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Influences on intentions for obstetric practice among family physicians and residents in Canada: an explorative qualitative inquiry

Abstract

Background

Many family medicine residency graduates indicate a desire to provide obstetric care, but a low proportion of family physicians (FPs) provide obstetric care within their practice. This suggests personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care. If decisionmakers plan to augment the number of FPs providing obstetric care, barriers to the provision of such care must first be identified. Within this paper, we explore the perspectives of both family practice residents and early-career FPs on the factors that shaped their decision to provide obstetric care.

Methods

In this qualitative study, we analyzed a subset of interview data from three Canadian provinces: British Columbia, Ontario, and Nova Scotia (n = 18 family practice residents; n = 39 early-career FPs). We used thematic analysis to analyze data relevant to obstetric care practice, applying the socio-ecological model and comparing themes across participant types, gender, and province.

Results

Participants described influences affecting their decision about providing obstetric care. Key influencing factors aligned with the levels of the socio-ecological model of public policy (i.e., liability), community (i.e., community needs), organizational (e.g., obstetric care trade-offs, working in teams, sufficient exposure in training), interpersonal practice preferences (i.e., impact on family life, negative interactions with other healthcare professionals), and individual factors (i.e., defining comprehensive care as “everything but obstetrics”). Many participants were interested in providing obstetric care within their practice but did not provide such care. Participants’ decision-making around providing or not providing obstetric care included considerations of personal preferences and outside influences.

Conclusions

Individual-level factors alone do not account for the decrease in the type and amount of obstetric care offered by FPs. Instead, FPs’ choice to provide or not provide obstetric care is influenced by factors at higher levels of the socio-ecological model. Policymakers who want to encourage obstetric practice by FPs should implement interventions at the public policy, community, organizational, interpersonal, and individual levels.

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Background

Family physicians (FPs) are trained to offer comprehensive healthcare across the life course [1]. Although family medicine scope of practice can include full obstetric care (prenatal, intrapartum/deliveries, and postpartum), many FPs in North America do not provide intrapartum care/deliveries as part of their practice [1,2,3,4,5,6,7]. Numerous factors shape FPs’ decision to provide obstetric care, including an interest in obstetrics early in medical training [3], concerns about irregular hours and work/life balance [1, 2, 5, 8], fear of poor patient outcomes [1, 2], and burnout [9]. Many family medicine residency graduates indicate a desire to provide obstetric care in their practice, demonstrating that personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care [1, 10].

A low proportion of FPs providing full obstetric care may be cause for concern, particularly in rural regions where many patients rely on FPs for obstetric care [1, 2, 4]. Additionally, the provision of obstetric care has been posited to influence burnout among FPs: its inclusion as part of the broad scope of practice is associated with lower levels of burnout [11]. However, in what is referred to as a family medicine-obstetrics paradox, among early-career FPs, including full obstetrics in practice has been associated both with risk factors that increase burnout (e.g., stress and call schedules) and with features that lessen burnout (e.g., enjoyment and variety in practice) [12]. Addressing barriers to the provision of obstetric care among FPs may help to protect them against burnout.

In this paper, we present the perspectives of both family practice residents and early-career FPs (< 10 years in practice) on factors influencing their decision to provide full obstetric care or not. Our study explored viewpoints from three Canadian provinces (British Columbia [BC], Ontario [ON], and Nova Scotia [NS]), providing a unique cross-provincial outlook across the early stages of FP careers when most FPs make the decision to provide obstetric care as part of their practice [13]. We apply a socio-ecological model [14] to help elucidate intervention opportunities if policymakers seek to augment the provision of obstetric care.

