The Family Doctor in Obstetrics: Who's Looking after the Shop?

Research

Stanley T. Bain, MD, FCFP Inese Grava-Gubins, MA Rachel Edney, MB, BS

The Family Doctor in Obstetrics:Who's Looking after the Shop?SUMMARYThis article constitutes a report on a survey of1338 family physicians/general practitioners inOntario. The survey, which achieved aresponse rate of 74%, investigatedrespondents' patterns of obstetrical practiceand attitudes towards that practice. Thedetailed statistics collected show a decline inFP/GP involvement in obstetrical care.

Physicians who had never practised obstetricscited inadequate training and lack of interestas their chief reasons. Physicians who hadgiven up obstetrical practice cited mostfrequently its interference with personal andfamily life, interruption of office schedule,rising CMPA fees, and low financial incentivesas reasons for their decision. In the youngestgroup of respondents, no significantdifferences were found between males' andfemales' rates of choice to practise or not topractise obstetrics. Respondents who hadnever practised obstetrics were likely to live inlarger communities, and those practisingobstetrics to live in smaller communities.Various changes in patterns of practice wereidentfified by some respondents subsequent totheir giving up obstetrics. A large majority ofthis group expressed satisfaction with thosechanges. Over half the respondents statedthat they would accept well-trained midwivespractising under supervision in a hospitalsetting. A strong majority of respondentsfavoured the concept of family physicianswith a special interest in obstetrics takingover, either alone or in association withobstetricians and/or midwives, the obstetricalcases declined by their colleagues. (Can FamPhysician 1987; 33:2693-2701.)

RESUMECet article constitue le rapport d'une enqueteeffectuee aupres de 1 338 medecins defamille/praticiens generaux ontariens. Cette enquete,dont le taux de reponses est de 74%, a vouluinvestiguer les modes de pratique obstetricale desrepondants et leurs attitudes face a cette pratique. Ledetail des statistiques colligees montre un declin del'implication des MF/omnipraticiens dans ledomaine des soins obstetricaux. Les medecins qui ne

font que peu ou pas d'obstetrique mentionnent queles raisons principales en sont l'insuffisance deformation et le manque d'interet. Quant auxmedecins qui ont abandonne la pratique obst6tricale,les raisons les plus frequemment invoquees sontl'interference avec la vie personnelle et familiale,l'interruption dans les horaires de bureau,l'augmentation du cou't des primes de l'Associationcanadienne de protection medicale et le peud'incitatifs financiers. Parmi le plus jeune groupe derepondants, on n'a constate aucune differencesignificative entre les hommes et les femmes quantau choix de pratiquer ou non l'obstetrique. Lesrepondants qui n'avaient jamais ou rarementpratique l'obstetrique etaient plus susceptibles devivre dans de grandes villes alors que ceux quipratiquent l'obstetrique vivent dans descommunaut6s moins populeuses. Certainsrepondants ont identifie divers changements dansleur mode de pratique suite a l'abandon del'obstetrique. La grande majorite de ce groupe s'estdite satisfaite de ces changements. Plus de 50% desrepondants ont mentionne leur accord a ce que dessages-femmes bien formees pratiquent sous

supervision dans un contexte hospitalier. Parailleurs, une forte majorite des repondants favorisele concept de l'implication de medecins de familleparticulierement interesses, soit en pratique solo,soit en association avec les obstetriciens et/ou lessages-femmes, a prendre la releve de leurs confreresqui abandonnent cette pratique.

Key words: obstetrics, family physicians, general practitioners

CAN.,FAM.PHYSICIAN Vol. 33: DCME 1 2693

CAN. FAM. PHYSICIAN Vol. 33: DECEMBER 1987 2693

Dr. Bain, a Fellow of the College,is a member of the Active Staff ofNorth York General Hospital,Willowdale, Ontario, and anassociate professor, Family andCommunity Medicine, in theUniversity of Toronto. Ms.Grava-Gubins is Director ofResearch of The College of FamilyPhysicians of Canada. Dr. Edney, aFellow of the College, is a familyphysician and a member of the staffof Etobicoke General Hospital,Mississauga, Ontario. Requests forreprints to: Ontario Chapter,College of Family Physicians ofCanada, 4000 Leslie Street,Willowdale, Ont. M2K 2R9

T HE DECLINING involvement inobstetrical care by Ontario's fam-

ily physicians represents a challengeto those responsible for health-careplanning and for teaching FamilyMedicine. The Ontario Chapter withthe College of Family Physicians ofCanada sponsored a study to deter-mine the extent to which involvementin obstetrics had declined, to discoverthe major reasons for this trend, andto determine whether their findingswould suggest any action that mightencourage family physicians to con-tinue to practise obstetrical care.

