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Association of Group Prenatal Care in US Family Medicine Residencies With Maternity Care Practice: A CERA Secondary Data Analysis

Wendy B. Barr, MD, MPH, MSCE; Sebastian T. Tong, MD, MPH; Nicholas M. LeFevre, MD

Background and Objectives: Group prenatal care has been shown to improve both maternal and neonatal outcomes. With increasing adaption of group prenatal care by family medicine residencies, this model may serve as a potential method to increase exposure to and interest in maternity care among trainees. This study aims to describe the penetration, regional and program variations, and potential impacts on future maternity care practice of group prenatal care in US family medicine residencies.

Methods: The CAFM Educational Research Alliance (CERA) conducted a survey of all US family medicine residency program directors in 2013 containing questions about maternity care training. A secondary data analysis was completed to examine relevant data on group prenatal care in US family medicine residencies and maternity care practice patterns.

Results: 23.1% of family medicine residency programs report provision of group prenatal care. Programs with group prenatal care reported increased number of vaginal deliveries per resident. Controlling for average number of vaginal deliveries per resident, programs with group prenatal care had a 2.35 higher odds of having more than 10% of graduates practice obstetrics and a 2.93 higher odds of having at least one graduate in the past 5 years enter an obstetrics fellowship.

Conclusions: Residency programs with group prenatal care models report more graduates entering OB fellowships and practicing maternity care. Implementing group prenatal care in residency training can be one method in a multifaceted approach to increasing maternity care practice among US family physicians.

(Fam Med 2017;49(3):218-21.)

Family physicians have traditionally played an important role in providing access to maternity care in many parts of the United States. Family physicians are ideally suited to provide maternity care due to their comprehensive training in providing care to patients of all ages and with every disease entity.1-3 However, maternity care provision by family physicians has dramatically declined in recent years, dropping from 23.3% in 2000 to 9.7% in 2010.4 This decline particularly endangers access to maternity care services in rural and urban underserved areas5,6 since few obstetrician/gynecologists choose to practice in these areas.7

Several studies have explored group care models and maternity care curriculum development as means to increase the number of family physicians providing maternity care.8-10 Meanwhile, group prenatal visits are emerging as a care model that is associated with improved maternity care outcomes11,12 and enhanced resident education.13 To date, there have been no comprehensive studies looking at the current implementation and impact of group prenatal care in family medicine training.14 The study by Sutter et al, which describes the original analysis of this CERA survey on maternity care training, includes group prenatal care as one of several factors that are associated with resident likelihood to practice maternity care. However, it did not specifically address the impact of participation in group prenatal care on future maternity care practice.10

The objective of this study is to (1) describe the current penetrance of group prenatal visits in family medicine residencies and (2) explore for associations between group prenatal care experiences in residency and resident performance of maternity care at graduation. Group prenatal care models the patient-centered, holistic approach of family medicine and, if participation were shown to be associated with increased future maternity care practice, could be advocated as an intervention to increase family physician maternity care provision.

 

Methods

 
 

Data was obtained from the publicly available Council of Academic Family Medicine Educational Research Alliance (CERA) Data Clearinghouse. CERA conducts biannual cross-sectional surveys of all US family medicine residency program directors. The first of two 2013 CERA omnibus surveys included specific questions on maternity care. In this survey, all 445 US family medicine residency program directors received an email invitation to participate in the survey in August 2013 followed by two email reminders prior to the survey closing in October 2013. The data was made publicly available in May 2014 on the Society of Teachers of Family Medicine website.

The survey’s maternity care section included a question on how residents are involved in prenatal care with “Residents participate in group prenatal visits” as one of the selection options. Chi-square tests were used to determine the demographic penetrance of resident participation in group prenatal care. Then, controlling for number of vaginal deliveries per resident, a logistical regression was completed to assess for associations of group prenatal care with residency program graduates’ maternity care provision.

The project was approved by the American Academy of Family Physicians’ Institutional Review Board.

 

Results

 
 

The CERA residency program directors’ survey had an overall response rate of 56.40% (251/445) with 95.22% of respondents or 53.71% of the overall sample (239/445) answering the question about prenatal group care provision by family medicine residents. 24.3% of family medicine residency programs reported resident participation in group prenatal visits. Residency program setting (community based, university administered, university based, or military), community size and residency program geographic region did not show statistically significant differences in penetrance of group prenatal care models, although there is a trend for higher penetrance in the Northeast (Table 1).

 

Table 1
 

Programs with group prenatal care reported an increased number of vaginal deliveries per resident (P=.04) with 27.59% having more than 80 deliveries per resident versus 13.83% in programs without group prenatal care. Group prenatal care programs also trended toward more continuity deliveries (P= .30) (Table 2). After controlling for average number of vaginal deliveries per resident, there is a 2.35 higher odds of more than 10% of graduates practicing obstetrics (P<.01) and a 2.93 higher odds of having at least one graduate enter an obstetrics fellowship in the past 5 years (P<.01) in programs with resident participation group prenatal care (Table 3).

