Using the Maternal Health Compact will help ensure that lower-resource hospitals have a relationship in place with a facility that can provide a higher level of maternal care when needed, they said.
This fourth action means that there’s a connection that “can be activated by lower-resource hospitals to get immediate consultation in the event of an unexpected obstetrical emergency whose care demands exceed their resources,” said Dr. Mann and her coauthors. When transport is necessary, it too can be facilitated if a compact is already in place.
The final, broader, recommendation from the obstetricians is that ACOG and AAFP collaborate “on an additional year of comprehensive training for family medicine physicians who are considering practicing obstetrics in rural areas.” The fourth year of training for these family physicians could help address widespread shortages of obstetricians and midwives in rural communities, Dr. Mann and her coauthors wrote. They observed that “pregnant women who live in rural areas may need to travel hundreds of miles to obtain routine prenatal care or consultation with an obstetrical specialist.”
Dr. Cullen, whose practice is in Valdez, Alaska, said he happily reciprocates the desire for collaboration. In his inaugural blog post after assuming the AAFP presidency in October, 2018, he extended warm thanks to his obstetrician and perinatologist colleagues. “The relationship between family physicians and obstetricians is vital in rural communities like mine. The training I received has saved lives and prevented catastrophe,” he wrote.
Dr. John S. Cullen
At the same time, Dr. Cullen said that he believes family physicians are the best hope for quality obstetrical care in rural communities. Dr. Cullen’s own training, he said, was structured to involve significant obstetric experience with obstetrician mentorship. “A 3-year residency left me very comfortable with fairly sophisticated obstetric management at graduation,” he added.
In his practice, Dr. Cullen said, a family physician hired a decade ago after a 3-year residency came with excellent obstetric skills, which have been further honed during the succeeding years of rural practice. During a 3-year residency, “family physicians receive training and demonstrate the skills and competencies required to deliver high-quality maternity care in any community, including those in rural settings,” he said in his statement.
“The bigger issue is really the closure of obstetric units in rural hospitals,” said Dr. Cullen. He pointed out that although obstetric services may have left a community, that rural hospital will still have miscarrying patients with hemorrhage, patients in preterm labor, and other obstetric emergencies arriving at the doorstep. These and other instances often “represent true emergencies without possibility of transfer, requiring immediate and effective response,” he wrote.
“We would encourage the authors to ensure an equal focus on improving care at all levels and in all hospitals, as well as relying on transfer as appropriate,” Dr. Cullen said in his statement.
Such mutual support can be bolstered by new technology, wrote Dr. Mann and her coauthors, because “telehealth and collaborations and consultation with clinics and regional hospitals can help increase the availability of maternity care in the United States.”
For Dr. Cullen also, the way forward is together. In his blog, he wrote: “As family physicians, we can only deliver obstetrical care to our patients with the cooperation of obstetricians and perinatologists. Conversely, obstetricians can only improve maternal and infant mortality rates, especially in rural areas, with the help of family physicians.”
SOURCE: Mann S et al. N Engl J Med 2018;379:1689-91.