Clinical Obstetrics, Gynecology and Reproductive Medicine Family physicians providing rural obstetric care makes good business sense

Family physicians practicing rural obstetrics makes great business sense. Obstetrical complications and outcomes for family physicians are comparable to those of OB/ GYN’s. The cost of malpractice insurance for family physicians who offer full service obstetrical care in Alabama is significantly less than for an OB/GYN. Family physicians can offer comparable obstetrical care to OB/GYN’s at a fraction of the cost. Family Physicians who practice obstetrics are almost never sued because of their long-term relationship with the patient and family. Family physicians have lower cesarean section rates than OB/GYNs primarily because they perform more vaginal births after cesarean sections (VBAC) which translate into shorter hospital stays, fewer complications, less expensive care, fewer operative risks and hopefully, happier patients.


Introduction
The availability of obstetrical care has decreased in countries worldwide including the United States [1]. The greatest need for obstetrical care is in rural, underserved areas of this country where the shortage is the most dramatic [2]. Rayburn's 2012 Obstetrics & Gynecology article states that almost half of the counties in the United States have no access to obstetrics providers, affecting some 10,000,000 reproductive-aged women aged 15 to 45 in 1,500 counties [2,3]. Most of these women live in rural, underserved areas which already face a great need for healthcare including obstetrics [3]. This lack of obstetric providers further contributes to the already high maternal and perinatal morbidity and mortality in rural areas [3,4]. Lack of obstetric care in rural areas translates into poor perinatal outcomes, poor access to care, more complications and more expensive care [5].

Family physicians practice in rural areas
Most family medicine obstetrics graduates practice in rural areas. Family physicians are more versatile and can see a larger variety of patients and conditions than a group of OB/GYN's. Family physicians are often the only obstetrics providers in rural areas [6]. Most graduating chief residents in OB/GYN practice in larger urban areas and rarely practice in small towns or rural, underserved areas. This contributes to the maldistribution of OB/GYNs in this country and further diminishes the number of rural obstetrics providers [3]. Family physicians practicing in rural areas mitigate this maldistribution of providers [7]. Obstetrician/gynecologists who go to small towns or rural areas to practice seldom stay very long because of the lifestyle, limited reimbursement and education for children and usually leave once prior commitments are satisfied [2]. OB/GYN residency graduates who choose to practice in large cities and those who pursue subspecialty fellowships and never practice general OB/GYN further exacerbate the shortage in rural, underserved areas.

Fewer Obstetrician/Gynecologists practice general OB/GYN
Less than half of graduating OB/GYN residents practice general OB/GYN as many pursue subspecialty fellowships, hospital medicine as laborists, and research and academic medicine [1]. The number of OB/GYN Residencies has decreased from 306 to 246 since 1993 [8]. Currently, there are no plans to increase that number [8]. In addition to the difficulty in finding sufficient teaching material, obtaining new Center for Medicare and Medicaid Services (CMS) funding for a new, non-primary care residency would be a formidable task. The overall number of Obstetrician/Gynecologists is decreasing [2]. The attrition rate of retiring Obstetrician/Gynecologists approximates the number of graduating OB/GYN residents [8]. While obstetrician/gynecologists stop delivering babies for a variety of reasons, the most common reason by far is malpractice litigation [2].

Family physicians are trained in obstetrical care
Obstetrics is part of Family Medicine Residency training, Family Medicine practice and the Patient Centered Medical Home [9]. Some Family Medicine graduates will practice full service obstetrics, some will only provide prenatal care, others will pursue an obstetrics fellowship, and most graduates will not practice obstetrics, at all. Various components of obstetrics care may be included in a number of different residencies, but only obstetrician/gynecologists and family physicians are trained to perform the full spectrum of obstetrical care including prenatal care, vaginal deliveries, cesarean sections, resuscitation of the newborn, and postpartum care [2]. In 2018, most family physicians who practice obstetrics will have completed an obstetrics fellowship. Some will have become certified by the Board of Certification in Family Medicine/Obstetrics [10].

