The Role of Family Physicians in Calgary's Low-Risk Obstetrical Care

The role family physicians play in healthcare is vast. Family physicians in Canada, and particularly in Calgary, have the freedom to work across disciplines that would normally be reserved for specialists elsewhere in the world.

This model is especially common in Calgary obstetrics, where family physicians frequently practice low-risk obstetrics through maternity groups. Maternity groups are sanctioned collectives of family physicians with a special interest in delivering babies. These groups typically split call at their respective hospitals, though exactly how call is divided varies from group to group. Maternity groups are solely dedicated to prenatal and delivery care for low-risk pregnancies, though many also do postpartum follow-up, newborn care, lactation medicine, and more.

I had the privilege of interviewing four low-risk providers across Calgary: two from Rockyview General Hospital, one from Foothills Medical Centre, and one from South Health Campus. Even within one city, their perspectives varied, reflecting the heterogeneity in how individual providers think about their scope and their place in the broader system.

Low-risk maternity physicians are distinct from obstetrician/gynecologists (OB/GYNs), who complete a five-year surgical specialty, and distinct from midwives, who do not attend medical school. Low-risk obstetrics seems to provide a middle ground between the two, providing dedicated medical care for healthy, non-complex pregnancies.

The most obvious difference between low-risk maternity providers and OB/GYNs is training. OB/GYNs complete a surgical residency, which gives them the skillset to perform procedures such as cesarean sections and other gynecological surgeries. Family physicians complete a two-year family medicine residency in which delivering babies is a core competency.

Some family medicine residents choose to pursue additional training in low-risk obstetrics, colloquially called a "plus one" or "R3". As Dr. Charissa Chen put it, "because I did a dedicated R3… I really got a lot of experience under my belt." However, this extra training doesn't seem to be about acquiring a new skillset so much as building confidence in the existing one of delivering babies.

"I think more important than the R3 is whether or not you've been able to accumulate enough of the experience for the things that are a little bit less normal" says Dr. Brianne Whittaker on the subject of a plus one.

The bottom line, shared by several providers I spoke with, is that Calgary is teeming with deliveries and an R3 is not required to join a maternity group at this time. That said, in a different climate, such as one with limited deliveries, an R3 could become more useful. As with anything, it is hard to predict the future, and this remains an ongoing discussion.

Another aspect that sets family physicians apart is the breadth of care they can offer around the pregnancy itself. Because they are trained generalists, low-risk providers are well positioned to offer lactation consultation, newborn care, menopause management, contraception counselling, mental health support and more. In fact, three of the four physicians I interviewed also run a general family practice alongside their low-risk obstetrics work. Additionally, an added perk is the ability to occasionally acquire a patient you've been following through pregnancy into your general family practice. Though, this depends on several factors and most interviewees were quick to note that their panels are full.

It's worth noting that while the structure around low-risk obstetrics has become more protocolized over time, the idea of family doctors delivering babies is not new. Obstetrics has long been part of family medicine training. It is simply that many family physicians don't end up practicing it the way a low-risk provider does.

Low-risk physicians are conscious of their scope of practice and trained on specific guidelines for the obstetrical complications that require a transfer of care to a high-risk obstetrician. High-risk obstetricians act as consultants, and these family physicians are responsible for recognizing when a case has moved beyond their scope and needs to be transferred. While guidelines exist, a substantial amount of presentations still fall into gray areas. In these situations, the providers I spoke with described numerous factors shaping their clinical decision-making. When I asked Dr. Kirsty Sloper what goes into deciding whether a patient needs to be transferred, she said she asks herself, "do I have the medical knowledge that can safely get them through this pregnancy?"

Many of these physicians also consider how a high-risk provider's management would differ from theirs, and how the high-risk OB would prefer to receive the case. As Dr. Chen put it, “if I wait to consult, what kind of position am I perhaps putting my obstetrical colleagues in?" Ultimately, it always came back to patient safety and how to optimize the scenario.

Maternity groups are upfront with patients that they are low-risk providers, meaning escalation to a high-risk OB may be necessary if complications arise. This is usually well received, since, as Dr. Whittaker put it, "people want to be low risk". Of course, this isn't universal. Some patients may treat low-risk providers with less respect than their OB/GYN counterparts, for reasons that can include unfamiliarity with the Calgary healthcare system, fear and worry about wanting the "best" for their baby, or a number of other factors. Still, opinions among the providers I spoke with were split on how common this really is, and several were clear that this does not happen often.

For medical students and residents wanting to get into this kind of practice, there isn't one fixed path in. Echoed throughout my interviews, what matters most is the amount of exposure you get to obstetrics during training. Dr. Angie Karlos encourages medical students to "do electives with OB to see some of the…things that can go wrong," as well as to shadow, in order to gain more exposure to obstetrics. This is particularly applicable for students at three-year programs like the University of Calgary, where timelines are compressed. For residents, she encourages "core low risk rotations at busier sites" to build volume, as she is a strong advocate that volume builds comfort in obstetrics.

These conversations point to a specialty that is essential to how Calgary delivers babies. Low-risk obstetrics is a discipline that depends on the relationships built between physician and patient, low-risk providers and high-risk colleagues, and low-risk physicians themselves. As many of them continue to practice general family medicine alongside their obstetrics work, they have the capacity to look after a patient over a lifespan. In doing so, they get to contribute to these meaningful moments in a person's life, helping carry them through pregnancy and delivery.