visits to family physicians’ and obstetricians’ offices. The outcome measure was the percentage of prenatal encounters with 1 or more secondary and tertiary nonobstetric diagnoses seen by family physicians and obstetricians.

Results: There were 6,203 visit records that met study criteria, representing 223 million visits to obstetricians and 21 million visits to family physicians. Of the prenatal encounters with a family physician, 17.6% (95% confidence interval [CI], 12.9%-22.4%) included 1 or more secondary and tertiary nonobstetric diagnoses compared with 7.8% (95% CI, 6.1%-9.6%) of prenatal encounters with an obstetrician (P <.01). After controlling for other variables, being seen by a family physician, compared with being seen by an obstetrician, remained an independent predictor of a prenatal visit with an additional nonobstetric diagnosis (OR = 2.57; 95% CI, 1.82-3.64).

Conclusions: Family physicians diagnose nonobstetric problems frequently and considerably more often than obstetricians while providing prenatal care. This practice style enhances access to comprehensive primary care for women.

Deutchman ME, Sills D, Connor PD. Perinatal outcomes: a comparison between family physicians and obstetricians. J Am Board Fam Pract. 1995;8(6):440-447.

Background: This retrospective study compared obstetrician and family physician patient population demographics, obstetric outcomes, delivery methods, and medical risk factors.

Methods: Obstetricians and family practice faculty and residents provided delivery services at an urban community hospital. A retrospective case study of all deliveries by obstetrician-gynecologists and family physicians in a 20-month period was analyzed with descriptive statistics, chi-square analysis, logistic regression, and power analysis. A modified risk score analysis was completed on all patients to assess comparability between the obstetrician and family physician patients.

Results: Risk score analysis of the two patient populations demonstrated no difference in high-risk patients (P = 0.102). Family physicians’ patients had a lower incidence of Cesarean section, use of forceps, diagnosis of cephalopelvic disproportion, and low-birth-weight babies. They had a higher incidence of spontaneous vaginal delivery, vaginal birth after previous Cesarean section, and vacuum extraction use. The overall Cesarean section rate for family physicians was 15.4 percent, compared with 26.5 percent for obstetricians.

Conclusions: These findings support the high-quality outcomes of perinatal care provided by family physicians. They also provide evidence for training and privileging family physicians to perform their own Cesarean sections.

Walter G, Jetty A, Topmiller M, Huffstetler A. Family physicians provide maternity care in and around the maternity care shortage areas, particularly rural. J Rural Health. 2024 Sep;40(4):664-670.

Purpose: This study examined demographic, practice, and area-level characteristics associated with family physicians’ (FP) provision of maternity care.

Methods: Using the American Board of Family Medicine Certification examination application survey data, we investigated the relationship between FPs’ maternity care service provision and (1) demographic (gender, years in practice, race/ethnicity), (2) practice characteristics (size, ownership, rurality), and (3) county-level factors (percentage of reproductive-age women, the number of obstetrician-gynecologists (OBGYNs) and certified nurse midwives (CNMs) per 100,000 reproductive-age women). We performed summary statistics and multivariate logistic regression analyses.

Results: Of the 59,903 FPs in the sample, 7.5% provided maternity care. FPs practicing in rural were 2.5 times more likely to provide maternity care than those practicing in urban areas. FPs in academic (odds ratio [OR] 4.6, 95% confidence interval [CI] 4.1-5.1) and safety-net settings (OR 1.9, 1.7-2.1) had greater odds of providing maternity care. FPs in the bottom quintile with no or fewer OBGYNs and CNMs had a higher likelihood of maternity care provision (OR 2.1, 1.8-2.3) than those in the top quintile, with more OBGYNs and CNMs.

Conclusions: FPs in high-needs areas, such as rural and safety net settings, and areas with fewer CNMs or OBGYNs are more likely to provide maternity care, demonstrating the importance of FPs in meeting the needs of women with limited maternity care access. Our study findings highlight the importance of considering the contributions of FPs to maternity care as the organizations prioritize resource allocation to areas of highest need.