Klein and his colleagues' havenoted that the decreasing participationof family physicians in obstetricalcare, evident mainly in Quebec andOntario, seemed to be related to the

Table 1Sex

Male Female

Total respondents(n= 1338) 80% 20%

CFPC Members(n=727) 77% 23%

Non-members(n=611) 83% 17%

Residency-trained(n=451) 71% 29%

ratio of obstetricians to the popula-tion. While family physicians are dis-tributed throughout larger and smallercommunities in Canada, obstetriciansare concentrated in the larger centres.Consequently, family physiciansbased in smaller communities aremore likely to practise obstetrics thanare physicians in larger urban centres.

In 1982, the Canadian Medical As-sociation determined that 56.5% ofCanada's family physicians practisedintranatal obstetrics. In 1985, a studyconducted in Alberta of family physi-cians' attitudes towards obstetricsfound that 66.7% of the respondentswere providing complete obstetricalcare, 24.8% no longer practised ob-stetrics, 8.5% had never practised ob-stetrics, and 10% were planning todiscontinue obstetrical practice withinthe following two years.3

Cutner and Peters4 have reportedon the effect of quality of training onthe continued interest shown by Fam-ily-Practice residents in the UnitedStates in practising obstetrics through-out their three-year training programs.Residents who retained an interest inobstetrics were more likely to havetrained in programs that followedmost closely the guidelines of theAmerican Academy of Family Physi-cians (AAFP). These guidelines pro-mote a joint Family Practice-Obstetri-cal Training Committee, a minimumof three months of obstetrical train-ing, an additional three months oftraining for residents planning to in-clude obstetrics in their practice, andadditional intensified experience fortrainees intending to practise in areaswhere specialist services are not read-ily available. Canadian authors,too,5-7 have emphasized the impor-tance of the obstetrical component ofResidency Training in Family Medi-cine.

MethodOur survey team sent question-

naires to 1802 randomly selected gen-

Table 2Medical School

Canada U.K. Elsewhere NA

Total respondents (n= 1338) 77% 11% 11% 1%CFPC Members (n=727) 87% 6% 7%Non-members (n=61 1) 66% 18% 16%Family Medicine ResidencyTrained (n=451) 90% 3% 7%

eral practitioners/family physicians(both members and non-members ofCFPC) of the nearly 8000 GP/FPS in theprovince of Ontario. After follow-upmailings, 1338 responses were re-ceived, representing a response rate ofover 74%. Respondents were asked torecord their year of birth, sex, loca-tion of medical school, CFPC Certifi-cation, current type of practice, com-munity size, hospital affiliation,details of training, and assessment oftheir own post-training competence inperforming various basic obstetricalprocedures. Those family physicianswho provided little or no obstetricalcare were asked to record the reasons.Those who had provided obstetricalcare at any time were asked to statethe number of years during whichthey had done so, to estimate themaximum number of births they hadattended in any given year, and torecord details of their practice. If theywere currently providing obstetricalcare, they were also asked if they hadever considered stopping. Those whohad stopped were asked about result-ing changes in their practice patternand patient satisfaction. The reasonsfor discontinuing or considering dis-continuing obstetrical practice wererecorded, and those who had discon-tinued or never undertaken the prac-tice of obstetrics were asked for infor-mation about their referral patterns.All respondents were asked abouttheir attitudes towards the role of mid-wives.

ResultsThe data obtained from all respon-

dents were analysed as a whole andwere also broken down by varioussubgroups of respondents as appro-priate for each question. These sub-groups included CFPC members andnon-members, rotating interns, andfamily medicine-residency trained re-spondents. In an attempt to gauge thefuture involvement of family physi-cians in obstetrical practice, we alsoidentified a core group consisting ofthose respondents born in 1946 orlater. Members of this group wouldnow be 40 years of age or younger,and most of them are likely to be inpractice for the next 25 years. Thisgroup numbered 653 and thus repre-sented approximately one-half of allof the respondents. For some analyseswe further subdivided from this group

CAN. FAM. PHYSICIAN Vol. 33: DECEMBER 19872694

those respondents born after 1954(n= 177).Demographics

Of the survey's overall sample,20% was female (Table 1). This fig-ure is comparable to the percentages

obtained in other studies and to the24% female membership in the On-tario Chapter-CFPC. Twenty-three per

cent of the CFPC members and 17% ofthe non-members were female. Thelarger percentage (29%) of femalephysicians in the group of residency-trained physicians reflects the increas-ing numbers of females entering Fam-ily Medicine Residency Programs.

Overall, 77% of the respondentswere graduates of Canadian medicalschools, as were 87% of the CFPC-member respondents, 66% of the non-

member respondents, and 90% of theFamily Medicine Residency-trainedrespondents (Table 2). The singlelargest group of graduates from non-

Canadian schools, 11% overall, were

graduates of United Kingdom medicalschools.

