Current source and future supply of maternity care providers in Texas

By Rebecca H. Gladu, M.D.
Associate Program Director
San Jacinto Methodist Family Medicine Residency
Baytown, Texas

Introduction

In 1999, Texas Family Physician published a report of the number of family physicians practicing obstetrics in Texas. The report included a review of the number of residents interested in doing obstetrics from both family medicine and obstetrics residencies in Texas. In essence, it was a snapshot of the state of obstetrics in the state. This is the follow-up study to the 1999 report.

This article reports the findings of a study by the TAFP Section on Maternity Care to determine the current and future supply of hospital obstetrical providers in Texas, especially in rural areas; estimate the percentage of family practice residents intending to practice obstetrics; and to develop a directory of Texas family physicians who provide obstetrics to improve future research and establish networking. In addition, the article compares the 2005 results with those from 1999.

Will family physicians in Texas continue to provide obstetrics services? Will obstetricians cover care in the rural areas? What factors are involved in physician decisions about choosing to deliver babies?

Methods

The study consisted of three surveys sent from TAFP to the future supply of obstetrics providers, all residents of family medicine and obstetrics-gynecology programs in Texas, all hospitals in Texas and current family medicine physicians practicing obstetrics obtained from the last survey. The resident survey, a five-item questionnaire, was mailed to 16 obstetric and 27 family medicine residency programs in Texas during spring 2005. Residency program directors were asked to distribute the questionnaire to every resident and return the completed survey by mail or fax. Questions asked participants to record their type of residency program, year of residency, whether or not they intended to provide obstetrical services in their practice, if they planned to practice in Texas and whether they planned to practice in an urban, suburban or rural setting.

The hospital surveys were also sent in spring 2005 to all of the Texas hospitals that indicated having at least one obstetrical bed. A letter was sent to the hospital administrator detailing the purpose of the study, questions to be asked and alerting the administrator that someone representing TAFP would call in two weeks to obtain the information by phone. The hospitals reported how many family physicians had obstetrical privileges and how many obstetricians were on staff. Information regarding the number of midwives, anesthesiologists, certified registered nurse anesthetists and the average daily census of total occupied beds was also requested. An additional list of current family physicians who are delivering was obtained from this survey.

The results of the 1999 survey generated a list of family physicians in Texas who provide obstetrics services. These 364 physicians were asked their name, address and practice type, whether they had ever provided obstetrical services in Texas, where they practiced, when they did, if they are presently delivering, if they are planning to continue providing obstetrical services in Texas and if so, for how long. They were then asked to add additional comments of what might help family physicians continue to deliver obstetrics services in Texas.

Results

The Supply Side: Physicians available and willing to provide obstetrics services
Resident survey response rate

Eighty-one percent, or 35 out of 43, of the residency programs surveyed sent at least one response. One family medicine and seven obstetrics programs did not respond. Thirty-three of 364 obstetrics and gynecology residents responded yielding a response rate for obstetrics residents of 9.06 percent. Two hundred ninety of 700 family medicine residents responded, making the response rate for family physicians 41.43 percent.

Resident survey results

Forty-three family medicine residents responded “yes,” that they will deliver babies in their future practices. Of these, 21 intend to stay rural and 28 plan to stay in Texas. Fifty-six say that they will probably practice obstetrics. Of these, eight desire rural practices and 44 plan to stay in Texas. Thirty-four percent of family medicine residents surveyed stated that they will or probably will include deliveries in their practices. Of those, only 10 percent plan to practice obstetrics in rural areas.

Thirty-one of the 33 obstetrics residents responding plan to include deliveries in their practices. Two obstetrics residents, or only 6 percent, stated they were planning to practice in rural Texas.

Hospital survey

Seventy-six percent of surveyed hospitals responded. Forty-nine percent of responding hospitals reported that no family physicians had obstetrical privileges. Only one hospital reported a midwife in practice without a physician on staff. Of the hospitals, 11.5 percent cited family physicians delivering with no obstetrician-gynecologists or midwives on staff.

Physician survey

Fifty-six percent of the physicians surveyed responded to the survey, 203 out of 364. These 364 doctors were identified by the 1999 survey as obstetrics providers. Of those, 83, or 23 percent, had stopped providing maternity services since 1999.

The survey uncovered 271 additional family physicians who provided obstetrics services in 2005 but did not receive the initial survey in 1999. We have not surveyed this group.

Three hundred sixty-three physicians were listed by hospitals in 1999 as providing obstetrics and still have a Texas license in 2005. Three hundred sixty-six physicians were identified as obstetrics providers on the survey of hospitals in 2005 and 107 of those were also identified on the 1999 survey; so in all, 259 new physicians were identified. Adding these together without duplicates, there are 622 family physicians identified as delivering babies in Texas. However, 83 physicians surveyed stated they had stopped delivering babies and noted reasons why they had stopped. So the total number of family physicians identified by the survey as currently delivering babies in Texas is 539 physicians. The Texas Medical Board lists 6,201 physicians who claim family practice as their primary specialty; hence 8.7 percent of the family physicians in Texas are delivering babies. The actual percentage may be slightly higher than this since not all hospitals in Texas responded to the survey.