Tong ST, Morgan ZJ, Bazemore AW, Eden AR, Peterson LE. Maternity Access in Rural America: The Role of Family Physicians in Providing Access to Cesarean Sections. J Am Board Fam Med. 2023;36(4):565-573. doi:10.3122/jabfm.2023.230020R1

Introduction: As an increasing number of rural hospitals close their maternity care units, many of the approximately 28 million reproductive-age women living in rural America do not have local access to obstetric services. We sought to describe the characteristics and distribution of cesarean section-providing family physicians who may provide critical services in maintaining obstetric access in rural hospitals.

Methods: Using a cross-sectional study design, we linked data from the 2017 to 2022 American Board of Family Medicine’s Continuting Certification Questionnaire on provision of cesarean sections as primary surgeon and practice characteristics to geographic data. Logistic regression determined associations with provision of cesarean sections.

Results: Of 28,526 family physicians, 589 (2.1%) provided cesarean sections as primary surgeon. Those who provided cesarean sections were more likely to be male (odds ratio (OR) = 1.573, 95% confidence limits (CL) 1.246–1.986), and work in rural health clinics (OR = 2.157, CL 1.397–3.330), small rural counties (OR = 4.038, CL 1.887–8.642), and in counties without obstetrician/gynecologists (OR = 2.163, CL 1.440–3.250).

Discussion: Although few in number, family physicians who provide cesarean sections as primary surgeon disproportionately serve rural communities and counties without obstetrician/gynecologists, suggesting that they provide access to obstetric services in these communities. Policies that support family physician training in cesarean sections and facilitate credentialing of trained family physicians could reverse the trend of closing obstetric units in rural communities and reduce disparities in maternal and infant health outcomes.

Deutchman M, Macaluso F, Bray E, et al. The impact of family physicians in rural maternity care. Birth. 2022;49(2):220-232. doi:10.1111/birt.12591

Background: Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available.

Methods: We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally.

Results: The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round-trip to access care if those FPs were to stop delivering.

Conclusions: Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families.

Quinlan JD. The Role of the Family Physician in Rural Maternity Care. Clin Obstet Gynecol. 2022 Dec 1;65(4):801-807.

Of the 28 million rural women of reproductive age in the United States, ∼7 million of them live in areas of limited access to maternity care. While only 6.7% of Family Physicians currently provide maternity care, they are the only delivering physicians in 27% of rural hospitals. Of the 1.6% of Family Physicians performing cesarean deliveries as a primary surgeon, 57.3% do so in a rural county and 38.6% do so in a county without an obstetrician. Cultivation of the next generation of Family Physicians providing maternity care is essential to prevent further spread of existing maternity care deserts.

G. Walter, M. Topmiller, A. Jetty, and Y. Jabbarpour, “Family Physicians Providing Obstetric Care in Maternity Care Deserts,” American Family Physician 106, no. 4 (2022): 377–378.

Many communities in the United States have few or no clinicians providing maternity care services, contributing to a national maternal and infant mortality rate that is much higher than that in comparable developed countries.1 The March of Dimes defines maternity care deserts (MCDs) as counties that have no hospitals providing obstetric care and no practicing obstetrician-gynecologists (OB-GYNs) or certified nurse midwives (CNMs).2 However, this definition excludes the thousands of family physicians who provide maternity care, particularly in rural areas.3,4 We sought to determine the extent to which family physicians provide obstetric care within MCDs throughout the United States.

Tong ST, Eden AR, Morgan ZJ, Bazemore AW, Peterson LE. The Essential Role of Family Physicians in Providing Cesarean Sections in Rural Communities. J Am Board Fam Med. 2021;34(1):10-11.

Of family physicians who perform cesarean sections, more than half do so in rural communities and 38.6% provide cesarean sections in counties without any obstetrician/gynecologists. As policymakers in the United States struggle with a widening landscape of ‘obstetrical deserts,’ efforts to adequately train a family physician workforce prepared to provide cesarean sections could help maintain access to local obstetric services in rural communities and reduce perinatal morbidity and mortality.

Barreto T, Jetty A, Eden AR, Petterson S, Bazemore A, Peterson LE. Distribution of Physician Specialties by Rurality. J Rural Health. Published online December 4, 2020. doi:10.1111/jrh.12548

Purpose: Physicians of all specialties are more likely to live and work in urban areas than in rural areas. Physician availability affects the health and economy of rural communities. This study aimed to measure and update the availability of physician specialties in rural counties.

