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BACKGROUND: The number of family physicians practising obstetrics in Canada is declining. On the assumption that factors related to the obstetrics training of family medicine residents may be influencing this trend, we conducted a cohort study of residents' stated intentions with regard to practising obstetrics, their educational experiences and their subsequent obstetric practice. METHODS: We followed a cohort consisting of all residents who enrolled in family medicine residency programs in Ontario in 1994 and 1995. The data, collected by mail-in survey at entry to, during and 2 years after completion of the 2-year training programs, consisted of residents' characteristics, stated plans during residency to practise obstetrics, obstetric experiences during training, attitudes and opinions related to obstetrics, and actual practice 2 years after completion of residency. We used logistic regression to determine the factors influencing whether a family physician practises obstetrics after graduation. RESULTS: Of the 498 residents who started programs in 1994 and 1995, 480 were eligible for inclusion, although not all of those eligible responded to the various surveys. At entry into the residency programs, 216 (52%; 95% confidence interval [CI] 47-57%) of the 411 respondents expressed an intention to practise obstetrics. By the end of residency, the proportion intending to practise obstetrics had fallen to 17% (95% CI 13-22%; 46 of 274 respondents), and only 16% (95% CI 12% to 20%) were actually practising intrapartum obstetrics (i.e., delivering babies) 2 years later. The proportions of residents in the 7 Ontario family medicine programs who were actually practising obstetrics 2 years later ranged from 2% of those from the University of Western Ontario to 38% of those from Thunder Bay. Three factors were independently associated with practising intrapartum obstetrics 2 years after completing residency: intention at the end of residency to practise intrapartum obstetrics (odds ratio [OR] 11.7, 95% CI 3.1-44.7, p = 0.001), not having the opinion that intrapartum care is too disruptive of personal life (OR 9.1, 95% CI 1.5-55.5, p = 0.02) and practising in a community of 15 000 or fewer people (OR 6.0, 95% CI 1.8-19.4, p = 0.003). INTERPRETATION: Residents who have positive attitudes toward obstetrics at the end of their training and who intend at that time to perform deliveries are more likely to be doing so 2 years later, especially if they practise in communities of 15,000 or fewer people.
Fewer family physicians are including obstetrics in their practices. This has caused concern about access to obstetrical care and has fueled the debate about the need for obstetrics curriculum in family practice residencies. Reasons frequently cited by previous research for this change in practice pattern include the rapidly escalating cost of liability insurance and the threat of lawsuit for obstetrical malpractice. The decrease in the availability of obstetrical care from family physicians has hampered access to obstetrical care, especially for rural Texans. Texas family physicians have not been surveyed previously about their obstetrical practices. For this pilot study I surveyed 205 of Texas' 4,700 family physicians and general practitioners (4%) about their past and present obstetric practices. The sample was randomly selected, and included both MDs and DOs. Of the 64.9% who responded, 28% were practicing obstetrics, 11% had never included obstetrics in their practices, and 61% had practiced obstetrics in the past. Forty percent of those who had discontinued obstetric practice did so after 1983. High malpractice premiums and fear of lawsuits were the most frequently chosen reasons for discontinuing the obstetric component of practice. Documenting this trend of decreasing availability of obstetrical care from family physicians, and sharing the data with policymakers, may help to prevent the disappearance of the family physician who delivers babies.
OBJECTIVE: To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician-gynecologists, family physicians, certified nurse midwives, licensed midwives). METHODS: All obstetrician-gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes. RESULTS: Fewer family physicians provide obstetric services than obstetrician-gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician-gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers' most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician-gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period. CONCLUSION: Liability insurance premiums rose dramatically from 2002 to 2004 for Washington's obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study's results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics. LEVEL OF EVIDENCE: III.
