By Toussaint Mears-Clarke, MD, MBA, Dignity Health Methodist Hospital of Sacramento, Sacramento, CA; Glenn Gookin, MD, PhD, Sierra Nevada Memorial Hospital, Grass Valley, CA; Annabelle Kraus, MD, Dignity Health Methodist Hospital of Sacramento, Sacramento, CA; Sarah Chaffin, MD, Dignity Health Methodist Hospital of Sacramento, Sacramento, CA

Background

Obstetricians provide the majority of maternal care in the United States. However, retention of these providers is concentrated in urban areas.¹ Specialist scarcity in rural communities has resulted in limited health care access and poorer health outcomes for patients, particularly women.² Alarmingly, these disparities are magnified for marginalized communities—such as women of color, individuals with disabilities, immigrants, and patients with non-heteronormative gender identities and sexual orientations—who often receive lower-quality health care.³

A diverse workforce to care for vulnerable obstetric populations is essential to promoting justice and equity within the health care system. In the United States, family medicine (FM) physicians have led the charge in caring for rural and underserved communities.¹ However, there is a shortage of FM physicians providing obstetric services. This deficit is projected to increase and, without intervention, will outpace the demand for women’s health care in rural regions.² ⁴

To address this gap and increase the number of family physicians trained to deliver obstetric care in rural and underserved communities, our hospital system applied for the Health Resources and Services Administration Primary Care Training and Enhancement–Community Prevention and Maternal Health grant. The grant supported a multifaceted approach to recruiting and retaining FM physicians committed to full-spectrum care, particularly in rural areas with high obstetric need.

Our objectives included developing partnerships among academia, primary care delivery sites, and community-based organizations to launch one of the few obstetrics fellowships for FM physicians in California and to significantly advance the obstetrics training, skills, and confidence of 24 existing urban FM residents. Fortuitously, implementation of this approach coincided with the creation of a new rural training program. Integrating 2 additional FM residents—already passionate about rural health care—into this rigorous obstetric training curriculum further strengthened the program’s objective: to broaden FM scope of practice in maternity care and create a sustainable pathway for FM physicians to serve in rural and underserved communities.

Intervention

The obstetric educational initiatives—including the Family Medicine Obstetrics Fellowship and the creation of an OB Track for FM residents—were implemented within 2 FM residency programs in Sacramento and Grass Valley, California. Collaborations were established with local perinatologists; Reproductive Health Education in Family Medicine programs (to provide opt-in abortion training); pelvic physical therapists; Title V programs; urogynecologists; obstetric hospitalist groups; private obstetrics and gynecology practices; and federally qualified health centers to provide education and oversight for learners.

Point-of-care ultrasound training was incorporated through the Butterfly Network and SonoSim platforms.

The fellowship began in July 2021, and the OB Track launched in the 2023 academic year. Both positions were application-based and employed place-based education as a strategy to recruit and retain physicians with an understanding of social determinants of health and a commitment to serving rural and underserved populations.⁶

Evaluation

As part of the project, the hospital system supported the development of a new rural FM residency training program designed to foster an environment in which family physicians could provide obstetric and inpatient care. At the project’s inception, as in many hospitals, no FM physicians were providing inpatient or obstetric services.⁷ The new residency program—combined with the fellowship and OB Track—created a pathway for FM physicians to practice inpatient and obstetric medicine in both urban and rural settings.

Graduates of the fellowship now provide full-spectrum FM in rural and urban underserved academic settings. Obstetric training at the urban site has expanded significantly, and the rural residency program has enrolled its third class.

Sustainability of the fellowship program beyond the grant period depends on strategic relationship-building with executive leadership, integration into the hospital’s graduate medical education funding and liability structures, and formal evaluation conducted in partnership with the American Academy of Family Physicians Residency Program Solutions consultation service. Continued demonstration of the fellowship’s value in physician recruitment and retention, enhancement of obstetric care, support of OB hospitalist teams, and cost containment further supports its long-term viability.

Additionally, a partnership with a private hospital-affiliated obstetrics group has secured funding in exchange for clinical service from the fellow, who practices as a family physician.

Conclusion

Maternal mortality and morbidity are rising in the United States and disproportionately affect rural and underserved populations.⁸ ⁹ The shortage of obstetricians in rural communities exacerbates barriers to care. The program’s initiatives offer a robust pathway for family physicians trained in obstetric care to help close the widening gap in the health care system (Table 1).

Table 1

Health systems that invest in primary care realize lower costs, higher patient satisfaction, decreased mortality, and improved quality of care.¹⁰ This program is committed to training primary care physicians capable of reducing health care costs while improving outcomes for underserved populations, enhancing access not only to obstetric care but to comprehensive family care beyond the parent-newborn dyad.

References

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2. American College of Obstetricians and Gynecologists. Health Disparities in Rural Women. ACOG. February 2014. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/02/health-disparities-in-rural-women
3. Backes EP, Scrimshaw SC. Systemic Influences on Outcomes in Pregnancy and Childbirth. National Academies Press; 2020. https://www.ncbi.nlm.nih.gov/books/NBK555488/
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8. Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System. CDC. February 4, 2020. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm#trends
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