Methods: This analysis included all counties with a Rural-Urban Continuum Code (RUCC) between 4 and 9. Geographically identified physician data from the 2019 American Medical Association Masterfile was merged with 2019 County Health Rankings, the Census Bureau’s 2010 county-level population data, and 2010 Topologically Integrated Geographic Encoding and Referencing shapefiles. Multivariate logistic regression was performed to assess the availability of physicians by specialty in rural counties.

Findings: Of the 1,947 rural counties in our sample, 1,825 had at least 1 physician. Specialties including emergency medicine, cardiology, psychiatry, diagnostic radiology, general surgery, anesthesiology, and OB/GYN were less available than primary care physicians (PCPs) in all rural counties. The probability of a rural county having a PCP was the highest in RUCC 4 (1.0) and lowest in RUCC 8 (0.93). Of all primary care specialties, family medicine was the most evenly distributed across the rural continuum, with a probability of 1.0 in RUCC 4 and 0.88 in RUCC 9.

Conclusions: Family medicine is the physician specialty most likely to be present in rural counties. Policy efforts should focus on maintaining the training and scope of practice of family physicians to serve the health care needs of rural communities where other specialties are less likely to practice.

Young RA. Maternity Care Services Provided by Family Physicians in Rural Hospitals. J Am Board Fam Med. 2017 Jan 2;30(1):71-77. doi: 10.3122/jabfm.2017.01.160072. PMID: 28062819.

Background: The purpose of this study was to describe how many rural family physicians (FPs) and other types of providers currently provide maternity care services, and the requirements to obtain privileges.

Methods: Chief executive officers of rural hospitals were purposively sampled in 15 geographically diverse states with significant rural areas in 2013 to 2014. Questions were asked about the provision of maternity care services, the physicians who perform them, and qualifications required to obtain maternity care privileges. Analysis used descriptive statistics, with comparisons between the states, community rurality, and hospital size.

Results: The overall response rate was 51.2% (437/854). Among all identified hospitals, 44.9% provided maternity care services, which varied considerably by state (range, 17-83%; P < .001). In hospitals providing maternity care, a mean of 271 babies were delivered per year, 27% by cesarean delivery. A mean of 7.0 FPs had privileges in these hospitals, of which 2.8 provided maternity care and 1.8 performed cesarean deliveries. The percentage of FPs who provide maternity care (mean, 48%; range, 10-69%; P < .001), the percentage of FPs who do cesarean deliveries (mean, 66%; range, 0-100%; P < .001), and the percentage of all physicians who provide maternity care who are FPs (mean, 63%; range, 10-88%; P < .001) varied widely by state. Most hospitals (83%) had no firm numbers of procedures required to obtain privileges.

Conclusions: FPs continue to provide the majority of maternity care services in US rural hospitals, including cesarean deliveries. Some family medicine residencies should continue to train their residents to provide these services to keep replenishing this valuable workforce.

Avery DM Jr, Hooper DE, McDonald JT Jr, Love MW, Tucker MT, Parton JM. The economic impact of rural family physicians practicing obstetrics. J Am Board Fam Med. 2014 Sep-Oct;27(5):602-10.

Background: The economic impact of a family physician practicing family medicine in rural Alabama is $1,000,000 a year in economic benefit to the community. The economic benefit of those rural family physicians practicing obstetrics has not been studied. This study was designed to determine whether there was any added economic benefit of rural family physicians practicing obstetrics in rural, underserved Alabama. The Alabama Family Practice Rural Health Board has funded the University of Alabama Family Medicine Obstetrics Fellowship since its beginning in 1986.

Methods: Family medicine obstetrics fellowship graduates who practice obstetrics in rural, underserved areas were sent questionnaires and asked to participate in the study. The questions included the most common types and average annual numbers of obstetrics/gynecological procedures they performed.

Results: Ten physicians, or 77% of the graduates asked to participate in the study, returned the questionnaire. Fourteen common obstetrics/gynecological procedures performed by the graduates were identified. A mean of 115 deliveries were performed. The full-time equivalent reduction in family medicine time to practice obstetrics was 20%.