BACKGROUND: Limited information exists on obstetric anesthesia experience and training within residency training programs in the United States. METHODS: A survey was sent to every academic anesthesiology training program in the United States (n=120), with follow-up reminders to non-responders. The survey included 14 questions divided into staffing, didactic teaching and epidemiology regarding the practice of obstetric anesthesia at each academic institution. RESULTS: A response rate of 78% (93/120) was achieved. The returned surveys were grouped into three tiers by the number of deliveries/year from the lowest (Group 1) to the highest (Group 3). The total number of obstetric deliveries at each institution ranged from 340 to 15 800. The average number of residents/month rotating on obstetric anesthesia was 2.6 and the number of months spent on the obstetric anesthesia service was 2.7. The average number of obstetric anesthesia lectures given was 12 per month. A total of 21.5 obstetric anesthesia fellows were reported to train at these institutions, with fellows being more common in larger institutions. Group 1 institutions were more likely to have anesthesiologists covering the main operating room and obstetric suite simultaneously. The average number of obstetric anesthesia staff members/institution was 4.3. The average cesarean section rate was 27.8%, with 5.8% being performed under general anesthesia. Neuraxial techniques were used in an average of 70.3% of laboring parturients, with combined spinal epidurals accounting for 24.6% of the techniques. CONCLUSION: The average number of obstetric deliveries per year for institutions with a resident training program was 3498+/-2383. Dedicated obstetric anesthesia staffing was more common when >3700 deliveries/year were performed; the presence of this staffing corresponded with a reduction in the use of general anesthesia for cesarean deliveries. Few differences in the resident lecture didactic exposure were observed in terms of numbers of lectures and months on the obstetric anesthesia service, although a significantly greater number of clinical cases was available to each resident in those institutions with greater overall numbers of obstetric cases.
In the late 1980s several published articles predicted a crisis in the availability of obstetric care due to declining numbers of rural obstetrical providers. Several state and national studies documented the adverse impact of malpractice and time demands on both urban and rural physicians. But only limited information is available to document current trends in rural obstetrical practice and assess whether or not the predicted crisis occurred. This study sought to provide that updated information for rural Minnesota. A telephone survey of all rural Minnesota obstetrical providers was used to document the number, location, and specialty of rural obstetrical providers, their practice limitations, and plans for future practice. This data was combined with state perinatal statistics for each county to further assess obstetrical care availability and perinatal outcomes. All rural Minnesota obstetricians and certified nurse midwives provide obstetrical care as did 69 percent of all rural family physicians. Only 27 percent of rural obstetrical providers put any type of restrictions on their obstetrical practices. During the past year, 67 currently practicing rural physicians have stopped providing obstetrical care while 55 new obstetrical providers have begun rural practice. Two to 3 percent of current rural providers plan to retire or discontinue obstetrical services during the next five years. The provider demographics from the survey identified eight counties with no prenatal providers, and 12 additional communities of decreased provider availability. However, only two of the counties with no prenatal providers and five of the counties with areas of limited providers had increased percentages of adverse prenatal outcomes such as low birthweight or late prenatal care. This study concluded that Minnesota does not have a serious statewide problem with availability of rural obstetrical providers. However, a few isolated regions of the state have limited provider availability, including limited availability of local high-risk services and consultants.
BACKGROUND: The loss of family physicians as obstetrics providers during the last decade has had a significant impact on access to obstetric services, especially for rural populations. The expense of malpractice premiums has been cited often as a reason for physicians' discontinuation of this service. METHODS: Seventy-six family physicians in northern California who recently discontinued obstetrics were surveyed regarding their decisions related to obstetric practice. Those physicians who indicated that a decrease in malpractice premiums would allow them to consider resuming obstetrics were resurveyed by telephone the following year. This telephone survey occurred following a 25 percent decrease in malpractice premiums for obstetrics by the major malpractice insurance carrier for family physicians practicing obstetrics in the study area. RESULTS: Twenty-nine of the 76 physicians in the original survey who had recently discontinued obstetrics stated they would consider resuming if conditions changed. Twenty-six (90 percent) of these physicians indicated that malpractice premiums needed to change for them to consider resuming obstetrics. Following the reduction in premiums, none of these physicians reported plans to resume obstetrics or even a likelihood that they would be resuming obstetrics. CONCLUSION: This study found that family physicians who discontinued obstetrics and cited malpractice premiums as a barrier to resuming obstetrics are unlikely to resume when rates decline. This finding suggests that other issues might be equally or more important in this decision.
