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Obstetric care for rural, underserved communities-Are we meeting our mission? University of Alabama Family Medicine Obstetrics Fellowship: 1986 to 2018

Daniel M Avery

University of Alabama, Tuscaloosa, AL, USA

Marion D Reed

University of Alabama, Tuscaloosa, AL, USA

John McDonald

University of Alabama, Tuscaloosa, AL, USA

Catherine Skinner

University of Alabama, Tuscaloosa, AL, USA

DOI: 10.15761/COGRM.1000263

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Abstract

Background: The University of Alabama Family Medicine/Obstetrics Fellowship in Tuscaloosa, Alabama was one of the first such training programs in the United States. This study updates the original study on success of the fellowship published in 2013.

Methods: Information on each graduate was obtained from The University of Alabama College of Community Health Sciences Department of OB/GYN records. Practice information was obtained from the internet by Google Search Engine.

Results: All but one of the 24 graduates (96%) have practiced obstetrics. Some 20 graduates (83%) have practiced in a rural area. Fourteen of the 24 (58%) are still practicing obstetrics in a rural area. Fifteen (63%) have practiced in Alabama. Seventeen graduates (71%) are still practicing at their original site.

Discussion: This study reports a high success rate of placing family medicine obstetrics graduates in rural, underserved areas and practicing there long term. Family medicine physicians trained in obstetrical and newborn care is one of the answers to reducing maternal and perinatal morbidity and mortality in rural areas of this country.

Introduction

The University of Alabama Family Medicine Obstetrics Fellowship was founded in 1986 by Dr. Paul Mozley, then professor and chair of obstetrics and gynecology at the College of Community Health Sciences at The University of Alabama in Tuscaloosa, Alabama [1,2]. The one-year training program included high risk obstetrics, operative deliveries including cesarean sections and outpatient and office gynecology. Obstetrics fellowships were designed to augment the obstetrics skills already obtained during family medicine residency training. Reports of fellowship outcomes in the literature are very limited. The outcomes of the University of Alabama Family Medicine Obstetrics Fellowship were reported in 2013 [1]. This paper is an update on progress of our graduates and addresses the question: Are we meeting our mission to provide obstetrics care to rural, underserved communities?

Long-term family medicine/obstetrics experiences are critical to attracting family physicians to training programs and to practice in rural, underserved communities. However, outcomes studies of family medicine obstetrics physicians are few. The first and longest study was published by Rodney in 2010 which looked at graduation, service location, hospital privileges, retention and career changes [3]. The response rate was 100%, 93% completed the fellowship, 96% obtained cesarean section privileges, 64% practiced in a rural area for at least 2 years and 61% of the graduates were still delivering babies [1,3]. In Pecci’s study of 165 graduates, 44% of fellowship graduates practiced in rural areas and 66% obtained cesarean section privileges [1,4].

The number of physicians overall practicing obstetrics, especially in rural areas continues to decline [2]. According to Rayburn, half of the counties in the United States have no obstetrical provider leaving some 10,000,000 reproductive-aged women without obstetrical care [5]. Many of these women live in rural, underserved areas where healthcare is already sparse [5]. Lack of access to rural obstetrical care has been associated with poor perinatal outcomes [1,6,7]. Family physicians providing obstetrical care has never been more important [1].  

Subjects and methods

Information on each fellow was obtained from the University of Alabama College of Community Health Sciences Department of OB/GYN records and the Family Medicine Obstetrics Fellowship Program records. Additional practice information was obtained from the internet by Google Search Engine. Records have been kept on each fellow since application, matriculation and graduation. All applicants were required to have completed an accredited family medicine residency prior to matriculation; one exception was made in which a current Family Medicine resident completed the fellowship between his second and third years of residency. Applicants were also required to hold a current unrestricted license to practice medicine in Alabama.

