Abstract

PURPOSE Family physicians (FPs) are an important segment of the maternity workforce, particularly in rural areas. This research explores the geographic distribution of family physicians providing maternity care and identifies opportunities for family physicians to expand access to maternity care.

METHODS This cross-sectional study used a co-location mapping approach to identify 3 types of counties based on the following: (1) family physicians as the only clinician provider of maternity care along with at least 1 hospital providing obstetric care (FP with Hospital); (2) family physicians as the only clinician provider of maternity care with no hospital providing obstetric care (FP Only); (3) no clinician providers of maternity care but county has at least 1 hospital providing obstetric services (Only Hospital).

RESULTS Most of the 325 counties across the 3 types are rural and concentrated in the central United States, the upper Midwest, and in Mississippi. More than one-third of these counties are found in just 4 states—Texas, Iowa, Nebraska, and Kansas. Although there are not clear differences in the geographic distribution of FP Only and FP with Hospital counties, Only Hospital counties are located primarily in a few states, including Mississippi, Missouri, Oklahoma, and Texas, and have significantly higher percentages of Black populations.

CONCLUSIONS Our findings demonstrate that while FPs are providing maternity care in rural areas across the United States, opportunities exist to expand their reach, particularly in Mississippi, Texas, and Oklahoma.

Key words:INTRODUCTION

Women in rural areas have less access to prenatal care, contributing to poor maternal health and birth outcomes compared with urban areas.1,2 These rural disparities are partly due to the growing number of hospital closures in rural areas3,4 and the presence of maternity care deserts (MCDs), defined as counties that lack obstetrician-gynecologist (OB-GYNs), certified nurse midwives (CNMs), family physicians (FPs) providing maternity care, and hospitals providing obstetrical care.2,5 The recent March of Dimes Maternity Care Desert report highlights the large number of rural counties in the United States that do not have any maternity care providers or hospitals and provides a starting point for targeted interventions to improve access to care.5

In addition to the work of the March of Dimes and the creation of MCDs, the growing US maternal mortality rate, particularly among Black women, has led to legislative efforts to address the maternity care crisis.4,6,7 The Maternal CARE Act directed the creation of maternal health professional shortage areas (HPSAs), known as Maternity Care Health Professional Target Areas (MCTAs). MCTAs are defined as primary care health professional shortage areas (HPSAs) that meet specific criteria based on the ratio of females ages 15-44 years to maternity care providers (these include only OB/GYNs and CNMs), low-income women, distance/travel time to care, fertility rates, social vulnerability, and maternal health indicators (pre-pregnancy diabetes, hypertension, obesity, and early access to prenatal care). Family physicians are not included in the MCTA criteria due to concerns over consistent data for the number of FPs providing maternity care.8 Similar to primary care, dental, and mental health HPSAs, maternity care providers have incentives to practice in these areas. For example, the National Health Service Corp (NHSC) programs place providers at sites located in areas with HPSA or MCTA scores above certain thresholds that can change annually.9

Addressing the rural maternity care crisis requires attention to barriers related to the workforce, the social determinants of health, and persistent racial and ethnic disparities. One often overlooked part of the maternity care workforce is the almost 5,000 family physicians that provide maternity care. While the percentage of FPs providing maternity care has decreased over the last few decades, rural areas still rely on FPs for providing maternity care and care during labor.10,11 Family physicians providing maternity care are more likely to practice in rural areas and are the largest group of such providers.12,13 One study found that FPs deliver in more than two-thirds of rural hospitals and were the only delivering providers in more than one-quarter of these hospitals.11 While research on the impact of FPs providing maternity care in rural areas is limited, one study found similar risks of mortality and maternal outcomes from FPs performing the delivery compared with OB-GYNs,14 with another study finding that obstetrical services in rural communities were associated with improved outcomes.15

Although the identification of MCDs and MCTAs are important first steps in targeting specific areas to improve access to maternity care, more research is needed on the role of FPs providing maternity care and opportunities for expanding access to maternity care in areas with little or no maternity care resources. This is particularly important when considering the increasing number of rural hospital closures over the past 2 decades, where 191 rural hospitals have closed since 200516 and the understated role of FPs providing maternity care. This study builds on previous research that found that family physicians provide maternity care in more than 40% of US counties and were the sole provider of maternity care in 181 maternity care desert counties.17 Improving the allocation of resources to address the maternity care crisis requires better understanding of geographic patterns and the characteristics of these counties. This research fills that gap by exploring the geographic distribution of areas dependent on family physicians for maternity care and identifying opportunities for expanding the reach of family physicians providing maternity care.