Methods

Study design and participants

We analyzed semi-structured qualitative interview data from an exploratory, cross-provincial study exploring practice intentions and decision-making among residents and early-career FPs (< 10 years in practice). The full details of this study are available in the published protocol [15]. Participants in BC, ON, and NS were recruited via provincial medical association newsletters, family medicine residency programme email lists, and social media (Twitter and Facebook). Participants were eligible to participate in the study if they were a family medicine resident, or if they were a FP who had completed their family medicine residency between 2008 and 2018 and were currently practicing. Participants also had to be practicing in BC, ON, or NS. Potential study participants completed a demographic screening questionnaire to ensure they met the study’s inclusion criteria and facilitate diverse purposeful sampling based upon previously identified characteristics (i.e., gender, relationship status, whether they have dependents, rurality, specialization, practice/training location, practice type/model) [15]. During the recruitment period, 359 residents and family physicians completed the demographic screening questionnaire. Of these, 32 family medicine residents and 69 early-career FPs were invited to participate in the study. Participants were chosen based upon responses to the questionnaire to ensure maximum variation. Interviews were completed with 31 of 32 family medicine residents and 63 of 69 early-career FPs invited to participate across the three Canadian provinces (NS, ON, BC). Seven interviews were declined due to scheduling conflicts, lack of response, or an undisclosed reason. Participants were offered an honorarium.

Data collection and analysis

Using semi-structured interview guides (Additional file 1), telephone interviews (~ one hour) with family medicine residents and early-career FPs explored factors shaping their practice intentions and choices [15]. To reduce the possibility of recall bias, interviewers used the same interview guide, and used probes to elicit rich responses. Interviews were conducted by three Master’s or Ph.D. trained qualitative research staff members under the supervision of experienced PhD university faculty and the principal investigators of this study (EGM, AG, LG, & RL). Interviews were audio-recorded and transcribed verbatim. Interviewers recorded interview summaries and reflections following each interview. Recruitment continued until no new themes were identified within the interviews. Data were analyzed iteratively through an inductive thematic analysis [16] and then inductively coded using codebooks developed with early interview transcripts by the three research staff members. Codebooks were refined iteratively to incorporate emerging themes. Study data were managed using NVivo software [17].

Data analysis for this paper involved thematic analysis of text relevant to obstetric practice pulled from thematic coding. In this paper, “obstetrics” typically refers to the FP practice of labour and delivery services, although participants may have referred to other aspects of obstetric care when using this term [12]. The team met to discuss themes until all were confident that participant perspectives were represented. Data were observed by gender and career stage (i.e., resident or early-career FP) and subgroup analyses were performed across these characteristics. Themes were organized according to a socio-ecological model [14] to identify specific factors influencing the decision to provide obstetric care at the level of the individual, interpersonal, organization, community, and public policy. Socio-ecological models have been used in healthcare research [18,19,20,21] and enable researchers to identify predictive factors beyond the individual level alone, situating the factors where improvements through policy and educational efforts could be directed. This study was approved by the Simon Fraser University (#H18-03291), University of Ottawa (#S-05–18-776), and Nova Scotia Health Authority research ethics boards (#1023561). Informed consent was obtained from all participants and all methods were carried out in accordance with relevant guidelines and regulations.

Results

Eighteen family medicine residents and 39 early-career FPs discussed obstetric practice during their interviews. Most participants who spoke about obstetrics practiced in NS. The sample included similar numbers of men and women with variations in relationship status and caring responsibilities who practiced in various settings and models (Table 1).

Table 1 Demographic characteristics of participating family practice residents (n = 18) and early-career family physicians (n = 39) who discussed obstetrics

Themes were identified at each of the socio-ecological model levels: 1) public policy factors (i.e., concerns about liability and risk in providing obstetric care); 2) community-level factors (i.e., community needs); 3) organizational factors (i.e., workload and practice variety considerations, call groups or teams as an enabler, influence of training and exposure to obstetric care, costs associated with sufficient training, gender-based barriers); 4) interpersonal factors (i.e., negative interactions with other healthcare professionals, impact on personal and family life); and 5) individual factors (i.e., defining comprehensive care as “everything but obstetrics”).

