Can family doctors save rural America from its maternal health crisis?

CAIRO, Ga. – Zita Magloire carefully adjusts a soft measuring tape over Kennady Evans’ pregnant belly.

Determining the baby’s size at the 28-week obstetrician visit is routine. But Magloire, a family physician trained in obstetrics, knows that finding a mother’s uterus, and therefore checking a baby, can be difficult for inexperienced doctors.

“Sometimes it’s kind of off,” Magloire said, showing a visiting medical student how to push hard and complete the practice exam. She moved her finger slightly to calculate the height of the fetus, “There it is, right here.”

Evans smiled and later said Magloire made her “comfortable.”

The 21-year-old recently moved from Louisiana to southeast Georgia, two states where both maternal and infant mortality rates are consistently high. She moved in with her mother and grandfather near Cairo, a farming community where the hospital had a busy labor and delivery department. Magloire and other doctors at the local clinic where she works deliver hundreds of babies there every year.

Scenes like the one between Evans and Magloire regularly play out in this rural corner of Georgia despite the grim realities facing mothers and babies across the country. Maternal deaths continue to rise, with black and Indigenous mothers at greatest risk; the number of babies dying before their 1st birthday rose last year; and more than half of all rural counties in the United States lack hospital services for delivering babies, increasing travel time for expectant parents and causing a decline in prenatal care.

There are many reasons labor and delivery units close, including high operating costs, declining populations, low Medicaid reimbursement rates, and staff shortages. Family medicine doctors still provide the majority of birth care in rural America, but few new doctors hired in less populated areas offer midwifery care, in part because they don’t want to be on call 24/7. Now that rural America is hemorrhaging health care providers, the federal government is investing dollars and attention to swell the ranks.

“Clearly the crisis is here,” said Hannah Hinkle, executive director of the Rural Training Track Collaborative, which works with more than 70 rural training programs. Federal grants have boosted training programs in recent years, Hinkle said.

In July, the Department of Health and Human Services announced an investment of nearly $11 million in new rural programs, including family medicine residencies that focus on midwifery training.

Nationally, the declining number of primary care physicians — internal medicine and family medicine — is making it difficult for patients to make appointments and, in some cases, to find a doctor at all. In rural America, training family medicine physicians in obstetrics can be more daunting because of low state reimbursement and rising medical liability costs, said Hinkle, who is also assistant dean of rural health professions at the university’s College of Medicine. of Illinois at Rockford.

In the 1980s, about 43% of general family physicians who completed their internships were trained in midwifery. In 2021, the American Academy of Family Physicians’ annual practice profile survey found that 15% of respondents practiced midwifery.

Yet family physicians, who also provide the full range of primary care services, are “the backbone of rural delivery,” said Julie Wood, a physician and senior vice president for research, science and public health at the AAFP.

In a study of 216 rural hospitals in 10 states, family practice physicians delivered babies in 67% of hospitals, and in 27% of hospitals they were the only ones delivering babies. The data counted babies born from 2013 to 2017. And the authors found that if those family doctors hadn’t been there, many patients would have traveled an average of 86 miles each way for treatment.

Mark Deutschman, the report’s lead author, said he was “on call for 12 years” when he worked in a town of 2,000 in state Washington. Clarifying that he was exaggerating, Deutschman explained that he was one of only two local doctors who performed C-sections. He said the best way to ensure family doctors can support obstetrics units is to ensure they work as part of a team to prevent burnout, rather than as solo doctors who do everything.

There needs to be a core group of doctors, nurses and supporting hospital administration to share the workload “so that someone is not on call 365 days a year,” said Deutschman, who is also associate dean for rural health at the university of Colorado Anschutz Medical Campus School of Medicine. The school’s College of Nursing received a $2 million federal grant this fall to train midwives to work in rural Colorado.

Across the country, teams of providers are ensuring rural midwifery units stay busy. In Lakin, Kansas, Drew Miller works with five other family physicians and a physician assistant who completed an obstetrics fellowship. Together, they deliver about 340 babies a year, up from just over 100 a year when Miller first moved there in 2010. Word of mouth and the closing of two nearby obstetrics units have boosted their supply. Miller said he’s seen friends and partners “from surrounding communities stop producing results just out of sheer burnout.”

In Galesburg, Illinois, Annevay Conlee has overseen the closing of four nearby obstetrics offices since 2012, forcing some pregnant people to drive up to an hour and a half for treatment. Conley is a family medicine practitioner and medical director who oversees four rural districts with a team of OB/GYNs, family physicians and nurse midwives. “There is no longer an option to be on call 24/7 for your women to deliver,” Conley said. “There needs to be a bit more harmony in recruitment to really support a team of doctors and midwives.”

In Cairo, Magloire said practicing midwifery was “just basic care”. In fact, pregnancy care accounts for only a fraction of her patient visits in this Georgia town of about 10,000 people. On a recent morning, Magloire’s patients included two pregnant people, as well as a teenager concerned about hip pain and an ecstatic 47-year-old celebrating weight loss.

Cairo Medical Care, an independent clinic located across the street from the 60-bed Archbold Grady Hospital, is in a community best known for its peanut crops and as the birthplace of baseball legend Jackie Robinson. The historic center has brick-accented streets and the oldest movie theater in Georgia, and a corner of the library is dedicated to local history.

The clinic’s six doctors, a combination of family medicine practitioners like Magloire and obstetricians, draw patients from surrounding counties and together deliver nearly 300 babies at the hospital each year.

Deanna Buckins, a 36-year-old mother of four boys, said she was relieved to find “Dr. Z’ because she ‘completely changed our lives’.

“She actually listens to me and accepts my decisions instead of forcing things on me,” Buckins said as she held her 3-week-old son, whom Magloire had given birth to. Years earlier, Magloire helped diagnose one of Buckins’ older children with autism and built trust in the family.

“Let’s say I come in with one child; before we left, we talked about every single kid about how they were doing and, you know, how they were getting on with life,” Buckins said.

Magloire grew up in Tallahassee, Florida, and resides in rural Kansas. Little Cairo, she said, allows her to see the patients as they grow — to talk to the children when the mothers or siblings come for appointments.

“She’s very friendly,” Evans said of Magloire. Evans, whose first child was delivered by an OB-GYN, said she was worried about finding the right doctor. The type of specialist her doctor was didn’t matter as much as being with “someone who cared,” she said.

As a primary care physician, Magloire can care for Evans and her children for years to come.

KFF Health Newsformerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism on health issues and is one of the primary operating programs of KFF — the independent source for health policy research, polling and journalism.

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