The Role of Family Medicine in Addressing the Maternal Health Crisis in the United States

Abstract

The United States (US) is experiencing a maternal health crisis, with high rates of maternal morbidity and mortality. The US has the highest rates of pregnancy-related mortality among industrialized nations. Maternal mortality has more than quadrupled over the last decades. Rural areas and minoritized populations are disproportionately affected. Increased pregnancy-care workforce with greater participation from family medicine, greater collaborative care, and adequate postpartum care could prevent many maternal deaths. However, more than 40% of birthing people in the US receive no postpartum care. No singular solutions can address the complex contributors to the current situation, and efforts to address the crisis must address workforce shortages and improve care during and after pregnancy. This essay explores the role family medicine (FM) can play in addressing the crisis. We discuss pregnancy care training in FM residencies as well as the threats posed by financial and medico-legal climates to the maternal health workforce. We explore how collaborative care models and comprehensive postpartum care may impact the maternal health workforce. Efforts and resources devoted to high impact solutions for which FM has considerable autonomy, including collaborative and postpartum care, are likely to have greatest impact.

Maternal Health Crisis in the US

The United States (US) is experiencing a maternal health crisis, with obstetric workforce shortages strongly contributing to this situation. Today, the US has the highest rates of pregnancy-related mortality among industrialized nations with 1205 maternal deaths reported in 2021 compared to 861 in 2020 and 754 in 2019. ¹ Severe maternal morbidity (SMM), defined as any health condition attributed to and/or aggravated by pregnancy and childbirth that has negative outcomes to the patient’s well-being, has also increased by 20% from 1993 to 2014 when postpartum hemorrhage is excluded. ² The maternal mortality rate, defined as the death of a person while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes, more than quadrupled from 1987 (7.2 deaths/100 000 live births) to 2021 (32.9 deaths/100 000 live births).^1,3 A spike in maternal mortality in 2020 and 2021 was likely exacerbated by the COVID-19 pandemic. However, the rate in 2022 (22.3 deaths per 100 000 births) suggests the alarming upward trend observed before the pandemic is continuing post pandemic. The leading causes of maternal death include cardiovascular diseases, such as cardiomyopathy and stroke, and mental health conditions, such as depression, suicide, and substance use. ¹

What is more, over 80% of maternal deaths are considered preventable and 53% of pregnancy-related deaths occur between 7 and 365 days after birth. ⁴ Postpartum care, services a patient receives after pregnancy and childbirth, is imperative in this context. Until recently, care models included a single 6-week postpartum visit and have fallen short of addressing patient-centered outcomes including sexual health, emotional health, and urinary incontinence. Moreover, more than 40% of birthing people in the US receive no postpartum care. ⁵

Challenges in Rural and Underserved Populations

Maternal health outcomes are worse for people who live in rural areas, and for those who are Black, Indigenous, and People of Color (BIPOC) . From 2016 to 2019, maternal mortality was nearly 2 times higher in rural areas compared to urban areas. ⁶ In 2021, the maternal mortality rate for non-Hispanic Black people was 2.6 times the rate for non-Hispanic White people. ⁷ Similarly, from 2017 to 2019 in the US, American Indian/Alaskan Native (AIAN) birthing people were twice as likely to die as White birthing people. ⁸

A likely cause for these disparities is the disproportionate impact of maternity care deserts on these populations. Maternity care deserts are counties in which pregnancy care services are limited or absent due to lack of facilities or providers, and barriers to accessing services. The closures of obstetrics units in smaller communities and rural hospitals exacerbates this issue, further hindering these populations from receiving appropriate pregnancy care. From 2004 to 2014, 9% of rural counties lost hospital obstetrics services and 45% had no obstetrics services to begin with. ⁹ An estimated 50% of birthing people living in rural areas travel more than 30 min to a hospital providing obstetrics services. ¹⁰