Reasons family physicians cited for ceasing to deliver babies:

Physicians who had stopped delivering babies sent many comments, a total of 83. The responses can be grouped into five major reasons for discontinuing services:

• The high cost of malpractice insurance,
• Increased or improved obstetrics training in residency and beyond,
• Requests for liability reform,
• Hospital call coverage issues — most involving the lack of ob-gyn colleagues covering for them, and
• Hospital privileging difficulties.

To address the training issues, currently in Texas there are two obstetrics fellowships available for family physicians interested in advanced maternity care. Two more are currently being planned by residency programs.

The Demand side: The burden of deliveries by county

Delivery statistics are available by county as public record. There are 254 total counties in Texas. From our responses, we found 140 of these counties have no obstetrics providers at all. There are 21 counties with only family medicine obstetrics providers and seven counties with one obstetrician and very few family medicine providers.

In 1999, the data showed 121 counties with no obstetrics provider and 43 counties with only family physicians delivering. A previous study in 1989 cited 92 counties with no obstetrics services and 96 counties with family physicians only.

From census data, in 2003 there were 377,374 total births in Texas. 192,269 babies were born in the six most populated counties — Harris, Travis, Tarrant and Hidalgo, Bexar and Dallas counties. 26,190 babies were born in the 140 counties with no providers and 8,898 babies in the seven counties with zero to one obstetricians and one to seven family physician providers. This means that almost 10 percent of all of the babies born in Texas in 2003 were born in areas with none or too few providers.

Infant mortality data available from the same period of time is interesting to consider as well. During the time period from 1999 to 2003 when many counties experienced loss of family physician obstetrics providers, the infant mortality rate overall for Texas increased from 6.2 to 6.6 percent. Infant mortality data is not available before 1997 or from 2004 and 2005 yet. Analysis by county is difficult due to small numbers of deliveries.

An average of 156 babies were delivered per provider in small towns. There are 21 counties with higher than average babies per provider. Add that to the 140 counties with no obstetrics providers and one can safely say that there are 161 counties with a true maternity provider need. In other words, 63 percent of the counties in Texas have an insufficient number of providers for their obstetrics needs.

Since only 10 percent of the family medicine residents and 6 percent of the obstetrics residents surveyed plan to provide services in rural Texas, the future supply of rural maternity care providers will not come from residents currently being trained in Texas residency programs.

Since 83 practicing family physicians have given up obstetrics care citing high cost as the main reason despite recent laws affecting caps and malpractice rates, the supply of doctors providing obstetrics care is decreasing. Most stated they enjoyed providing services, but the cost alone forced them to quit.

In only six years, the number of counties with no obstetrics providers has increased by 7.5 percent, from 121 counties to 140 counties. What will the next six years bring? Will there be any obstetrics care outside of major metropolitan areas? How many babies will be born in counties without obstetrics beds or providers available? In 2003, that was the reality for 10 percent of the babies born in Texas.

The good news is that the practice of obstetrics in Texas by family physicians is alive and well with at least 539 family physicians currently providing services. And, perhaps more importantly, a higher-than-national-average number of residents in family medicine residencies are interested in delivering in the future, almost 35 percent.

Areas for future study

From the results listed here, several questions arise. To determine reasons why family medicine residents don’t choose obstetrics, we could survey the current residents of family medicine. Reasons such as lifestyle and cost may be more important now than in the past.

Clearly the family physicians in this study say that high malpractice costs are the major reason for stopping obstetrics services. What then can be done to encourage more family physicians to include obstetrics in their basket of services for Texans? Can the Texas Academy provide this data to the Texas Legislature to seek further reform in the insurance industry?

Limitations

The low response rate from obstetrics residents was particularly difficult. With only 9 percent responding, no generalizations can be made about future obstetrician-gynecologist intentions. Additionally, the study would have been stronger by knowing which counties recently lost providers in the last six years, as knowing infant mortality rates before and after the family physicians left those 19 counties may have been important.

References

1. Gladu, R. Lange, G. and Groff, J, “Current Status and Future Supply of Providers,” Texas Family Physician, 1999, Jan/Feb/March, p. 14-16.

2. Moy JG, Pilot study report: obstetrical care by Texas family physicians, Tex Med, 1989; 85:53-6.

For more information about this study or to request a copy of the list of Texas family physicians who deliver babies, please contact the author at:

Rebecca H. Gladu, M.D.
4301 Garth Road Suite 400
Baytown, Texas 77521

I’d like to thank TAFP for supporting this study, and especially Kathy McCarthy, Paige Newman and Laurel Catlin for their help in the data collection, recording and analysis.