Type ofpractice and community size

Forty-five per cent of all of the re-

spondents are practising in communi-ties with a population over 100 000,and 17% in areas with a population offewer than 10 000 (Table 3). Forty-five per cent of respondents are asso-

ciated with hospitals containing more

than 300 beds, while 33% are asso-

ciated with hospitals containing100-300 beds.

Training

Considerable overlap occurred inanswers to questions relating to train-ing. For example, it is possible tograduate from a Family Medicine pro-gram following a rotating internshipor some other type of training duringthe first year. Five hundred and sixty-seven (42%) of the respondents hadcompleted a rotating internship, while451 (34%) had taken a Family Medi-cine Residency program. The re-

mainder had taken mixed training.Among Family Medicine Residency-trained respondents, 51% estimatedthat they had attended 50 or more

births, as did 40% of those trained inrotating internships. Forty-six per centof the Family Medicine Residency-trained respondents had received more

than two months of obstetrical train-ing, while only 27% of those taking a

rotating internship had done so.


Adequatefor needs

Of those respondents trained in ro-

tating interships, 70% believed thattheir training adequately met theirneeds on entering practice. Of theFamily Medicine Residency-trainedrespondents, 67% considered that

their training had been adequate.

Table 4 records the percentages of re-

spondents who felt confident in un-

dertaking various basic obstetricalprocedures after the completion oftheir training. Those who had takenadditional obstetrical training ex-

pressed a greater degree of confidencein undertaking these procedures.

Eighty-five per cent of all respon-

Table 3Community Size

PopulationLess than 10,001- 50,001- 100,001- More than10,000 50,000 100,000 500,000 500,000

Total respondents 17% 22% 14% 28% 17%(n= 1338)

CFPC Members(n=727) 15% 17% 14% 33% 18%

Non-members(n=611) 20% 27% 13% 22% 15%

Residency-trained 14% 17% 15% 35% 17%(n=451)

Size of Hospital1-50 51-100 101-300 301+ No hospitalBeds Beds Beds Beds Affiliation

Total respondents 4% 11% 33% 45% 4%(n= 1338)

CFPC Members(n= 727) 4% 9% 32% 50% 3%

Non-members(n=611) 5% 13% 35% 40% 6%

Residency-trained(n=451) 3% 10% 34% 49% 3%

Table 4Respondents' Confidencein Undertaking Obstetrical Procedures After Training

After After AfterCompletion Completion Completion

of of ofInternship FM Residency Additional

OB Training(n=1081) (n=451) (n=147)

Spontaneous vaginaldelivery 90% 90% 98%

Low forceps delivery 69% 67% 93%Induction of labour 53% 55% 81%Management

of postpartumhemorrhage 59% 63% 82%

Fetal monitoringa 32%Ola 51O%e 47%aManual removal

of placenta 53% 43% 81%Caesarean section 6% 6% 34%

a. Misleading, as many indicated that this procedure was not available atthe time of their training.

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dents believed that total obstetricalcare should be a compulsory part ofthe postgraduate training of familyphysicians/general practitioners. Sev-enty-nine per cent of the physicianswho had practised little or no obstet-rics ever, 87% of those who used topractise obstetrics but have nowstopped, 88% of those who still prac-tise obstetrics but have consideredstopping, and 94% of those who prac-tice obstetrics and have not consid-ered stopping hold the same view.

Number oJftimily physicianspracticing obstetricsWe found that 29% of all of our re-

spondents had never practised obste-trics (Figure 1). (It should be notedthat this category includes physicianswho practised obstetrics briefly, earlyin their career, and then stoppeddoing so.) Of this group, however,53% do provide prenatal care to someor all of their patients. An additional28% of the respondents had practisedobstetrics, but have now ceased to at-tend births. However, 48% of thisgroup still provide prenatal care tosome or all of their patients. Fivehundred and twenty-one (40%) of allrespondents currently practise obstet-rics, but 59% of this group have con-sidered stopping.Some physicians have suggested

that anyone who has ever practisedobstetrics has, at least at some point,considered stopping. In our question-naire, those respondents who statedthat they had considered giving up ob-

stetrical practice were channelled intoa series of questions exploring theirreasons. In selecting this response, arespondent was publicly, (albeit anon-ymously), stating that he or she hadconsidered this option seriouslyenough to answer the questions con-cerning their reasons. Those who hadnot considered this option withserious intent were directed to otherquestions.As a result, the data showed that