Concerns are particularly acute for AIAN birthing people. About 40% of AIAN birthing people are rural residents and, often, Indian Health Service facilities do not provide obstetric care. Thus, many AIAN patients give birth outside of culturally-centered health care systems. ¹¹ One study found AIAN patients were 20 times more likely to give birth at a hospital without obstetric services and had less access to complex obstetric care compared to White patients. ¹²

This analytic essay delves into potential solutions for the maternal health crisis, specifically exploring the role of family medicine (FM) in alleviating care shortages and enhancing quality of care. To achieve this, the essay is structured around 3 key points: Firstly, it examines the inherent strengths of FM that uniquely position it to address the crisis. Secondly, it analyzes recent changes in training requirements for FM that may impact workforce shortages and explores the influence of current policy on shortages. Finally, the essay delves into pregnancy care with a focus on collaborative care models and postpartum care. Throughout this essay, the term pregnancy care refers to a broad array of services including preconception, prenatal, intrapartum, and postpartum care and services. At times we refer to specific types of pregnancy care, for example postpartum. In this essay, whenever possible, we use gender-neutral language to describe pregnancy related care. Gendered language like “maternal” or “maternity” is used when describing established concepts or metrics like maternal mortality, the maternal health crisis, or maternity care deserts. In place of gendered terms like “mother” or “women,” we use terms like birthing people, parent, or pregnant people.

The Role of Family Medicine in Pregnancy Care

FM is uniquely positioned to play important roles in addressing the maternal health crisis. ¹³ FM physicians are well-suited to provide care to pregnant patients, patients who recently gave birth, and infants in rural and underserved areas because of their workforce distribution and comprehensive training. However, challenges prevent FM from achieving its broad potential to address the maternal health crisis.

Strengths and Identity

Today, FM is the largest contributor to the US primary care physician workforce, consisting of more than 86 000 physicians ¹⁴ who practice in more rural and urban underserved communities than any other primary care physician specialty. ¹⁵ In contrast, the distribution of specialty physicians, including Obstetricians (OB/GYN) and Maternal Fetal Medicine (MFM), is densely concentrated in urban and academic hospital settings. ¹⁶ Additionally, more than 50% of counties in the US do not have a board-certified OB/GYN. ¹⁷

Because FM is distributed similarly to the general population, they are often the main or only providers of pregnancy care in rural areas. One study showed that in 40% of hospitals where FM delivered, they were the only physicians providing pregnancy care. The study also revealed that the number of babies delivered by FM in rural settings has remained stable at 50%. ¹⁶

Family Medicine (FM) is considered a versatile physician specialty, providing comprehensive medical care to patients of all genders, ages, and racial and ethnic backgrounds. ¹⁸ FM seeks to understand patients within the unique context of their families and social environment as well as to address their individual needs. ¹⁹ Importantly, FM offers family-centered care in the prenatal and postpartum periods, allowing FM physicians to care for the mother-infant dyad. ²⁰ Given the focus and training on providing comprehensive primary care, FM has the infrastructure and is equipped to address the needs of pregnant and postpartum patients, ensuring they are adequately diagnosed, evaluated, and managed.

Challenges

The broad potential for FM to extend access and continuity for pregnancy care in the US is yet to be realized. The proportion of FM physicians providing pregnancy care has declined dramatically over the past few decades from over 40% in the 1980’s to just below 10% in 2010. ²¹ The same trend exists for FM physicians who provide pregnancy care to underserved populations and in locations designated as Health Professional Shortage Areas (HPSA). ²²

Several factors have contributed to declining rates of FM physicians practicing obstetrics or providing pregnancy care services. Some FM training programs only provide limited exposure to high-risk or comprehensive obstetrical services during residency training. ²³ In addition, there is increased competition with a growing number of additional areas of focus within primary care, including sports medicine, reproductive health, or Point of Care Ultrasound (POCUS), which have diverted FM physicians to other opportunities. ²⁴ Furthermore, a number of external financial and policy considerations, as well as lifestyle factors contribute to limited participation of FM in pregnancy care. The next section provides a deeper exploration of FM training and policy considerations for workforce shortages.