Conclusions: A family physician practicing obstetrics in a rural area adds an additional $488,560 in economic benefit to the community in addition to the $1,000,000 from practicing family medicine, producing a total annual benefit of $1,488,560. The investment of $616,385 from the Alabama Family Practice Rural Health Board resulted in a $399 benefit to the community for every dollar invested. The cumulative effect of fellowship graduates practicing both family medicine and obstetrics in rural, underserved areas over the 26 years studied was $246,047,120.

Dooley J, Kelly L, St Pierre-Hansen N, Antone I, Guilfoyle J, O’Driscoll T. Rural and remote obstetric care close to home: program description, evaluation and discussion of Sioux Lookout Meno Ya Win Health Centre obstetrics. Can J Rural Med. 2009 Spring;14(2):75-9.

Problem being addressed: Aboriginal and non-Aboriginal women in rural and remote settings struggle to access obstetric care close to home. Objective of the program: To deliver a full range of modern and safe obstetric care to 28 remote Aboriginal communities served by rural-based health care.

Program description: Rural family physicians provide intrapartum, cesarean delivery and anesthesia services to 350 rural, primarily Aboriginal women in a collegial, supportive environment.

Conclusion: Rural and remote obstetric services need support before they fail. Patient volume, remote location and organizational culture are key elements. Evidence teaches us that outcomes are best when women deliver closer to home.

Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States. JAMA. Published online March 8, 2018

Importance: Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown.

Objective: To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties.

Design, setting, and Participants: A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004.

Exposures: Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas.

Main outcomes and measures: Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks’ gestation).

Results: Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric services, and this was followed by a decreasing trend (-0.19 percentage points per year [95% CI, -0.25 to -0.14]).

Conclusions and relevance: In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

Hung P, Henning-Smith CE, Casey MM, Kozhimannil KB. Access To Obstetric Services In Rural Counties Still Declining, With 9 Percent Losing Services, 2004–14. Health Aff. 2017;36(9):1663-1671.

Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than eighteen million women of reproductive age living in rural America. Yet the extent of recent obstetric unit closures has not yet been measured. Using national data, we found that 9 percent of rural counties experienced the loss of all hospital obstetric services in the period 2004–14. In addition, another 45 percent of rural US counties had no hospital obstetric services at all during the study period. That left more than half of all rural US counties without hospital obstetric services. Counties with fewer obstetricians and family physicians per women of reproductive age and per capita, respectively; a higher percentage of non-Hispanic black women of reproductive age; and lower median household incomes and those in states with more restrictive Medicaid income eligibility thresholds for pregnant women had higher odds of lacking hospital obstetric services. The same types of counties were also more likely to experience the loss of obstetric services, which highlights the challenge of providing adequate geographic access to obstetric care in vulnerable and underserved rural communities.

Kozhimannil KB, Casey MM, Hung P, Han X, Prasad S, Moscovice IS. The Rural Obstetric Workforce in US

Hospitals: Challenges and Opportunities. J Rural Health. 2015 Fall;31(4):365-72.

Purpose: The purpose of this study was to describe the types and combinations of clinicians who are delivering babies in rural hospitals, their employment status, the relationship between hospital birth volume and staffing models, and the staffing challenges faced by rural hospitals.

Methods: We conducted a telephone survey of 306 rural hospitals in 9 states: Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin, from November 2013 to March 2014 to assess their obstetric workforce. Bivariate associations between hospitals’ annual birth volume and obstetric workforce characteristics were examined, as well as qualitative analysis of workforce changes and staffing challenges.

Findings: Hospitals with lower birth volume (<240 births per year) are more likely to have family physicians and general surgeons attending deliveries, while those with a higher birth volume more frequently have obstetricians and midwives attending deliveries. Reported staffing challenges include scheduling, training, census fluctuation, recruitment and retention, and intrahospital relationships.

Conclusions: Individual hospitals working in isolation may struggle to address staffing challenges. Federal and state policy makers, regional collaboratives, and health care delivery systems can facilitate solutions through programs such as telehealth, simulation training, and interprofessional education.

Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Services Research. 2011;11(1):147.

Background: In the past fifteen years there has been a wave of closures of small maternity services in Canada and other developed nations which results in the need for rural parturient women to travel to access care. The purpose of our study is to systematically document newborn and maternal outcomes as they relate to distance to travel to access the nearest maternity services with Cesarean section capability.