METHODSData and Analysis

This research includes county-level data from several sources, including data on the number of OB-GYNs, CNMs, and hospitals with obstetric services from the Area Health Resource File (AHRF) (2021-2022)18 and the number of FPs delivering babies from the American Board of Family Medicine (ABFM) (2013-2021).19 We define “FPs providing maternity care” as those that answered yes to the following survey question: “Please indicate which of the following you personally provide: Delivering babies (Yes/No).” These data were used to identify our 3 types of counties using a co-location mapping approach, which allows for exploring the geographic relationship between multiple categorical variables.20

We identified the 3 types of counties based on the following criteria: (1) counties that had no OB-GYNs or CNMs but had at least 1 FP providing maternity care along with at least 1 hospital providing obstetric care were defined as “FP with Hospital” counties; (2) counties with at least 1 FP providing maternity care that had no OB-GYNs, CNMs, or hospitals providing obstetric care were defined as “FP Only” counties; (3) counties with no OB-GYNs, no CNMs, or no FPs providing maternity care, but had at least 1 hospital providing obstetric services were defined as “Only Hospital” counties.

Next, we performed an analysis of variance (ANOVA) to explore differences between the 3 types of counties for various characteristics. These include race and ethnicity from the American Community Survey (2016-2020),21 social deprivation from the Robert Graham Center for Policy Studies,22 and the percentages of women aged 15-44 years receiving prenatal care in the first trimester (early PNC), the percentages of uninsured women (aged 18-49 years), the percentage of preterm births, the percentage of low–birth weight births, and infant mortality per 1,000 live births from the HRSA Maternal and Infant Health Mapping tool.23 We also use Rural-Urban Continuum Codes (RUCC) data from the US Department of Agriculture (USDA) to define the rural counties as non-metropolitan counties with RUCC codes 4-9.24 All maps and analysis were completed using GeoDa 1.20.0.22.25 This research was deemed exempt by the American Academy of Family Physicians (AAFP) Institutional Review Board (IRB).

RESULTS

Figure 1 shows clear geographic patterns for the 325 counties identified as FP with Hospital counties, FP Only counties, or Only Hospital counties, with almost 90% located in non-metropolitan areas. The 62 FP with Hospital counties are mainly in the upper Midwest (Iowa, Wisconsin, Minnesota) and central United States (Kansas, Missouri, Texas). FP Only counties (n = 181) are found across the United States, though most are concentrated in the central United States and more than one-third located in just 4 states (Nebraska, Texas, Iowa, Kansas). There are 82 counties that have a hospital providing obstetrical care but have no OB-GYNs, CNMs, or FPs providing maternity care—almost one-quarter of these Only Hospital counties can be found in Mississippi.

Figure 1.

Family Physicians Providing Maternity Care and Hospital Only Counties

Note: Data sources: Health Resources and Services Administration (HRSA). Area health resource file, 2021-2022. HRSA Data Warehouse. https://data.hrsa.gov/ and American Board of Family Medicine (ABFM), Continuing Certification Questionnaire (2013-2021). https://www.theabfm.org/continue-certification/

As displayed in Table 1, there were more than 120,000 births in FP with Hospital and FP Only counties, which are home to roughly 3.5 million people, including more than 500,000 women aged 15-44 years. Table 1 also shows that there were almost 40,000 births in the 82 Only Hospital counties, with almost 200,000 women aged 15-44 years living in these counties.

Table 1.

Characteristics of County Types

We also found clear differences for racial/ethnic composition, access to care, and maternal care outcomes across the 3 county types. FP with Hospital and FP Only counties have significantly smaller Black populations but significantly larger Hispanic populations when compared with Only Hospital counties. While there are no significant differences in early access to prenatal care and the percentage of uninsured women (aged 18-49 years), Only Hospital counties are more rural and have significantly higher rates of social deprivation and Black populations. Further, Only Hospital counties have significantly fewer FPs per population when compared with FP county types. Finally, the table shows clear patterns for maternal health outcomes—FP with Hospital and FP Only counties have significantly lower rates of preterm births, low birth weight, and infant mortality when compared with Only Hospital counties.