Workforce Shortages: Training and Policy Considerations

The maternal health crisis is compounded by a lack of health care professionals trained or motivated to fill care gaps. Traditionally, pregnancy care is provided by OB/GYNs, Certified Nurse Midwives (CNMs), and FM physicians. Here we focus on factors that influence FM participation in pregnancy care training. Recent changes to FM resident training requirements and policies regarding liability and compensation impact FM participation in pregnancy care.

Training in Family Medicine

FM obstetrical training requirements are more robust than any other specialty outside of OB/GYN. Family Physicians are trained to care for pregnant people with the completion of their residency training. ACGME recently updated requirements for pregnancy care training in FM residency programs with a greater emphasis on pregnancy care. ACGME requirements specify training on a broad array of obstetric-related conditions and procedures in which FM physicians must develop proficiency. These include diagnosing and managing early pregnancy complications, low risk prenatal care, common medical complications of pregnancy, uncomplicated spontaneous vaginal delivery, basic skills in obstetrical emergencies, and management of postpartum care including postpartum depression, breast feeding support, and family planning. ²⁵

In addition, ACGME requirements mandate the incorporation of care in the outpatient setting and care of parental-baby pairs, including 200 h or 2 months dedicated to pregnancy-related care. Regarding deliveries, each FM resident must perform 20 vaginal deliveries. However, FM residents who seek the option to incorporate comprehensive pregnancy-related care, have more vigorous requirements including a minimum of 80 deliveries performed or directly supervised and 400 h or 4 months of training dedicated to labor and delivery. ²⁵

Additionally, FM-OB training may include additional training with completion of a 12-month, full-time fellowship delivering obstetrical care. Obstetric fellowships for FM often focus on certifying in Advanced Life Support in Obstetrics (ALSO) and Neonatal Resuscitation Provider (NRP) programs and performing cesarean and vaginal deliveries. ²⁶ These requirements embrace the care of pregnant patients with a focus on continuity of care from preconception to prenatal and intrapartum periods through the postpartum period. ²⁷

Policy Considerations

Current policies impact how likely FM physicians are to provide pregnancy care. Three policy considerations are high costs of malpractice premiums, low reimbursement rates for pregnancy-related services, and priviliging difficulties FM physicians face. The following paragraphs briefly discuss these issues and some potential solutions to address them.

Providing pregnancy care requires additional liability coverage and a more challenging medico-legal environment than other domains, deterring some physicians and employers from offering pregnancy care services. ²⁸ Regarding malpractice premiums, a 2021 analysis in 7 geographic areas showed an average cost of $136 990 for obstetrics compared to $108 139 for general care, with year-over-year increases in some states. ²⁸ Florida state had the highest rate ($215 649), followed by Illinois ($179 497), and California had the lowest rate ($49 804). ²⁹ The analysis considered obstetrics in general rather than specifically FM physicians. FM physicians providing pregnancy-related care can expect to pay higher malpractice premiums. Rising premiums create challenges for FM physicians who must weigh the costs of providing pregnancy care. High premiums also create financial obstacles for institutions, particularly those in rural areas, interested in utilizing FM physicians for pregnancy care. ³⁰

One potential solution involves creation of a national malpractice system for obstetrics to eliminate the format of state-specific laws relating to injury claims and jury awards, and underwriting cycles. ³¹ A standardized system could benefit patients, providers, and institutions, by reducing burdens and costs associated with navigating the complex and volatile malpractice system. A nation-wide system could cap large premium increases and non-economic damages, orient liability as a system issue rather than an issue for individual providers, and eliminate or reduce transaction costs for insurance premiums.^32,33 There are increasing calls for innovative solutions, such as the creation of medical care or health courts dedicated to handling litigation and malpractice cases. ³³ Other promising solutions include early disclosures, compensation, and liability safety systems to ensure protections for physicians practicing evidence-based medicine. ³³