Public policy factors

Concerns about liability and risk in obstetric care

As a participant explained, deliveries’ riskiness is reflected in higher insurance costs for FPs who practice obstetrics. The perceived riskiness is described within the quotes from FPs and residents. As some expressed, it was “terrifying” to provide care related to labour and delivery, and exposure to high-risk situations discouraged them from providing obstetric care, even if they previously may have liked to. As an FP expressed, the higher fees and stress and the fact that “outcomes aren’t always favourable” may discourage FPs from providing obstetric care (Table 2).

Table 2 Illustrative participant quotes on concerns about liability and risk in obstetric care

Community-level factors

Community needs as a driver of what services to offer

FPs who would otherwise have provided obstetric care often did not end up doing so if their community had other needs, such as medical assistance in dying (MaiD), or if their patient population was primarily elderly. FPs also considered the services available from other healthcare providers within the community, explaining that if enough providers already offered obstetric care, they were less likely to do so themselves.

Interviewees described the needs of the communities where they practice as a driver of providing obstetrics care or not. FPs may be the sole primary care provider and feel obligated to offer as many services as they can to meet community needs, which may or may not include obstetrics. Participants described greater opportunity to offer obstetric care in rural communities compared to urban communities where such care is often shared with other obstetric providers (Table 3).

Table 3 Illustrative participant quotes on community needs as a driver of what services to offer

Organizational factors

Organizational factors can include influences within one’s work or educational settings. We identified five influencing factors at this level: considerations of disruption, workload, and variety within one’s practice; enabled by working in call groups or teams; influence of sufficient training and exposure to obstetrics; financial and opportunity costs of being sufficiently trained; and “gendered expectations” discouraged men from providing obstetrics.

Considerations of disruption, workload, and variety within one’s practice

FPs and residents shared concerns about the potential disruption to their practice due to the workload and unpredictable time commitment associated with deliveries as a deterrent to practice. However, a few FPs and residents described wanting variety in their practice and were thus motivated to offer obstetric care (Table 4).

Table 4 Illustrative participant quotes on considerations of disruption, workload, and variety within one’s practice

Enabled by working in call groups or teams

Among FPs and residents, sharing work amongst a call group or team was an enabler to providing obstetric care. One FP explained that, in some communities, it is difficult to participate in obstetrics and avoid burnout without a call group or team to support obstetric work. A resident explained that the availability of a good call group model was a key consideration of where to practice. However, the organization and sustainability of call groups can be challenging, potentially leading to burnout if providers are on-call too long or have nobody else to whom they can refer patients. This theme also relates to interpersonal factors, as participants described that they “trust” other providers who may deliver their patients’ babies (Table 5).

Table 5 Illustrative participant quotes on working in call groups or teams as an enabler

The influence of sufficient training and exposure to obstetrics

FPs and residents felt that adequate exposure to obstetrics during their training was influential in their decision to provide obstetric care. Alternatively, having insufficient exposure to obstetrics during training and fewer opportunities to build the skills and confidence needed to provide obstetric care discouraged many interviewees from providing such care. Having negative experiences during training was also discouraging. Some FPs described the importance of continued exposure to obstetrics during early-career practice opportunities, including through locum opportunities. FPs expressed the challenge of returning to providing obstetric care after time away, concerned about the loss of skills (Table 6).

Table 6 Illustrative participant quotes on the influence of sufficient training and exposure to obstetrics

Financial and opportunity costs of being sufficiently trained

Several FPs and residents considered the additional time and costs needed to get sufficient training as influencers of their decision not to provide obstetric care. Although they would have liked to offer such care, interviewees described wanting to enter the workforce or achieve personal goals rather than taking extra time needed for training (Table 7).

Table 7 Illustrative participant quotes on financial and opportunity costs of being sufficiently trained

“Gendered expectations” discouraged men from providing obstetrics

Some participants who identified as men described how gendered expectations moderated their exposure to obstetrics, ultimately discouraging them from providing obstetric care. They described an “anti-male” culture in educational spaces, assumptions that they would not be interested, patient preference or cultural safety, or feeling they could not empathize with birthing patients. An FP who identified as a woman described a positive experience with a male physician and the need for more men in the field (Table 8).