DISCUSSION

Our findings show clear geographic patterns. The majority of the 325 counties where FPs and hospitals are the only providers of maternity care are rural and concentrated in the central United States, the upper Midwest, and in Mississippi. In fact, more than one-third of these counties are found in just 4 states—Texas, Iowa, Nebraska, and Kansas. While it does not appear that there are differences in the geographic distribution of FP Only and FP with Hospital, Only Hospital counties are located primarily in a few states, including Mississippi, Missouri, Oklahoma, and Texas. One potential way to increase the number of FPs in these areas is through family medicine residency programs with rural training tracks (RTTs).26 Family medicine residents who are exposed to rural environments during their training are more likely to practice in rural environments, and this relationship increases based on the exposure’s duration.27 Even so, those who are trained in rural areas report competition with other OB providers and limited family medicine faculty participating in obstetric care as the chief contributing factors to achieving an appropriate number of deliveries for a sufficient skill base.28 Programs like the National Health Service Corps lead the way recruiting and retaining physicians to fill gaps in care. As FPs are not included in their monitoring definitions, however, current data underreports physicians participating in obstetric care.27 Based on our findings, it is important that HRSA continue to research evaluating MCTA scores to improve maternity care and the continued role of FPs providing obstetrical care. More importantly, MCTA scores should include family medicine physicians who participate in obstetric care.

A second important finding from this research is that Only Hospital counties have significantly larger Black populations and higher rates of social deprivation; many of these counties are found in Mississippi. Family medicine obstetrics fellowship programs can help prepare residents and increase the likelihood of providing obstetrical care—particularly in these high-need areas.29,30 Given that residents often remain close to their residency training location, increasing the number of obstetric fellowship opportunities in these areas could potentially increase the number of FPs doing maternity care in these areas.31 Mirroring fellowship programs in nearby states, Mississippi has started a fellowship to train family physicians to care for pregnant patients to begin in July of 2024.32 Medical liability premiums remain high in Mississippi, however, making hospital credentialling difficult. Therefore, more emphasis should be placed on the equitable distribution of maternity care providers to these areas and on policy changes needed to remove the financial barriers for health systems and providers. Further, residency and fellowship programs will need to be intentional about recruiting racial and ethnic minorities33 and including racial justice curricula34 for these programs to be successful. Supporting family practitioners who choose to fill this gap in care can be a key policy option for decreasing health care disparities.

Finally, we found that outcomes are more favorable in FP with Hospital and FP Only counties, suggesting that the impact of family medicine in obstetric care is instrumental in improving infant and maternal health.15 While more research is needed to understand this and we don’t know if individuals with higher risk pregnancies may be transferred to counties with more resources (leading to worse outcome data), there are a few possible explanations for our findings. Studies show that patients who can maintain continuity of care and deliver in their communities have higher levels of satisfaction with the health care system.35 Additionally, FPs are well suited to address the psychosocial and medical needs of pregnant patients. Family physicians tend to practice medicine in areas where other specialists do not, increasing access to prenatal care. Previous literature also finds that more than many other medical specialties, FPs are caring for patients with more comorbidities36-38 and lower socioeconomic status.39 Increasing the presence of FPs providing maternity care for these patients is extremely important to reduce maternal and infant morbidity and mortality.

This research described the geographic distribution of family physicians providing maternity care in areas lacking maternity care providers. The strength of our geospatial approach is that it allows for better understanding of geographic patterns of family physicians providing maternity care and identifies opportunities for expanding their reach. However, this research has a few limitations. First, the ABFM data on family physicians providing maternity care are from 2013-2021 and do not include all possible family physicians. Also, the data for other maternity care providers and hospitals with obstetrical services are from 2020, and we do not know if family physicians or other maternity care providers moved to a different county during or after the study period or if hospitals closed. These data limitations may partly explain the finding that 82 counties have a hospital with obstetrical services but no maternity care providers. Other possible explanations are that the ABFM and AHRF clinician data are based on practice address, which are usually different than hospitals, and that clinicians often deliver babies in multiple hospitals, some of which may be located in different counties. Follow-up studies should also include the demographics of FP maternity care providers, as research has shown that patients who share a similar ethnic background to their provider often have better health outcomes.40

Our findings demonstrate that while FPs are providing maternity care in rural areas across the United States, opportunities exist to expand their reach, particularly in Mississippi, Texas, and Oklahoma. This research highlights the importance of supporting rural training tracks, obstetric fellowship programs, and obstetric-focused family medicine residency programs in filling high-need area deficits. Restrictive abortion laws have created a migration of obstetric providers out of high-need areas, such as Texas, Oklahoma, Tennessee, and Idaho, leaving family physicians to meet increasing delivery demands.41,42 To encourage new doctors entering these states, expansion of maternity primary care centers is urgently needed at this critical time.

Received for publication February 12, 2024.Revision received February 6, 2025.Accepted for publication February 10, 2025.© 2025 Annals of Family Medicine, Inc.