OBJECTIVE: The objectives of this study were to track changes in medical students' interest in obstetrics from the beginning of their studies in medicine to the end of their pre-clinical clerkships and to identify factors that influenced this interest. METHODS: This was a cohort study of all Québec medical students who, in 2003, were about to begin their clerkships (n = 500). A questionnaire was administered at this time (T1) and at the end of the clerkship (T2). The main outcome variables were an intention to provide prenatal care without deliveries and an intention to deliver infants in future practice. Logistic regression analysis was used to assess relationships between the various determinants and the decision to practise obstetrics. RESULTS: A total of 353 students, or 70.6% of the cohort, completed both questionnaires. At the end of their clerkships, 32 students (9.1%) were definitely planning to include complete obstetrical care in their future practices, and 45 (12.7%) said that they probably would. Between the beginning and the end of their clerkships, only 8% of students had changed their minds in favour of an obstetrical career, and 20% had decided against it. An intention to deliver infants is associated with the following factors: considering the practice of obstetrics gratifying (odds ratio [OR] 6.73; 95% confidence intervals [CI] 3.30-13.70); having been exposed to obstetrical care outside the clerkship in obstetrics and gynaecology (OR 4.4; 95% CI 1.6-10.26); having completed university studies before studying medicine (OR 4.08; 95% CI 1.11-15.3); and having had a decisive, positive experience with obstetrics (OR 2.86; 95% CI 0.96-8.50). Students who believed that specialists had played a key role in their decision and that obstetrics is a demanding practice were less likely to plan a career that included delivering infants (OR 0.43; 95% CI 0.23-0.69 and OR 0.35; 95% CI 0.21-0.59, respectively). CONCLUSION: This study shows that an interest in practising obstetrics emerges very early in medical training. However, a student's learning experiences during an obstetrical rotation affect this decision. Departments of family medicine and obstetrics and gynaecology may be able to work together to create more positive role models.
OBJECTIVE: To examine factors affecting participation in obstetrics among obstetrician-gynecologists and changes in participation over time. METHODS: Using physician billings from Ontario, Canada, from 1992/1993 to 2001/2002, we examined the impact of physician age, gender, practice location, and years of practice on participation in obstetrics with multiple logistic regression and repeated measures analyses. We also examined differences in practice patterns between obstetrics providers and nonproviders using linear and log-linear regressions. RESULTS: Obstetrics participation declined with age, from 96% among physicians under age 35, to 34% among those aged 65 and over (2001/2002 figures). Regressions demonstrated a lower likelihood of performing obstetrics in successive years (odds ratio [OR] 0.95 per year; 95% confidence interval [CI] 0.93, 0.98) and among physicians who were older (OR 0.91 per year of age; 95% CI 0.90, 0.93), female (OR 0.57; 95% CI 0.36, 0.91), and practicing in cities with medical schools (OR 0.58; 95% CI 0.44, 0.78). The crude obstetrics participation rate dropped from 82% to 77%, from 1992/1993 to 2001/2002. The physician age-sex-adjusted participation rate dropped from 80% in 1992/1993 to 77% in 2001/2002. Obstetrics providers had almost double the annual billings of nonproviders ($364,000 verus $187,000; P <.001), but more on-call days worked (105 versus 13; P <.001). Nonproviders of obstetrics derived more of their billings from outpatient visits, psychotherapy, and diagnostic tests. The likelihood of an obstetrics nonprovider resuming obstetrics was 1.1% per year. CONCLUSION: The proportion of obstetrician-gynecologists practicing obstetrics declined modestly in the last decade, partly because of more female physicians in the workforce who were less likely to practice obstetrics. Planners should consider these trends when estimating how many obstetrician-gynecologists to train to meet future societal needs. LEVEL OF EVIDENCE: II-2
OBJECTIVE: To provide a contemporary picture of the general practitioner and specialist obstetric workforce in Victoria. DESIGN, PARTICIPANTS AND SETTING: Postal census by questionnaire of all 317 Fellows and 961 Diplomates on the Victorian database of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in September 2003. MAIN OUTCOME MEASURES: Sex, age and geographical distributions and patterns of retirement from and recruitment to the GP and specialist obstetric workforce in Victoria. RESULTS: 244 Fellows (77.0%) and 652 Diplomates (67.8%) participated. The average age of Diplomates was 42 years; only 20% were involved in procedural obstetrics. Of GPs practising procedural obstetrics, 56% intended to cease within 7 years. Two-thirds of specialist obstetricians continued to practise obstetrics. Among those ceasing obstetrics, almost half had done so since 2000. Among Fellows ceasing obstetric practice, there is a peak in the 50-60-years age group, but cessation of obstetric practice occurred across all age groups. CONCLUSION: The proportion of GPs involved in procedural obstetrics has fallen markedly over the past decade, with half of those ceasing practice in the 40-50-years age group. New GPs entering the workforce with the Diploma and overseas doctors are unlikely to meet the procedural workforce shortfall. Attracting the large cohort of doctors aged 40-50 years back to obstetric practice must be a priority. Given the pattern of retirements from obstetrics, there will be insufficient numbers of specialists to maintain current levels of service. The reasons include non-participation in obstetrics by new graduates and international medical graduates, the inadequate number of new graduates, and the predominance of women among specialists aged under 40 years, whose work output tends to be affected by family commitments.