Table 8 Illustrative participant quotes on “gendered expectations” discouraging men from providing obstetrics

Interpersonal-level factors

The interpersonal level includes interactions with other individuals. Two themes were identified at this level – negative interaction with other healthcare providers and impact on personal and family life.

Negative interactions with other healthcare providers

A few FPs described how negative interactions in obstetric care during training or early practice discouraged them from providing obstetric care. An FP explained how working in “toxic” workplaces solidified their decision not to provide obstetric care (Table 9).

Table 9 Illustrative participant quotes on negative interactions with other healthcare providers

Impact on personal and family life

Impact on family life was a commonly cited reason not to provide obstetric care, although only mentioned by interviewees who identified as women. Major challenges discussed by participants included arranging childcare, being away from their children, and coordinating schedules with a partner. Several participants felt that the unpredictable hours associated with labour and delivery discouraged them from providing obstetric care (Table 10).

Table 10 Illustrative participant quotes on the impact on personal and family life

Individual factors

Defining comprehensive care as “everything but obstetrics”

Although obstetric care is part of family medicine training, several FPs and residents did not consider it a necessary component of their definition of comprehensive care. Many participants offered, or planned to offer, comprehensive services but commonly noted that they described comprehensive care as “everything but obstetrics.” Among those respondents who did not plan to offer delivery services, some planned to offer prenatal care for pregnant patients up to around 20 weeks and then care for newborns and pediatric patients (Table 11).

Table 11 Illustrative participant quotes on defining comprehensive care as “everything but obstetrics”

Discussion

Among our family medicine resident and early-career FP participants, interest in providing obstetric care varied – some expressed interest in providing obstetric care, while others expressed disinterest. Many participants were interested in providing obstetric care but did not provide it. Participants’ decision-making around providing or not providing obstetric care included considerations of personal preferences and outside influences. Factors that influenced decisions to provide or not to provide obstetric care have been contextualized within the socio-ecological model.

Through this study, factors influencing the decision to provide obstetric care were identified at all five socio-ecological levels: public policy, community, organizational, interpersonal, and individual (Fig. 1) [14]. Public policy influences encompass regulatory policies and system-level decisions. Our analysis identified that concerns about liability and risk influenced decision-making about whether to provide obstetric care. Community-level factors include the community’s needs and the availability and distribution of resources within a defined region. FPs may be more likely to provide obstetric care in rural regions and less so in urban regions where other providers are available, or different services are needed. Organizational influences encompass characteristics of educational and work environments. Participants perceived that obstetric care could disrupt regular practice, but working in call groups could be an enabler to providing obstetrics. Interviewees suggested that sufficient exposure during training encouraged obstetrics provision and continued exposure allowed FPs to maintain necessary skills to provide obstetric care. Providers could be discouraged from providing obstetric care by the cost of receiving adequate training and negative “gendered expectations” of trainees who identified as men. Interpersonal-level factors include social relationships. Factors at this level included negative interactions with other healthcare providers and the impact that the provision of obstetric care could have on one’s personal and family life. Finally, individual-level factors include personal beliefs, which may be impacted by other levels of the ecological model. Most participants intended to offer a comprehensive practice yet felt that a comprehensive practice encompassed “everything but obstetrics,” a perception that may be shaped by higher-level influences, such as concerns about risk and community need.