The Alabama Family Practice Rural Health Board funds the fellowship stipend. Matriculating fellows sign contracts to practice for one year in a rural, underserved area of Alabama with a population less than 25,000 people. The University of Alabama is the contracting agent that assures the fellow’s practice in a rural area of Alabama. Graduates may also choose employment in a training program such as a family medicine residency program to teach obstetrics to future family physicians. There are 21 physicians who completed the program in one year. One fellow’s stipend was funded by his hometown hospital in another state in return for practicing there at the conclusion of his fellowship training. One practicing family physician completed the fellowship full time while practicing family medicine part time. He did not receive a stipend but was insured by the medical school malpractice trust fund. Two physicians completed the fellowship in two years each.

Fellows receive a teaching appointment at the University of Alabama School of Medicine at the rank of Instructor. Fellows are Family Medicine faculty members and receive active staff family medicine privileges at the DCH Regional Medical Center in Tuscaloosa, Alabama. Fellows precept residents in the family medicine clinics one afternoon a week. Fellows who graduate and wish to teach medical students and residents in their practice receive an adjunct faculty appointment. Half of the graduates have taught residents and/or medical students in their practice. One graduate became an assistant dean and another an associate dean at medical schools. The first graduate of the fellowship in 1988 remained with the College of Community Health Sciences as an OB/GYN faculty member.

The obstetrics fellowship is advertised on the American Academy of Family Physicians website list of available obstetrics fellowships. The fellowship is also listed on the recognized obstetrics fellowships for the Board of Certification in Family Medicine Obstetrics of the American Board of Physician Specialties in Tampa, FL. Curriculum, education and training follow the guidelines of the Board of Certification of Family Medicine Obstetrics. The UA institutional mission is to train family physicians to practice full service, high risk obstetrics including cesarean section and instrumental deliveries to be able to practice independently in a rural and often remote setting.

Results

Over the past 32 years, 26 physicians have been selected to be family medicine obstetrics fellows. Two fellows who matriculated in the 2018-2019 academic year are still in training as of 2019. Twenty-four fellows have matriculated and 23 (96%) completed training (Table). One who began the program transferred to another program mid-year, completed the training year and has practiced obstetrics. Ten of the 24 fellows were female and 14 were male. Seventeen graduates completed family medicine residency training at the UA Family Medicine Residency (71%); seven fellows trained at other residency programs (29%). One physician had entered practice and returned to pursue fellowship while practicing family medicine part-time. One physician did fellowship training between his 2nd and 3rd year of residency. Two physicians spent 2 years each in training.

Graduates have practiced in Alabama, South Carolina, North Carolina, Mississippi, Texas and Oklahoma. Graduates have also practiced outside the U.S. in Canada and Lebanon. Twelve graduates (50%) have participated as faculty and taught residents and/or medical students. One graduate has become an associate dean of a medical school and another an assistant dean of a medical school regional campus.

All physicians (100%) who have completed the fellowship have practiced family medicine. All but one physician practiced obstetrics (96%). One physician only provided prenatal care in a rural area. Twenty-two of the 24 graduates obtained cesarean section privileges after completing the fellowship and entering practice (92%). Of those 23 who practiced obstetrics, 14 are still practicing rural obstetrics today (58%). Twenty practiced in a rural area (83.3%) and 18 are still practicing rural (75%). Of the two who no longer practice in a rural area, one moved to another part of the state and practices family medicine and one left clinical medicine altogether. Fifteen graduates have practiced in Alabama (63%). Seventeen physicians still practice at their original site (71%).

Discussion

This study updates the outcomes for one of the oldest family medicine obstetrics fellowships, originally reported in 2013. This program has been in existence for 32 years. Seventeen physicians have practiced in their same site and 14 are still practicing rural obstetrics. Although the numbers are smaller than numbers reported by Rodney [3] and Pecci [4], this study reports a high success rate of placing family medicine obstetrics graduates in rural, underserved areas even when there is a contract to practice in a rural, underserved area of Alabama for a year (Table 1). It may be that satisfaction and success practicing in a rural area of Alabama for one year may be important in practicing their long term. One success of the fellowship has been family physicians and obstetrician/gynecologists working together often in an integrated practice to provide rural care at the College of Community Health Sciences.