In Alabama between 1985 and 1989, a total of 94 physicians outside of the four largest cities in the state dropped the obstetrics portion of their practices or left practice in their communities altogether. During the same period 82 physicians entered obstetrics practice in this area. The study presented here used survey and archival data to compare practice characteristics of generalists and specialists in rural and town counties who made different decisions about providing obstetrics care. More generalists left and more specialists entered practice both in town and in rural counties. Rural counties lost more obstetrics providers because more generalists provided the obstetrics care in these areas. Across both specialty and county categories, physicians in group practice who accepted Medicaid and had local access to larger numbers of patients were more likely to remain or begin new obstetric practices. During this period, some obstetrics specialists moved into rural communities that had previously supported only generalist physicians. These findings suggest that the options for organizing successful obstetrics practices have narrowed, putting solo and generalist physicians who operate small-scale obstetrics practices at a disadvantage. These physicians also face competition from obstetrics specialists who are beginning to enter practice in the rural areas of the state. Designing policies that effectively improve geographic access to care requires a realistic understanding of the practice constraints faced by obstetrics providers. For example, as centralized specialist group practices serve residents from surrounding rural areas, programs that facilitate linkages, such as satellite clinics and use of mid-level practitioners, can be promoted.(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: Maternal mortality in developing countries remains high due to lack of appropriate emergency obstetric care. Major obstetric intervention (MOI) rate can be used as an indicator of unmet obstetric needs and quality of care. OBJECTIVES: Identify indications for major obstetric interventions, determine MOI rates and assess extent of unmet obstetric need for women in Turkana district, Kenya. DESIGN: Descriptive bi-directional study. SETTING: Turkana district: Kakuma Refugee Camp, Kakuma Catholic Mission and Lodwar District Hospitals. SUBJECTS: Four thousand two hundred and eighty encamped refugee women and 7,630 women from the host population delivering in Turkana district between January 1995 and September 1999. DATA SOURCES: Maternity registers, inpatient case notes and theatre registers. MAIN OUTCOME MEASURES: Maternal mortality, perinatal mortality, major obstetric interventions, unmet obstetric need and length of stay. RESULTS: The subjects from the two study populations were similar with respect to age, parity and indications for surgical intervention. Caesarean section was the only major obstetric intervention. Overall, caesarean section rate was significantly higher among refugees than in the host population (3.1% versus 2.1%, p<0.01; CI 1.4-2.1). Maternal indications were the main reasons for c/s in both populations, with the c/s rate being higher for refugees than for local women (2.5% versus 1.7%). At least 0.8% of parturient women from the host population had unmet obstetric needs: this translates to 61 pregnant women who may have died or experienced birth-related complications over the study period. The mean length of hospital stay was much less for refugee women than for the host population (8.1 days versus 11.3 days). CONCLUSION: Encamped refugee women in Kakuma have better obstetric care than those from the host population, and the level of unmet obstetric needs in the district is high. This imbalance could be reduced through resource sharing and integration of refugee health care services with that for the host population.
To determine the reasons some family physicians continue to practice obstetrics when most of their colleagues do not, we surveyed family physicians in 26 counties of northern California whose practices include obstetrics and those who have recently discontinued it. In all, 70% of family physicians practicing obstetrics cited enjoying it as a reason for continuing this practice. Over a third of family physicians practicing obstetrics thought that obstetric practice was a responsibility to the community. Only 1 in 6 reported obstetrics to be important in terms of financial implications. Despite this, family physicians practicing obstetrics had a mean gross income derived from obstetric practice of $30,000 above the cost of their total malpractice premium. In contrast, a comparison group of family physicians who had recently discontinued obstetrics cited malpractice insurance costs most frequently as the reason for discontinuing it. Nearly 40% of these physicians indicated that they would be willing to return to obstetrics if circumstances were to change substantially. The most frequently cited change necessary for these physicians to return to obstetrics was a reduction in malpractice insurance rates.