 

Table 2
 
Table 3

 

 

Discussion

 
 

This study is the first to demonstrate that participation in prenatal group care during residency is associated with increased future maternity care practice. This association remains significant after controlling for increased vaginal delivery volume during residency, reducing the likelihood that residency obstetric volume confounds the association between prenatal group care and future maternity care practice. As such, in addition to efforts to restructure residency obstetric curriculum,8 implement tiered obstetric training pilots,15 and advocate for reducing legal and logistical barriers, implementation of group prenatal visits in residency programs may be another method in a multifaceted approach to increasing maternity care practice.

There are several limitations to this study. The CERA survey had a limited response rate (53.71%) although the results appear to be well distributed across residency practice settings and geographic region. Surveying program directors may also result in inaccuracy since some program directors may misreport resident participation in group visits and may be estimating graduates’ maternity care practice. Given the phrasing of the survey question, residents may have had varying experiences in group prenatal care, from shadowing to leading groups. Furthermore, the cross-sectional nature of this study means that part of the association between group prenatal care and increased maternity care practice could be spurious; for example, medical student applicants who are more interested in obstetrics may be more likely to select programs that offer group prenatal care in their residency practices.

While this study lays the foundation in showing an association between resident participation in group prenatal care and maternity care provision, further studies will need to elucidate any causation between these two factors. Furthermore, as prenatal group care is more widely implemented, a longitudinal study may help determine if those who are exposed to group prenatal care in residency continue to practice maternity care throughout their careers in family medicine.

Acknowledgments: This paper was presented at the 2015 North American Primary Care Research Group Annual Meeting, Cancun, Mexico.

The authors would like to thank the CAFM Educational Research Alliance for collecting the survey data and making raw data available. The authors would also like to thank Camille Hochheimer at Virginia Commonwealth University for assisting with data analysis.

Corresponding Author: Family Medicine Residency, Greater Lawrence Family Health Center, 34 Haverhill Street, Lawrence, MA 01841. 917-701-1507. Fax: 978-687-2106. wbarr@glfhc.org., 34 Haverhill Street, Lawrence, MA 01841. 917-701-1507. Fax: 978-687-2106. wbarr@glfhc.org.

 

References

 
 
  1. American Academy of Family Physicians. Family medicine, definition of (2010). http://www.aafp.org/about/policies/all/family-medicine-definition.html. Accessed July 14, 2015.
  2. Chen FM. Prepared but not practicing: declining pregnancy care among recent family medicine residency graduates. Fam Med 2006;38(6):423-6.
  3. Barr WB. Why pregnancy care should be an essential part of family medicine training. Fam Med 2005;37(5):364-6.
  4. Tong ST, Makaroff LA, Xierali IM, Puffer JC, Newton WP, Bazemore AW. Family physicians in the maternity care workforce: factors influencing declining trends. Matern Child Health J 2013;17(9):1576-81.
  5. Rosenthal TC, Holden DM, Woodward W. Primary care obstetrics in rural western New York. A multi-center case review. N Y State J Med 1990;90(11):537-40.
  6. Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG. Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use. Am J Public Health 1997;87(1):85-90.
  7. Barbieri RL. Geographic distribution of obstetric and gynecology resident training positions. Obstet Gynecol 2004;103(6):1317-20.
  8. Helton M, Skinner B, Denniston C. A maternal and child health curriculum for family practice residents: results of an intervention at the University of North Carolina. Fam Med 2003;35(3):174-80.
  9. Koppula S, Brown JB, Jordan JM. Experiences of family physicians who practice primary care obstetrics in groups. J Obstet Gynaecol Can 2011;33(2):121-6.
  10. Sutter MB, Prasad R, Roberts MB, Magee SR. Teaching maternity care in family medicine residencies: what factors predict graduate continuation of obstetrics? A 2013 CERA program directors study. Fam Med 2015;47(6):459-65.
  11. Ickovics JR, Hershaw TS, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol 2007;110(2 Pt 1):330-9.
  12. Barr WB, Aslam S, Levin M. Evaluation of a group prenatal care-based curriculum in a family medicine residency. Fam Med 2011;43(10):712-7.
  13. Page C, Reid A, Andrews L, Steiner J. Evaluation of prenatal and pediatric group visits in a residency training program. Fam Med 2013;45(5):349-53.
  14. Redding N. Retraining family physicians to deliver our babies. Can Fam Physician 2015;61(1):15-6.
  15. Coonrod RA, Kelly BF, Ellert W, Loeliger SF, Rodney WM, Deutchman M. Tiered maternity care training in family medicine. Fam Med 2011;43(9):631-7.

From Lawrence Family Medicine Residency, Tufts University (Drs Barr and LeFevre); and Virginia Commonwealth University (Dr Tong).


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