How Family Physicians Can Solve US Maternal Health Problems

February 26, 2024 - It’s not a secret that healthcare is staring down a maternal mortality problem. But what might be less known is the critical role family physicians can play in ameliorating it.

“This country has a lot of work to do on maternity mortality. We are not even keeping up with the other high-income countries,” Teresa Lovins, MD, a fellow of the American Academy of Family Physicians who practices at a direct primary care practice in Indiana, told PatientEngagementHIT in an interview.

Indeed, the nation’s maternal mortality problem has reached a boiling point. Numerous assessments from the Commonwealth Fund have found that the United States has the worst maternal mortality rate in the developed world, with its 2022 report showing that the mortality rate in the US is double that of South Korea.

Maternal mortality in America is a multifaceted problem, most experts agree.

In 2023, researchers concluded in a JAMA study that the twofold rise in maternal mortality that occurred in the US between 1999 and 2019 was driven in large part by maternal health disparities.

Per CDC figures, Black and American Indian/Alaska Native (AI/AN) people are three times more likely to die from pregnancy and pregnancy-related causes than their White counterparts.

There’s also the question of adequate prenatal and postpartum care. Without both, pregnant people run the risk of developing unchecked physical and mental health problems that could impact their well-being down the line.

But accessing prenatal and postpartum care isn’t always simple. Lapses in health insurance coverage for postpartum care can get in the way, while lengthy travel distances and other social determinants of health can keep even covered pregnant people out of the clinic or hospital.

Lovins and her colleagues at AAFP consider family physicians at the nexus of solving this care access problem, which ideally can help chip away at the nation’s overall maternal health and mortality issue.

“Any way that we can do that by getting family physicians involved early on in a pregnancy—because they're going to be the ones that follow patients after the pregnancy—is very appropriate,” Lovins advocated.

Right now, family physicians are leveraging their positions as primary care providers to fill in the gaps, especially for postpartum care. Family physicians, by definition, treat people of all ages, meaning many provide primary care for both the parent and the baby. This makes it easy for family physicians to home in on the fourth trimester of care, which occurs during the 12-to-16 weeks after delivery.

According to Lovins, this is a high-risk period of time during which most moms in a traditional model of OB care might not meet with a provider.

“In that timeframe, a significant number of the injuries and deaths occur to moms. A lot of those difficulties are physical difficulties such as hypertension, strokes, and cardiomyopathy, but there are also mental health issues after the delivery of a baby,” she mentioned. “Family physicians are uniquely capable of caring for those moms to make sure that that's being looked at and addressed during that fourth trimester.”

From a policy standpoint, that kind of work is bolstered by health insurance coverage. In particular, extended postpartum Medicaid coverage has been a boon for family physicians working to deliver fourth-trimester care to their patients, Lovins said. Moving forward, more energy from commercial payers to cover certain types of visits, like introductory visits between parents and family physicians before birth, could be helpful.

Absent policies that allow more extensive fourth-trimester care, Lovins said family physicians can help address postpartum maternal health needs at the point of care during visits for the baby.

“In a family physician's office, it's all about the family, so it's not as hard to just kind of have that conversation while you're examining the baby and find out where mom stands on things as you're looking at the typical exam for the baby,” she suggested. “You're really not interacting that much with the baby other than you're doing the exam, so you can talk to mom and find out how she's doing, too, at the same time. And that works out really well in a family physician's office, and so that's what we're encouraging our physicians to do.”

AAFP has issued guidance for family physicians about how these types of patient-provider communications can look, advising providers to ask about depression and physical symptoms like headache or blood pressure.

Other office staff members can also discuss these topics with postpartum people and relay concerning responses to the physician, while telehealth has also emerged as a viable stand-in, Lovins said.

But there’s also room for the family physician to play a bigger role in actual obstetric care, especially for pregnant people living in rural areas or maternity deserts. In August 2023, March of Dimes reported that maternity deserts affect 5.6 birthing people nationwide. About a third (36 percent) of all US counties are considered maternity deserts, meaning they have no or limited access to obstetric care.

Over 32 million women of reproductive age are susceptible to poor health outcomes because they can’t access reproductive healthcare, the report added, a trend that’s most common in rural states such as North Dakota, South Dakota, Alaska, Oklahoma, and Nebraska.

Pregnant people in maternity deserts certainly do need the prenatal, postpartum, and lifelong medical care that Lovins said family physicians are poised to provide, but they would also benefit from seeing more family physicians spearhead obstetric care that’s not always available to them.

“We are finding more and more hospitals and more and more counties without access to OB care, and when that happens, patients have to travel farther to get that care,” she explained.

And as many in healthcare know, long travel distances for any type of care are a deterrent to most patients.

“In rural areas, that's a big factor in trying to get the care that's appropriate for them,” Lovins continued. “Our family physicians, although it's only about 15 percent of our membership, do OB in those areas. It makes it much more accessible for the patient.”

“That's the first and foremost, is getting them into prenatal care appropriately, early enough with the right providers,” she concluded. “Family physicians fill a big need.”