only 16% of all of our respondentshave been practising obstetrics andhave not considered stopping. Thirty-seven per cent of the Family MedicineResidency-trained respondents havenever practised obstetrics, 20% havediscontinued the practice of obstet-rics, 25% practise obstetrics but haveconsidered stopping, and 18% prac-tise obstetrics and have never consid-ered stopping. Of all of the respon-dents who have practised obstetrics atany time and have stopped, approxi-mately 75% have done so since 1975.Our respondents' reasons for discon-tinuing obstetrical practice are foundin Tables 5 & 6. Interference withpersonal and family life is the leadingcause in both "main cause" and"contributing cause" categories. Thisappears to be a more significant rea-son for the younger family physi-cians. The 29% of respondents whohave never practised obstetrics pro-vided a different set of reasons, chiefof which was inadequate training(Table 7).The respondents' choices concern-

ing obstetrical practice are related to

the population figures of the communi-ties in which the respondents practise.Significantly greater numbers (57%)of those who have never practised ob-stetrics live in communities with apopulation of over 100 000 persons(Table 8). In comparison, 48% ofthose respondents who have discontin-ued the practice of obstetrics live incommunities of this size, as do 32% ofthose who practise obstetrics and haveconsidered stopping, and 35% of thosewho practise obstetrics and have notthought of stopping. Conversely, pro-portionately greater numbers (28%) ofrespondents who practise obstetricsand have not considered stopping livein communities with a population ofless than 10 000, as do 23% of thosewho practise obstetrics and have con-sidered stopping, 12% of those whohave discontinued the practice of ob-stetrics, and 13% of the respondentswho have never practised obstetrics.When male and female physicians'

patterns of obstetrical practice werecompared, some significant dif-ferences were found. Data for the vari-ous age categories of male and femalepractitioners were analysed separately(Tables 9 and 10). Significantly moreof the females than of the males in theage group of respondents born before1946 were likely never to have prac-tised obstetrics during their careers.Again, of the respondents born be-tween 1946 and 1954, significantlymore females than males had seldomor never practised obstetrics. Amongthe youngest respondents (those bornafter 1954) there were no significant

Figure 1Obstetrical Practice of Respondents (n=1338)

Have practised little Have stopped obstetricalor no obstetrics ever practice (n=370)(n=393) 29% of total 28% of total

Currently practise obstetrics(n=529) 40% of total

Have considered/ ~~~~~stopping \/\ ~~~~~obstetrical \

\ ~~~~practice\

\ ~~~~Have considered/stopping obstetrical practice

60%


differences between males and females likely as those born after 1954 never toin relation to choices concerning ob- have practised. Of those female physi-stetrical practice. cians practising obstetrics, signifi-Female family physicians, as a cantly fewer of the youngest respon-

group, have increased in number in dents (those born after 1954) had givenproportion to male family physicians, up this part of their practice, and morebut their patterns of obstetrical practice of them were practising obstetricshave not changed a great deal. Female without considering stopping.respondents born before 1946 were as Significantly more of the youngest

Table 5Reasons for Discontinuingor Considering Discontinuing Obstetrical Practice

A B C D E

1. Interference with personal andfamily life 42% 69% 87% 73% 90%

2. Interruption of office schedule 30% 51% 56% 44% 54%3. Increasing CMPA fees 28% 37% 37% 62% 65%4. Low financial incentive 26% 35% 39% 59% 64%5. Fee didn't compensate for lost

office time 24% 36% 39% 47% 54%6. Insufficient number of deliveries 22% 39% 37% 30% 34%7. Fear of litigation 17% 19% 25% 41% 47%8. Unrealistic patient expectations 10% 14% 19% 18% 16%9. Inadequate training 10% 13% 22% 12% 22%

10. Hassles with labour-room nurses 7% 13% 17% 8% 7%11. Not satisfied with own performance 6% 12% 14% 7% 10%12. Hassles with obstetricians 5% 9% 11% 6% 7%13. Other (personal reasons) 10% 24% 17% 8% 4%

A = all respondents who ever practised obstetrics (n= 902)B = all respondents who have discontinued obstetrical practice (n= 370)C = all respondents born in 1946 or later who have discontinued

obstetrical practice (n= 127)D = all respondents who practise obstetrics, but have considered

stopping (n= 305)E = all respondents born in 1946 or later who practise obstetrics, but

have considered stopping (n= 147)

Table 6Main Reason Given for Discontinuing the Practice of Obstetrics

A B C D E1. Interference with lifestyle 24% 26% 39% 29% 41%2. Other (personal reasons) 9% 15% 6% 4% 4%3. Insufficient number of deliveries 8% 9% 11% 7% 7%4. Increased CMPA fees 6% 4% 1% 10% 6%5. Low financial incentive 4% 3% 2% 8% 8%6. Interruption of office schedule 2% 4% 3% 1% 1%7. Unrealistic patient expectations 2% 3% 2% 2% 1%8. Inadequate training 3% 2% 2% 2% 3%9. Fear of litigation 3% 2% 7% 4% 6%

10. No main reason 16% 20% 20% 15% 18%

A = all respondents who ever practised obstetrics (n= 902)B = all respondents who have ceased to practise obstetrics (n= 370)C = all respondents born in 1946 or later who have ceased to practise

obstetrics (n= 127)D = all respondents who practise obstetrics, but have considered

ceasing to do so (n= 305)E = all respondents born in 1946 or later who practise obstetrics, but

have considered ceasing to do so (n= 147)

males (those born after 1954) havenever practised obstetrics. The oldermale respondents (those born before1946) were significantly more likely tohave practised obstetrics and now haveceased to do so. The youngest male re-spondents (those born after 1954) werealso significantly more likely than theolder respondents to be practising ob-stetrics without considering stopping.

