Table 5. Barriers and Facilitators to Rural Family Medicine Residency Program Success in Providing Robust OB Training (Illustrative Interview Responses).

Theme	Illustrative Responses
Accreditation	[Accreditation requirements] don’t assist or impair but help make an argument for administration and who to hire.
	[Accreditation] is huge. Might be the only way to hire an FP OB. To be able to say to leadership that this is needed for accreditation...[to have hard numbers] would help with hiring and encouraging OB to help with numbers.
	We got a citation a couple years ago for [not having sufficient numbers].
	I wish that ACGME requirements allowed to tailor to community needs and residents’ needs.
Institutional Sponsorship	If the board and administration aren’t supportive, this is dead in the water.
	From a rural perspective, you have to have clinical and hospital support.
Economic	We worry all the time something will happen and it will go away – because of loss of personnel or admin saying they do not support that effort.
	For a long time we were the only ones who took [state] Medicaid patients, and Medicaid was not a great payor source for those patients. That was an extra prenatal stream for our residents because no one else wanted it. Interesting dynamics.
Faculty	All of us that chose to come practice here came because we want to do OB.
	Number one need: family physicians who do OB and continue to do it.
	[Residents] have benefitted from faculty who have been in practice and doing OB for 20 years or more.
	It is a key feature that we have so many FP OBs in this organization...we can use that to market our program to new residents coming and we have the perspective to give them good training hopefully.
Resident interest	We are up front in recruiting [residents] that this is an OB-heavy environment.
	Residents are very interested. Residents want to do full scope. [Trying to] sell this idea to our CEO.
	It works well to let residents choose their own path. But if not enough people are interested in the OB part of that, the call schedule won’t be sustained.
Community Context	Community is not aware of family physicians doing deliveries.
	If they don’t know we’re here, they won’t choose us.
	Community members and the hospital board driven by community voices demanded that women’s health would be in the hospital.
	It’s important to continue to build community trust and support, provide safe care, have good outcomes, and good reputation in community.
Personnel	If the nursing staff isn't on board for training residents, it is really difficult.
	Need commitment from local hospital to continue to provide that – have nurses, anesthesia, OR on staff. Need commitment from all players in system.
	Nursing staff is not used to having residents around.
Policies	Every year we have to certify that we’re still doing OB, and those who do, the state gives a subsidy to help with malpractice costs.
	I find myself questioning the efficacy of regional/national policies like the ACOG/AAFP joint statement about maternity deserts – locally this was not heard, people can ignore if they disagree. Local policies are more about relationships.
	When you deliver a baby who lives in [neighboring state], we don’t get to be the primary care doc after delivery. We see them at the two-week well check, and then they get a PCP in [neighboring state]. That irks all of us that we can’t be their doctor. The state lines between us.
Solutions	I think it’s really important for programs to exercise family medicine according to the original intent to be all encompassing.
	One thing that could be potentially helpful for our residents that want more OB volume is to identify sites that would be higher volume centers.
	There is limited availability for fellowship training for FM-OB. Anything that would expand fellowship training would expand FM docs in OB.

Abbreviations: FP, family physician; OB, obstetrics; ACGME, Accreditation Council for Graduate Medical Education; ACOG, American College of Obstetricians and Gynecologists; AAFP, American Academy of Family Physicians; PCP, primary care physician.