Methods: Study population is all women carrying a singleton pregnancy beyond 20 weeks and delivering between April 1, 2000 and March 31, 2004 and residing outside of the core urban areas of British Columbia. Maternal and newborn data was linked to specific geographic catchments by the B.C. Perinatal Health Program. Catchments were stratified by distance to nearest maternity service with Cesarean section capabililty if greater than 1 hour travel time or level of local service. Hierarchical logistic regression was used to test predictors of adverse newborn and maternal outcomes.

Results: 49,402 cases of women and newborns resident in rural catchments were included. Adjusted odds ratios for perinatal mortality for newborns from catchments greater than 4 hours from services was 3.17 (95% CI 1.45-6.95). Newborns from catchments 2 to 4 hours, and 1 to 2 hours from services generated rates of 179 and 100 NICU 3 days per thousand births respectively compared to 42 days for newborns from catchments served by specialists.

Conclusions: Distance matters: rural parturient women who have to travel to access maternity services have increased rates of adverse perinatal outcomes.

Hughes S, Zweifler JA, Garza A, Stanich MA. Trends in rural and urban deliveries and vaginal births: California 1998-2002. J Rural Health. 2008 Fall;24(4):416-22.

Context:Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making.

Purpose: Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings.

Methods: Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers.

Findings: Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2-0.4] deaths per 1,000 births versus 0.1 [CI 0.1-0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6-0.9). Maternal death rates were not different.

Conclusions: Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.

Charron E, Castor G, Veach CP, Chubb R, Sachs VESS, Richards M, Markey CM, Meireles JFF, Cavanagh LE, Jorgensen E, Price J, Gold K. Enhancing a Family Medicine Obstetric Care Residency Program in Oklahoma. Am J Public Health. 2024 May;114(S4):S314-S315.

Tribal, rural, and underserved communities in Oklahoma face a scarcity of medical professionals that provide obstetric care services, resulting in limited access statewide to essential maternal and reproductive health care services. In 2018, Oklahoma had a maternal death rate of 30.1 per 100 000 live births—the fourth highest nationwide.1 In 2017, infant mortality rates in Oklahoma ranked as the third highest in the nation.2 Racial disparities are prevalent in the state, with the maternal and infant mortality rates nearly two to three times higher for Blacks than for Whites from 2016 to 2018.2,3 More than half of the state’s 77 counties are maternity care deserts.4 With nearly three times as many family medicine (FM) residents as obstetrics and gynecology (OB/GYN) residents across the United States,5 and as the largest specialty capable of providing obstetric care, FM physicians are a possible answer to the lack of rural obstetric care in Oklahoma…

Roskos SE, Barreto TW, Phillips JP, King VJ, Eidson-Ton WS, Eden AR. Maternity Care Tracks at US Family Medicine Residency Programs. Fam Med. 2021 Nov;53(10):857-863.

Background and Objectives: The number of family physicians providing maternity care continues to decline, jeopardizing access to needed care for underserved populations. Accreditation changes in 2014 provided an opportunity to create family medicine residency maternity care tracks, providing comprehensive maternity care training only for interested residents. We examined the relationship between maternity care tracks and residents’ educational experiences and postgraduate practice.

Methods: We included questions on maternity care tracks in an omnibus survey of family medicine residency program directors (PDs). We divided respondent programs into three categories: “Track,” “No Track Needed,” and “No Track.” We compared these program types by their characteristics, number of resident deliveries, and number of graduates practicing maternity care.

Results: The survey response rate was 40%. Of the responding PDs, 79 (32%) represented Track programs, 55 (22%) No Track Needed programs, and 94 (38%) No Track programs. Residents in a track attended more deliveries than those not in a track (at Track programs) and those at No Track Needed and No Track programs. No Track Needed programs reported the highest proportion of graduates accepting positions providing inpatient maternity care in 2019 (21%), followed by Track programs (17%) and No Track programs (5%; P<.001).

Conclusions: Where universal robust maternity care education is not feasible, maternity care tracks are an excellent alternative to provide maternity care training and produce graduates who will practice maternity care. Programs that cannot offer adequate experience to achieve competence in inpatient maternity care may consider instituting a maternity care track.

Magee SR, Eidson-Ton WS, Leeman L, et al. Family Medicine Maternity Care Call to Action: Moving Toward National Standards for Training and Competency Assessment. Fam Med. 2017;49(3):211-217.

