To the Editor:

I commend Dr. Ramírez on her well-written article describing an evidenced-based approach to prenatal care.¹ There is a need for a strong maternal health curriculum in family medicine residency programs. The 2023 revised Accreditation Council for Graduate Medical Education program requirements for family medicine continue to highlight the importance of family physicians providing care to pregnant patients, including low-risk prenatal care.² Although most graduates of family medicine residency programs will not continue to perform vaginal deliveries, more physicians who provide prenatal and postnatal care are needed in the United States.^3,4 According to the 2022 March of Dimes Maternity Care Deserts report, 36% of U.S. counties do not have an obstetric clinician of any type, affecting up to 6.9 million women.⁴ The lack of access to prenatal care is also an issue of health equity. In 2020, 1 in 5 Black women (20.1%) did not receive adequate prenatal care compared with only 1 in 10 White women (9.9%).⁴ As Dr. Ramírez states, a lack of prenatal care impacts maternal health.¹ From 2018 to 2021, the U.S. maternal death rate almost doubled to 33 maternal deaths per 100,000 live births.⁵ For the first time in its publication's history, the March of Dimes report has highlighted that family physicians are “…an integral part of the maternity care workforce.”⁴ Family physicians go where others will not, providing care in 93.5% of U.S. counties.⁴ One way to address maternity care deserts is to design residency curricula encouraging family medicine residents to practice low-risk prenatal care after residency regardless of whether they perform deliveries. We must continue to develop collaborative systems of care where family physicians work as part of a larger health care team caring for pregnant patients. In Georgia, we have begun exploring the establishment of such systems, and we look forward to collaborating with others on this important work.

In Reply:

I appreciate Dr. Lanham's comments and share the sentiment expressed in this letter. As noted by Dr. Lanham, family physicians are known to provide care to pregnant individuals with a higher burden on their health from a social determinants of health perspective.¹ With an estimated shortage of 9,000 prenatal care clinicians by 2030, the need for family physicians who provide prenatal care is glaring; however, 87% of family medicine residents opt not to provide this care after graduation, with those underrepresented in medicine being the least likely to provide this care.¹

The United States has the highest number of pregnancy-related deaths in the developed world, and maternal health disparities continue to worsen. Black patients have a three times higher risk of pregnancy-related deaths compared with White patients.² Maternal health inequities in the United States are deeply rooted in racism, discrimination, and social determinants of health. Addressing maternal health equity must include the enhanced recruitment and retention of racially and ethnically diverse physicians, consistent with the 2003 Institute of Medicine report.³ The U.S. population has become more diverse, but the same cannot be said for the physicians who care for them. Even 20 years after the publication of the Institute of Medicine report, only 1 in 5 family medicine residents was underrepresented in medicine (10% Hispanic/Latino, 9.3% Black or African American, 1.0% American Indian or Alaska Native, and 0.3% Native Hawaiian or other Pacific Islander).⁴ Recruitment and retention of physicians underrepresented in medicine is hampered by the persistence of structural racism despite increased diversity, equity, and inclusion efforts.⁵

Achieving maternal health equity in the United States requires enhanced education and training, allowing for mitigation of the continued impact of structural racism, racism in medicine, and social determinants of health. Addressing factors that continue to perpetuate racial trauma for students, residents, and physicians underrepresented in medicine helps improve the recruitment and retention of a physician group known to be desired for the provision of prenatal care by minoritized communities.⁶