On-call arrangementsSeventy-two per cent of those re-

spondents practising obstetrics haveon-call arrangements, and of these,84% have arrangements with anotherfamily physician and 14% with an ob-stetrician. Eighty-one per cent of re-spondents take their own obstetricalcalls even at times when their practiceis signed out to a colleague. Respon-dents who have ceased to practise ob-stetrics refer 50% of their patients toobstetricians, 10% to family physi-cians, and 22% to both. (Eighteen percent of the physicians in this categorydid not respond to this question.)Those physicians surveyed who hadnever practised obstetrics refer 51% oftheir pregnant patients to obstetricians,7% to family physicians, and 12% toboth. (Thirty per cent did not respondto this question.) Respondents choos-ing not to refer obstetrical patients toanother family physician base theirchoice on the following: patient re-

Table 7Respondents Who HavePractised Little or No Obstetrics:,

Reasons forCeasing A B C

Inadequatetraining 36% 40% 40%

Never been ofinterest 32% 26% 21%

Lifestyle 15% 20% 23%Distance from

hospital 4% 3% 4%Practisingemergencymedicine 6% 9% 9%

Inadequatevolume 4% 4% 6%

Currently doinglocums 5% 5% 5%

A = all respondents (n= 393)B = respondents born in 1946 or later

(n=242)C = Family Medicine Residency

trained (n= 166)


quests (21%); few family-physiciancolleagues practise obstetrics (11%);no family-physician colleagues prac-tice obstetrics (6%); desire to refer tothe best-qualified physicians (10%);convenience (2%); unwillingness ofother family physicians to accept extraobstetrical cases (4%); and other as-sorted personal reasons (12%).Overall changes in practicesince giving up obstetrics

Approximately 43% of the respon-dents who have ceased to practise ob-stetrics have noted no change in theirpractice pattern in relation to thenumber of children seen or to the pro-portion of office- or hospital-basedwork they do (Table 11). Forty-threeper cent of the respondents see fewerchildren, 42% indicated that theirpractices are now more highly office-based, and 39% said that their prac-tices are now less hospital-based.Eighty-eight per cent of the respon-dents reporting changes in their prac-tice patterns stated that they were satis-fied with these changes, and 79% ofthese respondents reported that theirpatients were satisfied with thechanges. The remaining 12% of thisgroup were personally dissatisfiedwith the changes, and 21% reportedthat their patients were dissatisfied aswell.

Role ofmidwivesThe response to the question, "If an

increasing number of Family Physi-cians stop obstetrical deliveries, whoshould do them?" is shown in Figure

2. There is a strong feeling (72%) thata selected group of family physicians/general practitioners with a special in-terest in obstetrics should attend thesedeliveries, either alone (28%), in asso-ciation with an obstetrician (23%),with a well-trained midwife (6%), orwith all three (15%). Although only asmall number of respondents (6%) be-lieved that well-trained midwivesalone should perform this service, theresponse to the question, "Would yoube willing to accept well-trained mid-wives performing low-risk deliveriesin hospital with supervision?" was an-swered affirmatively by 53% of the re-spondents. Significantly more femalephysicians, CFPC Certificants, gradu-ates of U.K. medical schools, andphysicians from larger communitiesand larger hospitals replied affirmati-vely to this question. Questions con-cerning other models of midwiferycare were not included in this survey,and therefore these responses shouldbe considered as only preliminary.Further research would be required todetermine the most suitable/acceptablemodels of midwifery from the perspec-tive of family physicians/general prac-titioners.

