AAFP Delivering on Maternity Care Training, Resources
I recently had the privilege of attending the Family Centered Maternity Care (FCMC) course in Madison, Wis. Just before I left home for the meeting, I was contacted by a family physician who was having difficulties obtaining privileges for operative obstetrics. Although this physician's identity must remain confidential, the story highlights the important role of family physicians who perform obstetrical care and the resources the AAFP has to help those in similar situations, which I will describe later in this post.
I won't recap the whole conference here, but there are some highlights I can't resist sharing. The location of this year's event was chosen to recognize the 25th anniversary of the Advanced Life Support in Obstetrics (ALSO) program. It was the brainchild of Jim Damos, M.D., and John Beasley, M.D., who were members of the University of Wisconsin Department of Family Medicine faculty when they created the course in 1991 to help rural family physicians maintain critical skills in obstetrical care. The AAFP took over the course in 1993, and it has become an important fixture in the training of family medicine residents in the United States, as well as that of an increasing number of practicing maternity care providers in all medical specialties, maternity care nursing staff and, in many hospital settings, all members of the maternity care team.
ALSO is one of the AAFP's most successful international programs, with updated translations in six languages. The course has been taught to more than 160,000 maternity care providers in 60 countries, and a growing body of international research shows its impact on reducing maternal mortality and improving infant survival. U.S. family physicians who support ALSO directly as volunteer faculty or indirectly through the AAFP Foundation are international ambassadors for maternal and child health.
On the home front, the embedded teamwork training and TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) principles in the ALSO course generalize to the fundamental team concepts on which the patient-centered medical home is built. This training can support the role family physicians can and must play in setting a practice and community agenda for quality and safety, and in leading teams delivering high-quality, high-value care.
There were many exciting talks during the FCMC course, as well as extraordinary family physician faculty. One of the most important messages was that even if we do not provide maternity care in our practices, addressing patients' future childbearing plans can be a critical opportunity to set the stage for successful pregnancies. When we see women of childbearing age, we should ask the "one key question," which is, "Are you planning to become pregnant in the next year?" Nearly half of pregnancies are unintended, but every visit gives us the opportunity to do preconception planning or offer birth control.
Finally, back to the challenging question on privileges for cesarean delivery.
We know that the percentage of our members who provide maternity care services and perform deliveries is falling overall, with less than 20 percent of members reporting that they delivered at least one baby in 2014. But in many rural communities, the only maternity care providers are family physicians who provide the full spectrum of care, including operative obstetrics.
A recent study of the rural obstetric workforce by the University of Minnesota Rural Health Research Center found that for 23 percent of 244 rural hospitals in the nine states surveyed -- including many critical-access facilities -- family physicians were the only clinicians delivering babies.
The AAFP has many resources to help physicians maintain obstetrical privileges. The Academy's position paper on cesarean delivery states that credentialing and privileging decisions should rely on evidenced-based training and experience criteria. Furthermore, it states that family physicians must be full participants in interspecialty/cross-specialty privileging discussions and policy decisions at the hospital medical staff level.
We have formal relationships with the American College of Obstetricians and Gynecologists (ACOG) and the American Osteopathic Board of Obstetrics and Gynecology, and practicing family physicians represent family medicine on important interspecialty committees regarding maternity care. A large contingent of family physicians represents us at the AMA, and two ACOG representatives are voting members of our ALSO board. All of these relationships serve to improve the collaboration between our respective specialties and make it harder for anyone to create or support policies that exclude physicians from providing care where they can document appropriate training and experience.
The AAFP and ACOG have a longstanding joint statement regarding privileging. It says, in part, that the assignment of hospital privileges "should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to assure the provision of high-quality patient care."
It also says that the standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the criteria for privileges in that area of practice.
"Provisional privileges in primary care, obstetric care and cesarean delivery should be granted regardless of specialty as long as training criteria and experience are documented," the statement says. "All physicians should be subject to a proctorship period to allow demonstration of ability and current competence. These principles should apply to all health care systems."
It has been relatively rare for family physicians to take legal action regarding cesarean privileges, and those cases have not always been decided in favor of the family physician. But with each court decision, there has been significant improvement in the process of interdisciplinary privileging.
The Academy has a detailed protocol for family physicians to follow when faced with privileging issues, including when to engage their constituent chapter and how to request the AAFP's support if efforts at the local level are unsuccessful.
A 2014 study by the University of Alabama clearly shows one more benefit of family physicians offering obstetrical care. Researchers found that a family physician practicing in rural Alabama adds nearly $1.5 million to the local economy by offering such services.
Perhaps the greatest leverage we have in convincing hospitals to support obstetrical care by family physicians is to argue that not only do lifelong continuous therapeutic relationships begin with prenatal care and delivery, they extend across the growth, development and lifespan of families, and they bring economic benefits to the communities we serve.
Carl Olden, M.D., is a member of the AAFP Board of Directors.
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