A glimpse of the future

I don’t try to describe the future. I try to prevent it.

Ray Bradbury

The October issue of Canadian Family Physician focuses on intrapartum care and the role of family physicians.^1–5

Canadian Family Physician has, over the past 2 decades or more, brought the issues surrounding intrapartum care to the attention of our readers and the discipline of family medicine as a whole.^6,7 The overall trend for family physicians to give up practising obstetrics is well documented in both Canada and the United States. The proportion of Canadian family physicians who include full obstetrics in their practices has declined along the following trajectory: in 1997, 20% delivered babies; in 2001, 17.7%; in 2004, 12.9%⁸; and in 2010, 10.5%.⁹ Today most births in Canada are attended by obstetricians and midwives.

Medicolegal anxieties, lifestyle issues, economic factors, interruption of office-based practice, and insufficient training have repeatedly been identified as reasons for this trend. Past studies have focused on the family practice residency experience as it relates to patterns of obstetric practice after graduation and on the factors that influence family medicine trainees to choose to practise obstetrics.¹⁰

This steadily declining role of family physicians in the provision of intrapartum care has many implications, some obvious and some less so. The most obvious, and a profoundly philosophical one, is that it represents the disappearance of a model of care by family physicians that extends from birth to death and throughout the life cycle of individuals and their families.

Less obvious implications, but no less critical, are those discussed by Dr Karen Fleming in her important commentary in this month’s issue of the journal (page 1033).¹ Dr Fleming powerfully and convincingly argues that conditions such as gestational diabetes, hypertensive disorders of pregnancy, and excess maternal weight gain, all of which are on the increase (in part because more women delay pregnancy until later in their reproductive years), provide crucial glimpses into a woman’s future cardiovascular health risks. Not only that, it is well known that there is an intergenerational risk associated with all of these conditions.

If fewer and fewer family physicians are providing intrapartum care, Dr Fleming argues, there is a real risk that family physicians might miss out on important information that could help them reduce women’s risk of developing diabetes and cardiovascular disease many years after their pregnancies. There is good evidence, for example, that women with gestational diabetes mellitus can slip through the cracks.¹¹ In a survey study of more than 200 women with gestational diabetes mellitus and their primary care providers, Keely et al showed that rates of postpartum screening with oral glucose tolerance tests were low, but that reminder letters to both providers and patients could improve follow-up screening rates.¹¹

The days when most family physicians provided comprehensive intrapartum care and continuity of care from birth to death might be over, but family physicians will continue to play an important role in the care of patients throughout the rest of the life cycle. In that capacity, the identification of risk factors and the prevention of future diabetes mellitus and cardiovascular disease will be crucial. Regardless of which models of intrapartum care emerge in the future, it will be essential for family physicians to be intimately familiar with the pregnancy history of their female patients. The future health of these women and their children will depend on it.

• Copyright© the College of Family Physicians of Canada