Discussion/FutureProjectionsOf all of the respondents practising

obstetrics at any time who later discon-tinued this part of their practice, ap-proximately 75% had ceased to prac-tise obstetrics since 1975. This findingraised the question: "What has oc-curred during the past 12 years to

Table 8Choice of Obstetrical Practice by Population of Community

Less than 10,001- 50,001- 100,001- 500,001 NA10,000 50,000 100,000 500,000 or more

All respondents whohave never practisedobstetrics 13% 16% 11% 33% 24% 3%(n=393)All respondents whohave discontinued OBpractice 12% 20% 18% 26% 22% 2%(n =390)All respondents whopractise OB but haveconsidered stopping 23% 30% 13% 24% 8% 2%(n=305)All respondents whopractise OB and havenot consideredstopping 28% 26% 10% 28% 7% 0%(n=227)

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change dramatically the pattern of ob-stetrical practice of family physiciansin Ontario?"Our study results point us in a

number of directions. They indicatethat respondents practising obstetricswere likely to be living in Ontario'ssmaller communities, and those notpractising obstetrics were likely to beliving in the province's larger commu-nities. The observation relating obste-trical practice choices to communitysize supports that of Klein and his col-leagues,' who found that in largercommunities, where numerous obste-tricans are available, family physiciansare less likely to practise obstetrics.By subdividing the data according

to the age-defined subgroups that wedescribed earlier, a progressive in-crease was seen in the proportion offamily physicians who have seldom ornever practised obstetrics: 30% of thetotal group of respondents belonged tothis category, 36% of those born after1946, and 46% of those born after1954.On detailed examination of these

differences in practice patterns amongthe age groups, when considered bysex, the data showed that the increasedpercentage of the youngest physicianschoosing not to practise obstetrics re-sulted both from the larger numbers ofmale physicians choosing not to prac-tise obstetrics, and from the higherpercentage of female physicians in thisage category. Among female familyphysicians, regardless of age, the pro-portion (approximately 50%) of thosechoosing not to practise obstetrics hasremained more or less the same. Theyounger male physicians are now ap-proaching the same rate (46% accord-ing to our data) of choosing not topractise obstetrics. Those who ceasedto practise obstetrics were significantlymore likely to be the older male re-spondents.Our study data for the youngest

group of respondents is limited, but itnow appears that the current propor-tion of female-to-male residents infamily medicine programs is nearlyequal, and that the youngest physi-cians of both sexes in equal propor-tions, have chosen not to practice ob-stetrics.Our study team examined in detail

the respondents' reasons for not prac-tising obstetrics. Tables 5, 6, and 7summarize the reasons stated by vari-ous subgroups of respondents for


never having practised obstetrics, orfor ceasing to do so, or for consideringgiving up the practice of obstetrics.One of the primary reasons given byall of the above-mentioned groups isthe interference obstetrical practicecauses with their lifestyle and familylife. They next cited financial losses,in terms both of office time and ofCMPA fees.A number of respondents said that

the chief reason for their initial lack ofinvolvement in obstetrical care wastheir belief that they had been inade-quately trained in obstetrics. In addi-tion, a number of respondents hadchosen to spend extra time taking ob-stetrical training. This latter groupshowed the highest degree of confi-dence in undertaking various basic ob-stetrical procedures on starting prac-tice. A recent report, produced by theSociety of Obstetricians and Gyneco-logists of Canada in collaboration withthe College of Family Physicians ofCanada, recommended a longer periodof training than most family physi-cians/general practitioners have under-taken to date. Such an extension oftraining time might tend to increase thenumbers of graduates of Family Medi-cine Residency Programs who chooseto do obstetrics, although it might nothave much effect on those who havenever been interested in this area offamily practice. In addition, a smallnumber of respondents who had dis-continued obstetrical practice statedthat their reason for doing so was thatthey considered themselves inadequa-tely trained or were dissatisfied withtheir performance.The retrospective nature of our

study may have influenced the respon-dents' responses to some questions,such as the perceived adequacy of theirtraining on starting medical practice.One's memory of the reasons underly-ing a decision made 10 to 15 years agocan be affected by all that has occurredsince. The family physician who chosenot to practise obstetrics may re-member inadequate training as a primereason for the choice. A colleague whotrained in the same program might ini-tially have felt the same sense of inad-equacy, but might have gained compe-tence through experience and thesupport of fellow practitioners andconsultants.

According to Klein and his col-leagues,' some training environmentsmay adversely affect the trainees'


Table 9Choice of Obstetrical Practice by Age Subgroup

A B C D

All respondents 22% 40% 23% 15%born before 1946 69% male 92% male 92% male 85% male(n=620) 31% female 8% female 8% female 15% female

All respondents 36% 22% 25% 17%born between 66% male 76% male 83% male 84% male1946 and 1954 34% female 24% female 17% female 16% female(n=476)

All respondents 49% 6% 20% 25%born after 1954 61% male 80% male 71% male 67% male(n=171) 39% female 20% female 29% female 33% female

A = all respondents who have never practised obstetrics (n =393)B = all respondents who used to practice obstetrics but have now stopped

(n=370)C = all respondents who currently practice obstetrics, but have considered

stopping (n=305)D = all respondents who currently practice obstetrics, and have not thought

about stopping (n=227)