FM physicians must also consider reimbursements for pregnancy services. In the US, Medicaid financed 41% of births in 2021. ³⁴ Not all births are reimbursed at the same rates. The Health Care Cost Institute compared the average payment for childbirth between Medicaid and employer sponsored insurance and found that payments for births through employer sponsored plans were considerably higher than payments from Medicaid. ³⁵ Low compensation for delivery is a persistent issue and has been cited as a reason for decreased FM participation in pregnancy care as early as 1992 and as recent as 2023.^36,37

Solutions have been offered for addressing low reimbursement rates. One alternative to the fee-for-service model is value-based alternative payment models (APM). One APM features payment for care bundled up to a threshold amount. For example, a set amount bundled payment could cover prenatal, pregnancy, and postpartum care. Providers in this model share in cost savings by providing efficient, quality care below the threshold payment. On the other hand, if costs of care exceed the threshold payment, providers may have to pay back losses. ³⁸ The Center for Healthcare Quality and Payment Reform has proposed an APM for pregnancy care, and demonstrates how this model can improve health outcomes for patients and increase cost savings for payers. ³⁹ Ultimately, reimbursement is complex, and a variety of facilitating and inhibiting factors influence the development, implementation, and applicability of APMs. ⁴⁰

FM physicians often experience difficulties obtaining obstetrics privileges in many institutions. Some barriers include inaccurate perceptions that FM physicians are unable to provide high quality obstetrics care, financial policies to increase income of existing specialist staff and not integrate FM physicians, and institutional policies requiring FM physicians to obtain multiple departmental approval to acquire obstetrics privileges.^40,41 To address these systemic barriers, health systems should consider developing a single credentialing authority dedicated to reviewing and approving privileging requests. Privileging criteria for obstetrics care should also be uniform and consistent across departments and specialties, and FM physicians should be represented in privileging review committees.^40,42

Improving Pregnancy Care

The maternal health crisis must be mitigated in a comprehensive manner, expanding the ability and number of pregnancy-care providers while shifting the way care is delivered. Collaboration is essential for effectively addressing the crisis. Many of the problems and conditions resulting in severe maternal morbidity and mortality in rural and underserved areas can be addressed by collaborative models of care ⁴¹ and increased use of telehealth. In addition to increasing use of collaborative care models, increasing emphasis on postpartum care, including screening for cardiovascular and mental health issues, has potential to improve outcomes and is an effective way FM physicians can address the current crisis.

Collaborative Care Models and Telehealth

Collaborative care models can be defined as integrated systems of delivering care involving a multidisciplinary and collaborative team providing care to meet the individual needs of patients prior to, during, and after pregnancy. ⁴² One example of collaborative care is the hub-and-spoke model. This model arranges service resources into a network, with an anchor establishment (hub) offering a broad range of services, complemented by secondary establishments (spokes) offering limited services. Spokes route patients in need of more intensive services to the hub, meaning that rural providers offer prenatal care and basic obstetrics and transfer higher-risk patients to a higher level of care, better equipped to handle high-risk births. ⁴³ Overall, this enables rural communities to better leverage their local healthcare workforce. ⁴⁴

One well-known hub-and-spoke approach is the evidence-based Extension for Community Healthcare Outcomes (ECHO) Model^®, using tele-mentoring from Hub-based experts to amplify the capacity for safe and effective care, including pregnancy care, in rural and underserved areas. ⁴⁵ Another example is Western North Carolina’s project Care that Advocates Respect, Resilience, and Recovery for All (CARA), a comprehensive substance use treatment program for pregnant patients and patients who recently gave birth. The Mountain Area Health Education Center (MAHEC) in Asheville acts as the hub to provide more specialized, intensive services as well as consultation and support to the spokes, partner clinics providing more limited services. ⁴⁶