Maternity care is an integral part of family medicine, and the quality and cost-effectiveness of maternity care provided by family physicians is well documented. Considering the population health perspective, increasing the number of family physicians competent to provide maternity care is imperative, as is working to overcome the barriers discouraging maternity care practice. A standard that clearly defines maternity care competency and a systematic set of tools to assess competency levels could help overcome these barriers. National discussions between 2012 and 2014 revealed that tools for competency assessment varied widely. These discussions resulted in the formation of a workgroup, culminating in a Family Medicine Maternity Care Summit in October 2014. This summit allowed for expert consensus to describe three scopes of maternity practice, draft procedural and competency assessment tools for each scope, and then revise the tools, guided by the Family Medicine and OB/GYN Milestones documents from the respective residency review committees. The summit group proposed that achievement of a specified number of procedures completed should not determine competency; instead, a standardized competency assessment should take place after a minimum number is performed. The traditionally held required numbers for core procedures were reassessed at the summit, and the resulting consensus opinion is proposed here. Several ways in which these evaluation tools can be disseminated and refined through the creation of a learning collaborative across residency programs is described. The summit group believed that standardization in training will more clearly define the competencies of family medicine maternity care providers and begin to reduce one of the barriers that may discourage family physicians from providing maternity care.

Peterson LE, Blackburn B, Phillips RL Jr, Puffer JC. Structure and characteristics of family medicine maternity care fellowships. Fam Med. 2014 May;46(5):354-9.

Background and Objectives: Fewer family physicians are providing maternity care. Maternity Care Fellowships (MCFs) provide training in advanced obstetrical skills, including cesarean sections. These programs lack official recognition and certification. MCF graduates have been studied, but there are no studies of the fellowships. The objective of this study was to assess the structure and organization of family medicine MCFs.

Methods: We identified MCFs from the American Academy of Family Physicians website. Twenty-nine unique and active programs were included in the final sample. We surveyed programs via an anonymous internet methodology. The survey asked about program structure, organization, and educational aspects of the program.

Results: A total of 18 programs responded, for a 62% response rate. Eighty-eight percent of MCFs were 1 year in length, and the mean number of fellows per year was 1.9. All but one program were associated with a residency training program, and 55.6% were based in community hospitals. All but two programs had a standardized curriculum. Eighty-eight percent of MCFs had obstetricians involved in teaching or clinical supervision. Mean estimated number of deliveries performed by fellows were 80 vaginal and 108 caesarian. Graduates of MCFs were largely able to obtain caesarian privileges after graduation, and many were working in rural and/or underserved areas. Many MCF directors favored formal accreditation and a standardized curriculum across programs.

Conclusions: Despite lack of formal accreditation, MCFs have academic affiliations and internally standardized curricula. MCFs provide an obstetric workforce for rural and underserved areas, and formal accreditation may ensure program survival and boost educational standards.

Chang Pecci C, Leeman L, Wilkinson J. Family medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med. 2008 May;40(5):326-32.

Background and Objectives: Family medicine obstetrics and maternal-child health fellowships offer family physicians additional training in pregnancy care. Our objectives were to assess the content of these fellowship programs, the clinical practices of fellowship graduates, and factors associated with inclusion of cesarean delivery in practice after fellowship training.

Methods: A survey was sent to graduates of obstetrics or maternal-child fellowships around the country regarding their fellowship experience and current practice characteristics.

Results: A total of 165 graduates responded, for a response rate of 64%. Cesarean delivery, postpartum tubal ligation, and dilation and curettage are taught in most fellowships. Involvement in residency education and caring for outpatient family medicine patients are also included in most fellowships. Forty-four percent of fellowship graduates practice in rural areas, 88% are based in community hospitals, and 49% are faculty in family medicine residency programs. Most fellowship graduates are comfortable caring for high-risk pregnancy patients and performing related operative procedures. Sixty-six percent of graduates reported obtaining cesarean delivery privileges. Practicing in the Northeastern part of the United States decreased the likelihood of graduates having cesarean delivery privileges while practicing in a rural community increased it.

Conclusions: A majority of family physicians care for high-risk pregnancy patients and perform operative procedures related to pregnancy after completing an obstetrics fellowship.