Family physicians are almost never sued
Family physicians including those who practice obstetrics are almost never sued [9]. Family physicians usually care for whole families and have strong, long term relationships with them, not just for the term of the pregnancy. There is a stigma of suing a "town doctor" in a small town. People are concerned that their family physician could leave and the town would be without medical care. In our studies comparing outcomes of OB/GYNs and Family Physicians who delivered some 14,576 babies, no suits were brought against family physicians [7]. The hospital would not disclose the number of suits against OB/GYNs for the same period and study group [7].

Cost of malpractice insurance is less for family medicine
The cost of malpractice insurance for family physicians who offer full service obstetrical care in Alabama is often quoted by providers to be one-third to half of the rate for an OB/GYN. This is due, in part, to the fact that family physicians who practice obstetrics are rarely sued because of the relationship between patients and their primary care physicians. Obstetrician/gynecologists are in the highest risk category, while Family Physicians practicing full service obstetrics are in one of the lowest risk categories [1].

Reimbursement for OB/GYN Care is the same regardless of specialty
Physician reimbursement for total obstetrical care including vaginal delivery or cesarean section, postoperative care and postpartum care are the same for Obstetrician/gynecologists and family physicians practicing obstetrics. Minor outpatient (such as dilatation and curettage, bilateral tubal ligation) and office gynecologic procedures (such as colposcopy and cervical biopsy and intrauterine device placement) are also reimbursed at the same rate. There are financial benefits of rural practice from Medicaid that are also unrelated to specialty. In Alabama, for instance, physicians living and practicing in rural areas do not pay state income tax for the first five years of practice [2].

Outcomes are the same for OB/GYNs and family physicians
Both our research and that of others demonstrate that the obstetric outcomes for obstetrician/gynecologists and family physicians practicing obstetrics are similar. Obstetrician/gynecologists and family physicians practicing obstetrics have similar rates of delivery complications studied except for fourth degree extensions of episiotomies, cervical lacerations and transfusions which were higher for family physicians [11]. The research literature shows that the maternal and perinatal outcomes of family physicians and obstetrician/ gynecologists are the same [12]. In our study of neonatal outcomes of 26,331 infants delivered by obstetrics fellowship trained family physicians and OB/GYNs, the neonatal outcomes were comparable [13].

Family physicians practicing obstetrics have lower cesarean section rates
In our 2013 study, family physicians had lower cesarean section rates than OB/GYN's (30.8% for family physicians vs 39.0% for obstetrician/ gynecologists) in part, because family physicians do more vaginal births after cesarean section than obstetrician/gynecologists (18.31% for family physicians vs 4.30% for obstetrician/gynecologists [7]. Lower cesarean section rates translate into less surgery, fewer complications, shorter hospital stays and less expensive care [7]. In Berman's study, the cesarean section rate for family physicians was 12.9% compared to 20.2% for obstetricians [14]. Instrumental deliveries (15.69% vs 8.76%) and transfusion rates were higher for family physicians (2.32% vs 1.38%) [11]. Babies delivered by family physicians are more likely to be delivered vaginally [12], thus contributing to lower rates of cesarean sections [12].

Family medicine is a second pathway for practicing obstetrics
Obstetrics and Gynecology remains a competitive residency that easily fills during the Match (National Resident Matching Program).  [15], while OB/GYN programs are not [8].

FM/OB fulfills the alabama medical scholarship loan program
Family Medicine and Family Medicine/Obstetrics practice fulfills the loan repayment program of the Alabama Medical Scholarship Program; OB/GYN, however, does not even in underserved areas.

Family medicine residencies and residency positions are increasing
Family Medicine is the only residency that is increasing in this country [10,16]; OB/GYN is not (9). OB/GYN residencies have decreased from 306 to 246 over the last 20 years and there is no plan to increase them [17].