Additionally, a comprehensive approach to addressing the maternal health crisis in the US requires integration and effective implementation of telehealth practices. Definitions of telehealth vary, but a generally agreed upon conceptualization is that telehealth encompasses a range of remote healthcare services delivered via technology. ⁴⁷ Some specific examples of telehealth services include virtual appointments, remote monitoring, and teleconsultations with pregnancy specialists or other subspecialists.^48,49 Potential benefits of telehealth include increased access to services, decreased inequity, reduced costs, reduced the need for in-person visits, increased efficiency, improved patient outcomes, and enhanced early detection and treatment initiation of adverse complications.^47,49

Enhancing Postpartum Care

In addition to increased use of collaborative care models and technology, FM physicians have opportunities to improve postpartum care in ways that could help mitigate the current crisis in maternal health, even outside of directly providing pregnancy or obstetrical care. FM training includes care for families and individuals across the life span, qualifying FM to provide primary care for both the patient and the infant. ¹⁹ Family physicians routinely see newborns and infants in their practices. Conveniently, parents who recently gave birth accompany children to over 90% of well-child checks, which provides family physicians opportunity to screen and perform interventions in the early and later postpartum periods. ⁵⁰ Screening can lead to early detection and intervention for mental health and cardiovascular issues that contribute to more than half of maternal deaths occurring 7 to 365 days postpartum. ⁴

Incorporating parent screenings into well child checks or other appointments with postpartum patients constitutes a simple process that FM and other specialties (eg, pediatrics) can implement and is in line with recommendations from professional organizations. The American Academy of Pediatrics recommends screening patients who recently gave birth for postpartum depression during well-child checks. Again, collaboration is of essence in that workflows need to be in place for pediatricians to refer patients with positive mental health screens or concerning blood pressure. Family physicians are able to add patients to their schedules at the time of screening for any concerning findings.

Summary and Next Steps

The current maternal health crisis in the US is complex and multifaceted. Some contributing factors relate to structural issues within the nation’s healthcare system. In contrast to other developed nations, the US does not have universal healthcare, but instead, a complex multi-payer system that includes both public and private funding. Access to affordable and accessible healthcare is limited for many patients. These issues have a disproportionate impact on rural, impoverished, and minority populations who have limited access to care, receive lower quality care, and suffer worse outcomes. ⁵¹

Overall, the US spends more than other nations on healthcare, but has worse health outcomes in many areas, pregnancy care being a notable example. ⁵² Moreover, funding and Medicaid reimbursement for pregnancy care has decreased. ⁵³ Decreased funding coupled with the competition of other subspecialties, increased costs of malpractice and lifestyle and flexibility considerations have resulted in severe shortages of pregnancy care providers. Workforce shortages and how care is delivered contribute to the poor pregnancy care outcomes in the US. This complex, multi-faceted situation necessitates a multi-faceted response. This essay explored important factors related to possible responses, with a focus on the role FM can play in these responses. We discuss these factors in light of 2 important considerations. First, what is the level of control or autonomy FM has in possible responses, and second, what is the likely impact of responses on the maternal health crisis?

Enhancing Training in Pregnancy Care

Presumably, ACGME’s greater emphasis on pregnancy-care training, including a minimum requirement of vaginal deliveries and the elective track emphasizing comprehensive pregnancy care are a response to the current crisis in maternal health and dwindling participation of FM in pregnancy care. However, the impact of requirement changes remains to be seen. Whereas the new requirements may result in increased pregnancy care training for some residencies, other residencies may have already required more than 20 deliveries. Contrary to their likely intent, new requirements might result in a decrease in the amount of training in pregnancy care for some residencies. FM residencies have considerable autonomy in determining the amount and type of pregnancy care training in FM residencies. Beyond meeting ACGME requirements, residencies are constrained by what is feasible and affordable. Despite considerable control or autonomy, potential impact of increased focus on pregnancy training is unknown. There is evidence to suggest that when residents receive more training in pregnancy care they are more likely to include it in their practice.^54,55 Nevertheless, increased training is unlikely to dramatically increase the number of FM physicians providing pregnancy care.

