Family Physicians' Declining Contribution to Prenatal Care in the United States

One Pagers | Dec 15, 2002 Janelle Guirguis-Blake, MD; Ed Fryer, PhD; Mark Deutchman, MD; Larry Green, MD; Susan Dovey, MD, MPH; Robert Phillips, MD, MSPH

There has been a substantial decline in prenatal care by family physicians over the past 20 years in all geographic regions of the country. Even so, during the past two decades, FP/GPs have provided over two million prenatal visits per year. As the field re-explores future scope, it should consider the erosion of the provision of prenatal care, its effect on the U.S. population and the specialty, and possibilities for revitalization of prenatal care in residency curricula and practice.

We analyzed National Ambulatory Medical Care Survey (NAMCS) data spanning 1980-1999 identifying all prenatal visits performed by physicians. In order to create comparison periods consisting of an equal number of annual surveys using all NAMCS data available over the past 20 years, data were aggregated for seven surveys prior to 1993 (early period) and seven surveys after 1992 (later period).

Overall, there were 27.4 million live births in the early period and 27.5 million live births in the later period, yet there was a decrease in total number of prenatal visits performed by all physicians in the country as well as a decrease in number of visits per FP/GP and obstetrician. Total prenatal visits by all medical specialties decreased from 192 million in the early period to 182 million in the later period with the loss of visits seen largely in areas outside of Metropolitan Statistical Areas (non-MSAs). The table below focuses on the two specialties that, together, provide almost all physician-delivered prenatal visits to US women. FP/GPs provided 33.2 million visits (17.3% of all prenatal visits) in the early period; this contribution dropped to 18.6 million visits (10.2%) in the later period. Most strikingly, there was a 50% drop in number of prenatal visits by FP/GPs in non-MSAs. FP/GP visits decreased in all regions, including the Midwest, where there was the greatest drop in number of visits over time. In the Midwest, FP/GPs delivered 15.5 million visits in the early period and 6.1 million visits in the later period.

These results support the general impression that FP/GPs' contribution to prenatal care has declined over time. Plausible explanations for these changes include increases in non-physician providers, changes in specialist workforce, or poor access to prenatal services. Nevertheless, FP/GPs continue to make an important contribution to prenatal care especially in non-MSAs. It is unclear whether rural regions would be adequately served if FPs abdicated prenatal care since evidence suggests that these areas are vulnerable to FP/GP service withdrawal.

Table. Prenatal Visits Provided by FP/GPs in Two Seven-Year Periods

RegionVisits in early period in millions (% of total visits in regions)Visits in later period in millions
Region: MSAVisits in early period in millions (% of total visits in regions): 10.0 (8.4%)Visits in later period in millions: 11.8 (7.7%)
Region: non-MSAVisits in early period in millions (% of total visits in regions): 17.7 (38.7%)Visits in later period in millions: 6.8 (23.7%)
Region: NortheastVisits in early period in millions (% of total visits in regions): 1.6 (5.0%)Visits in later period in millions: 1.0 (3.8%)
Region: MidwestVisits in early period in millions (% of total visits in regions): 15.5 (28.8%)Visits in later period in millions: 6.1 (13.6%)
Region: SouthVisits in early period in millions (% of total visits in regions): 8.6 (15.2%)Visits in later period in millions: 6.4 (9.7%)
Region: WestVisits in early period in millions (% of total visits in regions): 7.4 (14.9%)Visits in later period in millions: 4.9 (11.0%)
Region: Total VisitsVisits in early period in millions (% of total visits in regions): 33.2 (17.3%)Visits in later period in millions: 18.6 (10.2%)

Table. Prenatal Visits Provided by OBs in Two Seven-Year Periods

RegionVisits in early period in millions (% of total visits in regions)Visits in later period in millions
Region: MSAVisits in early period in millions (% of total visits in regions): 104.3 (88.0%)Visits in later period in millions: 136.2 (88.6%)
Region: non-MSAVisits in early period in millions (% of total visits in regions): 25.7 (56.2%)Visits in later period in millions: 21.4 (74.6%)
Region: NortheastVisits in early period in millions (% of total visits in regions): 29.1 (91.2%)Visits in later period in millions: 24.2 (91.0%)
Region: MidwestVisits in early period in millions (% of total visits in regions): 37.1 (68.8%)Visits in later period in millions: 37.5 (83.5%)
Region: SouthVisits in early period in millions (% of total visits in regions): 46.0 (81.1%)Visits in later period in millions: 58.7 (88.5%)
Region: WestVisits in early period in millions (% of total visits in regions): 40.8 (82.4%)Visits in later period in millions: 37.2 (83.4%)
Region: Total VisitsVisits in early period in millions (% of total visits in regions): 152.9 (79.6%)Visits in later period in millions: 157.5 (86.4%)
Region: Definitions
Early period= seven annual surveys between 1980-1992 (1980, 1981, 1985, 1989-1992)
Later period= seven annual surveys between 1993-1999
MSA=Metropolitan Statistical Area=county or group of contiguous counties that contains at least one city with a population of >50,000 or a Census Bureau-defined urbanized area of at least 50,000 with a metropolitan population of >100,000.
Non-MSA=non-Metropolitan Statistical Area=county that does not meet above criteria.
MSA plus non-MSA not equal to 100% due to missing NAMCS data.

The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP. 

Published in American Family Physician, Dec 15, 2002. Am Fam Physician. 2002;66:2192. This series is coordinated by Sumi Sexton, MD, AFP Associate Medical Editor.