Table 1. Practice Information for Graduates 1974-2018

24 physicians matriculated & 23 graduated1

 96%

All 24 graduates practiced Family Medicine

100%   

23 graduates practiced obstetrics2

 96%

14 are still practicing obstetrics

 58%

22 obtained cesarean section privileges

 92%

20 practiced in a rural area

 83%

18 are still practicing in a rural area

 75%

14 are still practicing rural obstetrics

 58%

12 have taught residents & medical students

 50%

15 have practiced in Alabama

 63%

17 have practiced at the same site

 71%

1 stayed at UA & became OB/GYN faculty

 

1One physician changed to another program and graduated

2One physician only provided prenatal care

Conclusion

Updated statistics reveal that fellowship trained Family Medicine/Obstetrics physicians continue to choose rural communities and are successful in obtaining cesarean section privileges. Family medicine physicians trained in obstetrical and newborn care is one of the answers to reducing maternal and perinatal morbidity and mortality in rural, underserved areas of Alabama and the United States–Avery (2003).

References

  1. Avery DM, Marshall E, Hooper DE, Parton JM (2013) University of Alabama Family Medicine Obstetrics Fellowship, 1986-2012: Results and Outcomes. J Fam Med Ob 7(1).
  2. Avery DM, Paul David Mozley, MD, FACOG, FACS, FAPA—Founder of Obstetrics Fellowships in the United States.
  3. Rodney WM, Martinez C, Collins M, Laurence G, Pean C, et al. (2010) OB fellowship outcomes 1992-2010: where do they go, who stops delivering, and why? Fam Med 42: 712-716. [Crossref]
  4. Pecci CC, Leeman L, Wilkinson J (2008) Family medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med 40: 326-332. [Crossref]
  5. Rayburn WF, Klagholz JC, Murray-Kregan C, Dowell LE, Strunk AL (2012) Distribution of American Congress of Obstetricians and Gynecologists fellows and junior fellows in practice in the United States. Obstet Gynecol 119: 1017-1022. [Crossref]
  6. Cohen D, Coco A (2009) Declining trends in the provision of prenatal care visits by family physicians. Ann Fam Med 7: 128-133. [Crossref]
  7. Powell JT, Skinner CA, Lavender PD, Avery DM, Leeper JD (2018) Impact of rural family medicine/obstetric care on the infant mortality rate in rural Alabama. J Am Bd Fam Med 31: 542-549.

Editorial Information

Editor-in-Chief

John Livingston Powell
University of North Carolina School of Medicine
USA

Article Type

Research Article

Publication history

Received date: August 31, 2019
Accepted date: September 10, 2019
Published date: September 13, 2019

Copyright

©2019 Avery DM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Avery DM, Reed MD, McDonald J, Skinner C (2019) Obstetric care for rural, underserved communities-Are we meeting our mission? University of Alabama Family Medicine Obstetrics Fellowship: 1986 to 2018. Clin Obstet Gynecol Reprod Med 5: DOI: 10.15761/COGRM.1000263

Corresponding author

Daniel M Avery

University of Alabama, Tuscaloosa, AL, USA

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Table 1. Practice Information for Graduates 1974-2018

24 physicians matriculated & 23 graduated1

 96%

All 24 graduates practiced Family Medicine

100%   

23 graduates practiced obstetrics2

 96%

14 are still practicing obstetrics

 58%

22 obtained cesarean section privileges

 92%

20 practiced in a rural area

 83%

18 are still practicing in a rural area

 75%

14 are still practicing rural obstetrics

 58%

12 have taught residents & medical students

 50%

15 have practiced in Alabama

 63%

17 have practiced at the same site

 71%

1 stayed at UA & became OB/GYN faculty

 

1One physician changed to another program and graduated

2One physician only provided prenatal care