Policy Changes

Addressing high malpractice premiums, low reimbursement rates, and difficulties in privileging could prove more effective for increasing FM participation in pregnancy care than enhanced training. A number of policy solutions have been put forth, including the creation of a national system to handle malpractice issues including setting caps on premiums and on premium price increases. In addition, APMs have been proposed as a means to improve reimbursement, and creation of a single credentialing authority to address credentialling difficulties. The likelihood of the adoption of these or other solutions is not known, neither is their effectiveness in decreasing premiums, increasing reimbursements, and fascilitating credentialing.

These solutions and other policy changes resulting in a more desirable climate in which FM physicians can provide pregnancy care could meaningfully increase the pregnancy care workforce and reduce care shortages. However, FM physicians have little control over these policy matters other than advocating for change.

Collaborative Care Models

FM adopting collaborative care models can improve the quality of pregnancy care and better leverage the existing workforce and resources. As previously discussed, the hub and spokes model and telemedicine have potential to improve access to risk appropriate, patient-centered care, including increased access to specialists. The hub and spokes model is especially well suited for FM physicians in rural areas. Any FM physician could confidently operate as a spoke providing prenatal care, knowing they have support from hub specialists. In addition, FM physicians with advanced OB training can operate as hub specialists.

The hub and spokes model and greater utilization of telemedicine could substantially improve pregnancy care. Although these models do little to increase the pregnancy care workforce, they can more effectively utilize the existing workforce and therefore have a more immediate impact. Innovative ways of incorporating telehealth services can be particularly impactful for birthing people living remotely, such as those living on reservations. FM physicians have considerable control over their participation and initiation of these models in the areas where they practice.

Improving Postpartum Care

Given the majority of pregnancy-related deaths are preventable and over half occur postpartum, enhancing postpartum care is essential. FM physicians are a key and underutilized workforce that can be further leveraged to provide comprehensive postpartum care, even among those FM physicians not currently providing delivery care. Improving postpartum care including screenings at well-child checks for the entire postpartum year is likely to reduce pregnancy-related deaths. FM physicians also have control over the postpartum care they deliver and can incorporate parent screenings into well-child check appointments immediately, with minimal effort or increased costs. For example, medical assistants could obtain parent vital signs during well child checks.

Conclusion

There are no easy answers to complex questions. However, FM is poised to play a critical role in addressing the maternal health crisis. Quantifying FM’s current contribution to pregnancy care is not easy. According to 1 estimate, FM physicians currently perform half of all rural deliveries. ¹⁶ Recent estimates also suggest that only roughly 10% of FM physicians provide pregnancy care services. ²¹ Based on these estimates, doubling the number of FM physicians providing pregnancy care is likely to meaningfully increase the availability of pregnancy care, especially in rural areas. However, our review of the issues contributing to the current crisis suggest that while increasing workforce is important, FM’s ability to do so may be limited. The added value of FM participation in pregnancy care may be their ability to provide continuity care to patients preconception, prenatal, intrapartum, and especially postpartum; and their ability to care for both birthing people and infants.

Enhanced pregnancy training for FM residents may have modest direct effects and may encourage more FM residents to include pregnancy care in practice. Policy changes reducing the costs and increasing the benefits of providing pregnancy care would have a high impact on reducing care shortages. Family physicians can be powerful catalysts for change in advocating for these policy improvements. Additionally, adopting collaborative care models and improving postpartum care are likely to have high impacts on the maternal health crisis and are within the capability and scope of work of FM physicians. Resources and efforts will be most effectively focused on these areas of potentially high impact that are well within the control of FM physicians.