Childbirth Philosophy 6: The Role of the Family Doctor

As I've been keeping up with this blog and establishing productive dialogues with natural childbirth and alternative birth practice advocates, I've been struck by the recurring statement women often make of me and the birth center where I work:  "I wish we had doctors who practice like you/hospitalist like yours where I live."  This is both flattering and alarming, because it reminds me most women don't live in areas where providers and hospitals support minimally interventions during labor and birth.  

One reason why my hospital continues to provide opportunities for natural/alternative childbirth practices is because the majority of the births are attended by midwives (two CNMs and one licensed midwife) and family doctors.  Other blogs already provide excellent advocacy for midwifery-directed childbirth care, so I'm choosing to focus on those aspects of my family practice training which have influenced my own childbirth philosophy.

According to the American Association of Family Physicians, 20.6% of family doctors provide hospital-based obstetric services.  Family doctors are more likely to provide obstetric services if they practice in the Midwest or Mountain states, and less likely if they live in the Mid-Atlantic or Southeastern states.  However, most family doctors practice low-risk obstetrics; only 4.3-6.5% practice higher-risk OB such as managing gestational diabetes, preeclampsia, or performing C-sections.  My own scope of practice occupies the middle of the spectrum because I do follow women with medical complications of pregnancy.  The point to take home is that most family doctors are trained for low-risk pregnancy, a feature they share in common with midwives.

A few other elements which distinguish family practice from OB/GYN training in childbirth:

1. Organizing principles of wellness care and prevention of illness.
2. Inclusion of routine pediatrics within the specialty reinforces the importance of healthy prenatal practices and avoidance of interventions which pose unnecessary risk to the fetus.
3. Training in behavioral medicine which emphasizes active listening and patient involvement in his or her own care.
4. Embracing a team concept in delivering maternity care.

Now, I realize some family physicians practice much more conservatively than others, so there is no guarantee a woman who receives prenatal/childbirth care from a family doctor will receive a completely non-interventive birth.  I remember one FP attending who was supervising me on an imminent delivery of a multiparous woman.  As the baby's head crowned, the heart tones dipped down into what I call an outlet deceleration, which does not--in my experience--signal a bad outcome.  My high-strung attending looked me in the eye and asked, "Have I ever told you how much I love episiotomies?"  I told him he could tell me later, and the woman went on to deliver a vigorous baby over an intact perineum.  

Practice styles vary widely depending on the kind of residency training a family doctor received as well as his or her own ability to integrate experiences and form an independent opinion.  I learned a very standard, highly interventionist practice style from my OB and FP attendings, but my own practice style is much more laid-back and very much informed by pediatric as well as obstetric training experiences.  For example, I only apply a fetal scale electrode (FSE) if I have no other choice to spare a woman the risk of a knee-jerk C-section.  The reason?  The memory of a two-week old infant I took care of when I was an intern.  He developed an abscess at the site of an FSE and had to stay in the hospital for two weeks of IV nafcillin.  Nurses who read this blog might wince at the idea of giving nafcillin to a newborn, because it is pretty hard on veins, but we did it.  The very memory of that abscess is enough to make me think twice about using an FSE if I don't have a damn good reason to do so.

One of the worries I have for my specialty is that family physicians will gradually get pushed out of providing childbirth care.  This may happen for a number of reasons:  a lot of people finish residency and decide they never want to stay up all night ever again; others will move to Florida or urban Massachusetts and practice in an area where family doctors can't get privileges to attend births; finally, the obstetrical standard of care may, on one of its pendulum swings, veer to a conservative extreme which finally excludes non-OBs from attending births.  I hope this doesn't happen because family docs have a great tradition of providing womb to tomb care, and if we stopped welcoming new people as they emerge from the womb, we will lose a lot of what makes our specialty unique.

Comments

[Theresa]

Hi Carolyn,

Good for you for providing rural care! I do not mean to imply any divide between midwives and family doctors in providing childbirth care. I actually perceive a greater potential divide between OB/GYNs and family doctors, and a strong urban bias against family doctors attending births. I'm lucky to be in a good collaborative environment with the midwives and OBs in our community.

[Carolyn McIntosh]

I am a rural midwife and midwifery educator in New Zealand. In our country family doctors used to provide most of the non obstetric maternity care and all but a very small handful have now exited from this service. There is no reason why they cannot continue to provide maternity care, they have the ability to be paid for this service (although they would rightly say not enough), and there is no legislation which opposes their practice. The decision not to provide maternity care is based on the issues you highlight here. They do not want to be on call all the time or up all night and they are not adequately paid for this if they do it. Many state as you do that it is an enjoyable and meaningful part of their practice and have slowly and reluctantly departed from this service.
Unfortunately they have often laid the blame for there withdrawal at the feet of the midwifery profession, claiming they have been forced out of practice by midwives. This has established a culture in some places, and often within the media, of "them versus us". I think is so unfortunate, for both of our professions, and for the families we work with. I urge you not to speak of being 'forced out' maternity care. If and when you do decide not to provide a maternity service you will do so for your own reasons, not because midwives force you out of practice. We all have the best interests of women at heart and our professions, involved in primary care, have a firm belief in the ability of women to birth their babies. We should be able to have a mutually respectful relationship and to work together for the benefit of women and their families.
I have enormous respect for the rural GPs (family doctors)I have worked with over the years. I am so pleased to see you acknowledge the work of midwives. May we always share this respect and I hope you are able to continue to provide your excellent service well into the future.

[Chantel]

Love you. Love your blog. I've been following it for awhile. Doctors like yourself are gems in the rough. Thanks should be given more often.

So, thank you.

[doctorjen]

I feel very strongly about family docs continuing to provide maternity care. I think the grand majority of births ought to be attended by non-surgical providers and the surgeons reserved for when their particular skill set is needed (or has a significantly higher chance of being needed.) I think midwives are fantastic - but family docs also have a unique role in providing maternity care. I truly believe in "family centered maternity care" and love having been at the births of so many fo my little clients. My partner, now practicing in the same location for 26 years, has now attended some births of women who he helped bring into the world many years ago! I've not been at it that long yet, but I have quite a few families where I care for the grandparents, the parents, and the children - and even a couple 4 generation families.
I hate to see a trend toward fewer and fewer family docs attending births and family practice residencies providing less obstetric experience. I do understand that some folks choose not to get up in the middle of the night, or are just uncomfortable with the unpredictability , or worry about liability issues - but I'd hate to see family docs get out of the business of womb-to-tomb care!