A study was designed to investigate the status of obstetric practice by Pennsylvania family physicians and its relationship to family practice residency training. A 50% probability sample of all family and general physicians and of all graduates of Pennsylvania family practice residency programs was surveyed by mail. Ten percent of Pennsylvania family physicians and general practitioners reported currently practicing obstetrics, 44% of whom said they planned to stop within 3 years. Telephone survey information from nonresponders suggests that even fewer (5%) of the state's family physicians may actually be practicing obstetrics. Family practice residency training, postresidency obstetric training, and small community size were the best predictors of current obstetric practice. Family physicians in the smallest communities, however, were also those most likely to be planning to stop, and graduates of residency programs were increasingly choosing not to practice obstetrics. Cost of liability insurance and fear of lawsuits were primary reasons cited for stopping obstetrics. Family physicians have been major providers of obstetric care in the nation's rural areas. Now, increasingly firm evidence that fewer family physicians are practicing obstetrics signals increasing shortages in obstetric care for women in rural communities. Changes in the practice climate and obstetric training programs for family physicians seem essential to help reverse these trends.
BACKGROUND: Obstetric sonography is a valuable diagnostic procedure for family physicians who provide obstetrics; however, physicians tend to use technology that was effectively modeled during residency. The purpose of this study was to learn how many family medicine residency program directors had an interest in and a need for training in obstetric sonography, as well as whether they were willing to commit faculty and finances for adding the technology to their programs. METHODS: All program directors listed in the 1989 American Academy of Family Physicians (AAFP) Directory of Family Practice Residency Programs (n = 379) received a five-item questionnaire about obstetric services and use of sonograms in their programs and their desire for training in obstetric sonography. RESULTS: More than 81 percent of respondents said their programs provided obstetrics. Sixty-eight percent of these respondents used sonograms, and 53 percent indicated a need for training in obstetric sonography. Forty-five percent of all respondents, regardless of whether their programs offered obstetrics, indicated a desire for training. CONCLUSIONS: The high level of interest in obstetric sonography can be explained, in part, by the 81 percent of respondents whose programs provided obstetrics. These figures suggest a need to establish a training curriculum in obstetric sonography for family medicine residency programs. Our training program, designed to reach faculty, residents, and practicing physicians, is described.
OBJECTIVE: The purpose of this study was to investigate the clinical usefulness of the measurement of ultrasonic obstetric conjugate. STUDY DESIGN: In 209 pregnant women, ultrasonic obstetric conjugate was measured twice at 28 and 36 weeks of pregnancy. In 26 of these patients the measurement of obstetric conjugate by x-ray pelvimetry was also performed at 36 weeks of pregnancy because of medical indications. Obstetric outcome was investigated in association with ultrasonic obstetric conjugate. The relationship between ultrasonic obstetric conjugate and x-ray pelvimetry was investigated. RESULTS: Ultrasonic obstetric conjugate ranged from 10.7 to 15.1 cm. In 12 patients (5.7%) ultrasonic obstetric conjugate was less than 12 cm. Six of them (50.0%) underwent cesarean section because of dystocia. This percentage was significantly higher than 7.1% of the cesarean section rate (14 of 197) in patients with ultrasonic obstetric conjugate more than 12 cm (P <.001). A close positive correlation was observed between ultrasonic obstetric conjugate and x-ray pelvimetry (r = 0.91; P <.0001). CONCLUSIONS: We conclude that ultrasonic obstetric conjugate measurement is a safe and useful procedure in the prediction of dystocia.
OBJECTIVE: The purpose of this study was to investigate the psychiatric consultation condition in the obstetric ward with particular attention paid to the reasons for referral, psychiatric diagnoses and recommendations. METHODS: This study was conducted in a medical center with 73 obstetric beds. All psychiatric consultations of obstetric inpatients during a 3-year period were included in this study. Data were derived from clinical charts and consultation records that included demographic data, reasons for referral, psychiatric diagnoses and treatment recommendations. RESULTS: Within the 3-year period, 28 patients were referred for psychiatric consultation, or 0.3% of the 9,972 obstetric admissions. The obstetric group represented 0.7% of all the psychiatric consultations. The most common reason for the referral was anxiety. Many obstetric problems, medical histories and psychiatric histories were found in these 28 patients. The most common diagnoses were depression or dysthymia, and schizophrenia. The diagnosis of organic mental disorders was rarely found. The vast majority of the psychiatric consultants were likely to recommend medication and psychological intervention. CONCLUSION: Even though there is a low psychiatric consultation rate among the obstetric inpatients, it does not mean that the prevalence rate of mental disorders is low in the obstetric patients. Psychiatric problems may be neglected or happen after patients are discharged. Organic mental disorders were rarely found in the obstetric patients which suggested a different pattern of mental disorders in the obstetric patients compared to other patients. The stress during child delivery needs further study for it may exacerbate or predispose a mental disorder. It is suggested that collaboration between obstetric staff and the consultation-liaison psychiatrists may provide better care for pregnant women patients.