Table 10Choice of Obstetrical Practice by Sex and Age Subgroup

A B C D

Male respondents 17% 43% 25% 15%born before 1946(n= 534)Female respondents p 00 49% 22% 13% 16%born before 1946(n=86)

Male respondents 31% 22% 28% 18%born between 1946and 1954 (n=360)

Female respondents & P 50% 22% 17% 11%born between 1946 Jand 1954 (n= 1 16)

Male respondents 46% 7% 22% 25%born after 1954(n= 1 12) not

Female respondents significant 56% 3% 17% 24%born after 1954(n=59)

A = all respondents who never practised obstetrics (n=393)B = all respondents who used to practice obstetrics but have now

stopped (n=370)C = all respondents who currently practice obstetrics, but have

considered stopping (n=305)D = all respondents who currently practice obstetrics and have not

thought about stopping (n=227)

2699

choice to include or not include obste-trics in their practice. Family practiceresidency training in a tertiary-carecentre oriented to high-risk care maycreate the impression that obstetrics isa risky business best left to others. Onthe other hand, exposure to familypractice role models who incorporateobstetrics into a busy family practicein a community-hospital setting wouldplace the trainee in an environmentwhere elective monitoring and episio-tomy rates are low, and an expectantapproach is taken to the conduct ofnormal labour. The creation of a sec-tion of Family Practice Obstetrics in ateaching hospital might not only facili-tate appropriate training in family-cen-tered in-hospital maternal care, butmight also promote and maintain opti-mal obstetrical skills through continu-ing medical education and audit of pa-tient care.1 Training in family practiceobstetrics should ensure the acquisi-tion of the level of skill and confidencerequired to identify the high-risk pa-tient; it should also enable the familyphysician to provide the unique conti-nuity of care required for the woman

and her family who seek a natural, lesstechnical delivery.The study date showed that 81% of

family physicians take their own ob-stetrical calls, even though their prac-tice is otherwise signed out. This find-ing is not surprising, given the bondthat develops between the attendingphysician and the obstetrical patientduring family and prenatal care. En-couraging on-call arrangements withcolleagues and peers might allowmany family physicians to spend unin-terrupted time with their own familiesand even reduce the "interuption oflifestyle" that is given as a reason fordiscontinuing obstetrical practice.

Indeed, urgent attention must begiven to the problem of how to reducethe interference of obstetrical practicewith the physician's lifestyle and fam-ily life, as this is becoming a majorreason for family physicians to leavethe practise of obstetrics. As this rea-son is mentioned even more frequentlyby the younger physicians, this prob-lem will not decrease, and is likelyonly to worsen. Further study of prac-tice management among those family

Table I 1

All RespondentsWho Have StoppedPractising Obstetrics

(n= 370)See infants and

children:

Office-basedpractice:

Hospital-basedpractice:

MoreLessNo changeNAMoreLessNo changeNAMoreLessNo changeNA

3%43%44%9%

42%5%43%10%

4%39%43%14%

All RespondentsBorn in

1946 or LaterWho Have

Stopped PractisingObstetrics(n= 127)

6%24%59%10%

39%6%44%12%

4%37%46%13%

(n=233) (n=77)Personallysatisfied Yes 88% 87%with reported No 12% 13%changes:

(n=261) (n=81)Patients are Yes 79% 77%satisfied No 21% 23%with reportedchanges:

2700

practitioners who have never thoughtof discontinuing obstetrical practicemight determine why there is less in-terference with lifestyle in their prac-tices and/or provide insight into effec-tive obstetrical practice-managementstrategies.

Sharing some of the responsibilitywith a well-trained midwife might pro-long the family physician's involve-ment in obstetrics. While our studyshowed that most respondents gener-ally supported the role of the well-trained midwife in a hospital setting, italso showed clearly that the midwifewas to work "with supervision". Asmentioned earlier, other models ofmidwifery care were not explored andwould need to be the subject of furtherresearch.

Financial concerns are also amongthe leading reasons for giving up ob-stetrical practice. Among the reasonsstated were interruption of officeschedule, increasing CMPA fees, lowfinancial incentive, and a fee that doesnot compensate for the loss of officetime. All these responses indicate thatthe financial considerations relating toobstetrical services provided by familyphysicians must be re-examined. Asuitable fee-for-service mechanismwill be needed to encourage familyphysicians to continue to practise ob-stetrics in Ontario.When asked who should attend ob-

stetrical deliveries if an increasingnumber of family physicians/generalpractitioners cease to practise obste-trics, 72% of respondents stated that aselect group of family physicians witha special interest in obstetrics shouldprovide this service, either alone or inco-operation with obstetricians and/ortrained midwives. There was quite adiscrepancy, however, between whatthe respondents believed the situationshould be and their own practices.When physicians who themselves hadgiven up obstetrical practice wereasked to whom they referred their ob-stetrical patients, 50% stated that theyreferred their patients to obstetricians;10% referred their patients to familyphysicians, and 22% referred them toboth. Those who had never practisedobstetrics referred only 7% of obstetri-cal cases to a family physician and12% to both family physicians and ob-stetricians. The chief reason cited fornon-referral of such patients to a fam-ily physician was patient requests(21%). This response may indicate


public unawareness of the fact thatmany family physicians still practiseobstetrics, and that they could ask forreferral to a family physician whopractises obstetrics, as it is not neces-sary to have an obstetrician to deliver ababy! A public-education programmight serve to promote family practiceobstetrics.