Family medicine obstetrics fellowships are increasing
Currently, 40 Family Medicine/Obstetrics Fellowships are advertised on the AAFP website [17]. Some 42 fellowships are listed on the American Board of Physician Specialties website [10].

Family medicine obstetrics board certification & surgical competency testing
Board certification in any specialty is imperative today. The Board of Certification in Family Medicine Obstetrics was created in 2005 by the American Board of Physician Specialties to certify family physicians who have completed obstetrics fellowships [10]. The examination consists of a case list of cesarean section deliveries, a written examination, an oral examination and an onsite, visualized documentation of surgical competency. This board was one of the first to include surgical competency testing. Board certification in Family Medicine Obstetrics has enabled obstetrics fellowship graduates to Medicine Residents are trained in Obstetrics than OB/GYN [1]. Practicing obstetrics may make family medicine more attractive financially [1]. For a medical student who wants to deliver babies, it may be easier to matriculate into a Family Medicine Residency than an OB/ GYN Residency. It makes great business sense for Family Physicians to provide rural obstetrical care.
Family medicine physicians trained in obstetrical and newborn care is the answer to reducing maternal and perinatal morbidity and mortality in rural, underserved areas of this country (Avery, 2003).
obtain full service obstetrics privileges in many hospitals, especially among institutions in larger cities.

More family medicine residents are trained in obstetrics than OB/GYN residents
More Family Medicine residents are trained in obstetrics each year than OB/GYN residents based on the number of residency programs of each as discussed above. There are nearly twice as many Family Medicine Residencies as OB/GYN [1]. There are 246 OB/GYN Residencies and 477 Family Medicine Residencies [1]. Obstetrics makes family medicine more attractive financially Fewer medical students are choosing family medicine as a residency and career [18]. The average debt at graduation at our state medical school is reported as $200,000. Debt from private medical schools may even be higher. Despite interest in primary care and family medicine, and interest in and a commitment to return to rural areas to practice family medicine obstetrics, medical students today are choosing specialties that will help them defray significant educational debt [1]. With delivery and surgery reimbursements, Obstetrics may make Family Medicine more attractive financially [1].

Integrated OB/GYN and FM/OB call and practices
Today, many obstetrician/gynecologists work with and share call with FM/OB's. Occasionally OB/GYNs back up FM/OBs or take unattached gynecologic call for a hospital while FM/OB's take unattached OB call. Often, they scrub together for difficult cesarean sections. An OB/GYN may "scrub in" with a FM/OB if a cesarean hysterectomy or laparotomy for bleeding is needed. FM/OB's are better trained than OB/GYNs at managing medical complications of pregnancy as a result of their broader training in adult medicine. Some practices, including the medical school where the authors practice, employ both OB/GYN's and FM/OB's who collaborate frequently and take call together. Much is to be gained by working together rather than competing.

Discussion
Family Physicians nationwide provide high quality pregnancy care. Since 1970, the number of physicians delivering babies has been decreasing. Family Medicine Physicians are trained to practice obstetrics [9]. Most family medicine physicians who practice obstetrics go to rural areas. Family physicians practicing obstetrics are almost never sued [9] and therefore their malpractice insurance is one third to one half of what Obstetrician/Gynecologists pay for coverage. Reimbursement for care is the same for both specialties. Family physicians practicing obstetrics have lower cesarean section rates because they perform more VBAC's (vaginal birth after cesarean sections) [7]. Outcomes for both specialties are similar [12], Family medicine is a second pathway for medical students to train in obstetrics since there are twice as many Family Medicine Residencies compared to OB/GYN [1]. Family Medicine and Family Medicine Obstetrics practice in underserved areas fulfil the Alabama Medical Scholarship Loan obligations while OB/GYN does not.
Family Medicine Residencies and Family Medicine Obstetrics Fellowships are increasing are increasing [9,10,17]. Because there are more Family Medicine Residencies than OB/GYN, more Family