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EditorialEditorial

A glimpse of the future

Nicholas Pimlott
Canadian Family Physician October 2013; 59 (10) 1031;
Nicholas Pimlott
MD CCFP
Roles: SCIENTIFIC EDITOR
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Figure

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.

Footnotes

  • Cet article se trouve aussi en français à la page 1032.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Fleming K
    . Pregnancy. Window into women’s future cardiovascular health. Can Fam Physician 2013;59:1033-5. (Eng), 1045–7 (Fr).
    OpenUrlFREE Full Text
  2. 2.
    1. Bialystok L,
    2. Poole N,
    3. Greaves L
    . Preconception care. Call for national guidelines. Can Fam Physician 2013;59:1037-9. (Eng), e435–7 (Fr).
    OpenUrlFREE Full Text
  3. 3.
    1. Prince GD
    . Unruptured vasa previa with anomalous umbilical cord formation. A case of postpartum physician tachycardia. Can Fam Physician 2013;59:1076-8.
    OpenUrlFREE Full Text
  4. 4.
    1. Kidd M,
    2. Avery S,
    3. Duggan N,
    4. McPhail J
    . Family practice versus specialist care for low-risk obstetrics. Examining patient satisfaction in Newfoundland and Labrador. Can Fam Physician 2013;59:e456-61.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Ordean A,
    2. Kahan M,
    3. Graves L,
    4. Abrahams R,
    5. Boyajian T
    . Integrated care for methadone-maintained pregnant women. Canadian primary care cohort study. Can Fam Physician 2013;59:e462-9.
    OpenUrlAbstract/FREE Full Text
  6. 6.↵
    1. MacDonald S
    . Duty to deliver. Producing more family medicine graduates who practise obstetrics. Can Fam Physician 2007;53:13-5. (Eng), 17–9 (Fr).
    OpenUrlFREE Full Text
  7. 7.↵
    1. MacLean C
    . Maternity care in Canada: what can we deliver? Can Fam Physician 2010;56:960. (Eng), 961 (Fr).
    OpenUrlFREE Full Text
  8. 8.↵
    1. Biringer A,
    2. Maxted J,
    3. Graves L,
    4. Maternity and Newborn Care Committee
    . Family medicine maternity care: implications for the future. Mississauga, ON: College of Family Physicians of Canada; 2009.
  9. 9.↵
    1. College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada
    . National Physician Survey, 2010. National results by FP/GP or other specialist, sex, age and all physicians. Mississauga, ON: College of Family Physicians of Canada; 2010. Available from: http://nationalphysiciansurvey.ca/wp-content/uploads/2012/07/2010-NationalFP-Q15.pdf. Accessed 2013 Sep 3.
  10. 10.↵
    1. Ruderman J,
    2. Holzapfel SG,
    3. Carroll JC,
    4. Cummings S
    . Obstetrics anyone? How family medicine residents’ interests changed. Can Fam Physician 1999;45:638-47.
    OpenUrlPubMed
  11. 11.↵
    1. Keely E,
    2. Clark H,
    3. Karovitch A,
    4. Graham I
    . Screening for type 2 diabetes following gestational diabetes. Can Fam Physician 2010;56:558-63.
    OpenUrlAbstract/FREE Full Text
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Canadian Family Physician: 59 (10)
Canadian Family Physician
Vol. 59, Issue 10
1 Oct 2013
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