Other reasons often given for non-referral of obstetrical patients to a fam-ily physician were that few or no fam-ily physician colleagues practiseobstetrics (17%), or that family physi-cians do not want to take on additionalobstetrical cases (4%). According toour study data, 40% of our respon-dents do practise obstetrics, and 7%have even considered stopping be-cause of the low number of deliveriesthey attend. The situation may dependon the practice setting and on the avail-ability of obstetricians in the area, butit may also stem from a lack of sharedknowledge among family physiciansconcerning who among their col-leagues is practising obstetrics andwould be willing to take referral pa-tients. In a large city, in particular,where there may be many hundredfamily physicians-and many obstetri-cians as well-a central registry offamily physicians practising obstetrics

might also serve to promote and pre-serve the place of obstetrical care infamily practice.

ConclusionsOur study has identified some sa-

lient points relating to the place of ob-stetrics in family practice in Ontario.We put forward for consideration thefollowing items:* It must be accepted that not allfamily physicians wish for various rea-sons to practise obstetrics. Among theyoungest physicians (those born after1954) approximately 50% have notpractised and do not intend to practiseobstetrics. The remaining half how-ever, might be encouraged to continuein obstetrical practice or recommencethat practice.* Interference with their lifestyle andfamily life is a major concern for thosewho have discontinued or are consid-ering discontinuing obstetrical prac-tice. Encouraging group obstetricalon-call arrangements, as well as shar-ing some of the responsibility with awell-trained hospital-based midwife,might help to reduce the effect of thisconcern. Further in-depth study ofpractice management in family prac-tices where there has been no thoughtof giving up obstetrical practice might

identify additional practice-manage-ment strategies in this area. Further re-search into models of midwifery careshould also be conducted.* Financial concerns are part of anumber of reasons given for giving upor considering giving up obstetricalpractice. Reimbursement for obstetri-cal services must be re-examined at theappropriate level in Ontario, and amore suitable payment mechanismmust be implemented.o Existing obstetrical training pro-grams for family physicians should bere-evaluated. Training in family-prac-tice obstetrics should provide the levelof skill and confidence required toidentify the high-risk patient and tocare properly for and deliver the low-risk patient.* A public-education program mightheighten public awareness that familyphysicians do indeed practise obste-trics, and that low-risk obstetrical pa-tients do not need the care of an obste-trician.* Registries of family physicianspractising obstetrics and willing totake referral patients should be estab-lished to assist family physicians whowish to refer their obstetrical patientsto other family physicians.

References1. Klein M, Reynolds JL, Boucher F, et al.Obstetrical practice and training in Cana-dian family medicine: conserving an en-dangered species. Can Fam Phys 1984;30:2039-9.2. Woodward C, Adams 0. Physician re-source data bank numbers, distribution andactivities of Canada's physicians. Can MedAssoc J 1985; 132:1175.3. Gorsche RG, Falk WA. Family physi-cians' attitudes towards obstetrics in Al-berta. Can Fam Physician 1983; 31:1869-77.4. Cutner LP, Peters RK. Obstetrics/gyne-cology for family practice residents: a sur-vey of family practice programs in the LosAngeles area. Fam Pract Research J 1983;3, 2:64-73.5. Perkin RL. Position paper: family prac-tice obstetrics in Canada from The Collegeof Family Physicians of Canada to theCanadian Medical Association Sub-Com-mittee on Obstetrical Care. September1986.6. Perkin RL. Family practice obstetrics:SOGC Bulletin March/April 1986.7. Hannah WJ, Pace AM, Klein MC. Thefamily physician's role in obstetrics.SOGC Bulletin, July/August 1986.

Figure 2If an increasing number of Family/General Practitioners stopperforming obstetrical deliveries, who should do them? (n= 1338)

A selected group of Only a selected group offamily physicians, family physicians withand obstetricians special interest in/ 23% obstetrics

23% ~28%

Obstetricians A selectedonly A group of family

15% selec~Ated Trained physicians &group of midwves ined midwivesfamily only 6%

physicians, 6%obstetricians,

NA and trained5% midwives

Obstetricians, 15%and trainedmidwives2%


The Family Doctor in Obstetrics: Who's Looking after the Shop?

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