In the heart of a city, the distances in rural communities may be difficult to envision. The space between neighbors can sometimes be measured in miles rather than blocks; a drive to the nearest hospital may take dozens of minutes rather than a handful.
The trickle-down effect of such distances can impact many aspects of health care, but especially maternal care and delivery, says Mark Deutchman, MD, a professor of family medicine and associate dean for rural health at the University of Colorado School of Medicine.
As principal investigator of a study recently published in the journal Birth analyzing the impact of family physicians in rural maternity care, Deutchman and his co-investigators found that of the 185 rural hospitals surveyed in 10 states, family physicians delivered babies in 67% of the hospitals and were the only physicians who delivered babies in 27% of them.
Further, the study found that if family physicians stopped delivering babies in these rural hospitals, patients would have to drive an average of 86 miles round-trip to access maternal care.
The purpose of this study was, number one, to understand the extent of family physicians providing maternity care in rural areas. Number two, and even more important, was to understand what would happen to women if family practitioners did not practice maternity care, and that's the real take-home message: Family physicians are really, really important."
Mark Deutchman, MD, professor of family medicine and associate dean for rural health, University of Colorado School of Medicine
Study highlights importance of family physicians providing maternity care
On this topic, Deutchman speaks from experience. For more than 12 years he practiced family medicine in White Salmon, Washington, a town of 2,000 residents on the Columbia River. The local hospital is federally designated critical access, which means it has fewer than 20 beds, among other standards.
"One of the major things I was involved in was maternity care," he says. "I had a lot of OB patients and did a lot of deliveries. I was also one of the major providers of surgical OB, of C-sections when they were needed.
"I'm an advocate for and student of the quality of outcomes in areas where family physicians are a woman's provider of obstetric and gynecologic care. I think that women deserve to have excellent care no matter where they are and no matter who provides it."
After leaving rural practice, Deutchman became a faculty member at the University of Tennessee-Memphis, where he helped train family medicine residents for rural practice. He continued that focus after joining the University of Colorado School of Medicine in 1995. In 2005, he founded the school's rural track, which this year became a full-fledged program.
His recently published research evolved from previous, similar studies he conducted in Colorado and Montana with medical students
"It wasn't a study of quality -; we weren't looking at individual cases and weren't looking at outcomes -; but we wanted to better understand how much and the sort of maternal care family physicians are providing at rural hospitals," he explains.
After refining the survey tool used in the previous studies, Deutchman reached out to colleagues across the country. Those who responded represented 10 states and collected data about rural and frontier hospitals in their states. They gathered data about the hospitals' obstetrics capacity, who delivers babies at the hospitals and what their specialty is, and other data.
"Ultimately, we were looking at how important is it for family physicians to provide maternity care and what would access be if they didn't?" Deutchman says.
Rural program provides specialized training needed for medical students and residents
The study's results, Deutchman says, highlight the importance of comprehensive, specialized training for medical students and residents who are interested in practicing in rural communities.
"Basically, the rural program is a way to attract, admit and support medical students and physician assistant students who want to live and work in rural areas when they finish their training," he explains. "We need to have a program so that people who are interested in rural practice will have their aspirations supported and also have a way to test their assumptions about rural practice and see if it's really right for them.
"The last thing we want is for students to have romanticized ideas, and then they show up in a small town and it wasn't what they had in mind. We also don't want to have that revolving door where physicians go to a small community for only two or three years, which fosters distrust and a lack of attachment between doctors and the community."
Through the rural program, students not only receive on-campus experience in the classroom and clinical training, but they get significant rural clinic experience with partners throughout Colorado. That aspect of the training is vital, Deutchman says, because students learn in-person about rural health care systems and economics, community engagement, health care ethics, and how to practice in a community where physicians might regularly see patients at the grocery store.
Since 2005, Deutchman says, 191 students in the CU School of Medicine have graduated in the rural track, 40% of whom concentrated on family medicine.
"A common question is, 'How do you get people interested in rural practice and providing care like delivering babies?'" Deutchman says. "Partly, we start out with people who are initially interested, then we help nurture that interest with real facts and real practical experience.
"Basically, the whole state of Colorado is short of primary care, especially in rural areas, which cannot support one of every kind of sub-specialist. Rural communities need versatile, broadly-trained and skilled physicians who can share clinical responsibilities with each other to avoid burnout. Family physicians can provide acute care, chronic care, end of life care, deliver babies, put on casts, repair lacerations -; in the most accessible, cost-effective fashion. It's vital we train and support these physicians who go out and support these rural communities."
Deutchman, M., et al. (2021) The impact of family physicians in rural maternity care. Birth. doi.org/10.1111/birt.12591.