Fig. 1
figure 1

The socio-ecological barriers and enablers to offering intrapartum care

In North America, fewer FPs are providing obstetric care [2, 5,6,7]. Results from our study indicate that individual preference alone may not account for this decline, as many participants in our study wished to provide obstetric care but were discouraged from doing so by several systemic factors. As McLeroy and colleagues argue, system-level problems require system-level solutions [14]. If system planners wish to increase the number of FPs providing obstetric care, interventions should address these systemic challenges. Public policy deterrents could be mitigated by addressing provider concerns about liability and risk in obstetric care and associated costs [7, 22, 23]. At the community level, community needs will continue to drive service offerings; it may be valuable in rural areas to have greater interprofessional, collaborative team support for FPs who wish to provide obstetric care [2, 7, 23]. Additional organizational interventions include increasing exposure to obstetrics during training, creating supportive cultures within training institutions, and improving acceptance of men who wish to provide obstetric care [24]. Collaborative working arrangements such as care teams and obstetrics on-call groups could facilitate obstetric practice [2, 7]. Working with supportive colleagues could reduce the impact of providing obstetric care on one’s practice and family life by sharing the responsibilities to meet the community’s needs [6, 7, 22]. Formal team arrangements can also reduce interpersonal difficulties between obstetric providers [25].

Strengths and limitations of the study

This study provides rich insights into the factors influencing family medicine residents’ and early-career FPs’ decision to provide obstetric care or not. While we conducted interviews with a substantial number of participants, recruitment was purposeful and participants self-identified interest in participating; thus, their views are not generalizable to the population of all family medicine residents and FPs. Around half of the participants who spoke about obstetrics were from the province of Nova Scotia, which may also affect generalizability to FPs working in other jurisdictions. As with all qualitative research, the experiences and perspectives of the researchers played a role in the identification and interpretation of findings. The team includes a variety of skilled personnel, including FPs, family medicine educators, health services researchers, and experienced PhD-trained qualitative researchers who worked to ensure participant perspectives were accurately represented and the research was performed in a rigorous and credible way.

Future work could explore whether the concepts identified within our analyses are generalizable to the population (e.g., through a survey of all family medicine residents and early-career FPs). Such research would inform the development of policies and interventions that may remove barriers to the provision of obstetric care for those FPs who wish to provide such care.

Conclusions

Our objective was to present the perspectives of family practice residents and early-career FPs concerning factors influencing their decision to provide obstetric care. Using a socio-ecological model, influencing factors were identified at the public policy, community, organizational, interpersonal, and individual levels. Our results demonstrate that the decision to provide obstetric care is not influenced solely by individual factors. Instead, barriers at all levels of the socio-ecological model must be addressed if a goal is to enable more FPs to provide obstetric care.

Availability of data and materials

Participants of this study did not agree for their data to be shared publicly, so supporting data are not available.

Abbreviations

FP:

Family Physician

BC:

British Columbia

ON:

Ontario

NS:

Nova Scotia

MAiD:

Medical Assistance in Dying

OB:

Obstetrics

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Acknowledgements

The authors would like to thank all participants in the study for their time and contribution.

Funding

This project was funded by a Canadian Institutes of Health Research (CIHR) Grant (#155965).

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Authors

Contributions

EGM, KH, LRM, and RB conducted the sub-analysis focused on obstetric care and drafted and revised the manuscript. EGM, LJG, MRL, and AG conceived the larger project, obtained grant funding, supervised data collection and coding, helped develop the overall study’s coding template, interpreted results and reviewed the manuscript; ER and LJ collected data, helped develop the overall study’s coding template and coded the data, interpreted results, and reviewed the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Emily Gard Marshall.

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Ethics approval and consent to participate

This study was approved by the Simon Fraser University (#H18-03291), University of Ottawa (#S-05–18-776), and Nova Scotia Health Authority research ethics boards (#1023561). Informed consent was obtained from all participants and all methods were carried out in accordance with relevant guidelines and regulations.

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Not applicable.

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All other authors have declared no competing interests.

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Marshall, E.G., Horrey, K., Moritz, L.R. et al. Influences on intentions for obstetric practice among family physicians and residents in Canada: an explorative qualitative inquiry. BMC Pregnancy Childbirth 22, 857 (2022). https://doi.org/10.1186/s12884-022-05165-1

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Keywords

  • Family practice
  • Obstetrics
  • Scope of practice
  • Socio-ecological models