Assessing Family Medicine Obstetrics Training Needs to Strengthen Maternal Health in Underserved and Rural US Communities

Abstract

Background:

Family medicine obstetricians (FMOBs) are essential for providing maternity care in underserved communities, yet their numbers have sharply declined, contributing to maternity care deserts and persistent inequities. To address the FMOB workforce gap, a large urban residency implemented the PROMOTE OB track (PRimary care Obstetrics and Maternal Outcomes Training Enhancement). We explored FMOB residents’ training needs, practice barriers, and perceived patient needs from the perspectives of faculty and graduates involved in obstetrics training.

Methods:

We conducted 7 focus groups with university FMOB faculty, non-OB FM graduates, FMOB graduates, obstetrics and gynecology (OB/GYN) faculty and fellows, and maternal-fetal medicine (MFM) faculty and fellows. Discussions were guided by a semi-structured protocol exploring training gaps, collaborative care, structural and cultural barriers, and unmet patient needs. Focus groups were audio-recorded and transcribed verbatim, and transcripts were then analyzed thematically.

Results:

During focus group discussions (n = 7), participants emphasized that FMOB training must go beyond procedural competencies to include cultural humility, structural competency, and interprofessional collaboration. Five thematic domains emerged: (1) FMOB training needs and curriculum gaps; (2) building collaborative care teams in residency; (3) preparing FMOBs to address structural barriers to care; (4) navigating cultural barriers to care; and (5) responding to unmet provider-perceived patient needs in underserved settings.

Conclusions:

FMOB training must prepare residents for the clinical and contextual realities of underserved maternity care. Programs should standardize competencies, expand mentorship, and ensure structured exposure to diverse care settings. Sustained policy-level investment is needed to strengthen training infrastructure and expand the FMOB workforce. Aligning curricula with community needs and national policy priorities may improve access to equitable, comprehensive maternity care.

Introduction

Family medicine obstetricians (FMOBs) provide essential maternity care in rural and underserved communities, yet their numbers have sharply declined. In the 1980s, more than 40% of family physicians practiced obstetrics, compared to fewer than 10% by 2010, with high-volume practice dropping nearly 50% between 2009 and 2016.^{1 -5} Multiple factors contribute to this decline, including medico-legal risk, inadequate institutional support, lifestyle concerns, and limited training opportunities.^6,7 Without renewed investment in FMOB training and retention, maternity care inequities will deepen for communities who rely most on FMOBs for accessible, high-quality care.^{8 -10}

The United States continues to experience alarming maternal mortality compared to our peer nations, rising from 17.4 to 22.3 deaths per 100 000 live births between 2018 and 2022.^{11 -13} Black women are disproportionately affected.^14,15 In Philadelphia, the current study’s geographical setting, non-Hispanic Black mothers accounted for 43% of births but 73% of pregnancy-related deaths between 2013 and 2018, ¹⁴ a trend also observed at the state level. ¹⁵ In rural and urban underserved areas, shortages of trained prenatal and obstetric providers remain a critical driver of these inequities.^10,16 Addressing the FMOB workforce gap is central to advancing maternal health equity.

FMOBs are both necessary and sufficient for achieving equitable maternity care in the US. They provide comprehensive, continuous, and preventive care that addresses patients’ medical and social determinants of health in regions with limited access to specialty care.^{17 -19} Their role has become even more urgent given declining numbers of obstetrics-gynecology trainees in rural states and the concentration of specialists in urban centers, challenges that have intensified in the post-Dobbs era.^20,21 Yet while exposure to underserved settings during residency strongly predicts future practice location, only about 10% of family medicine programs offered such experiences as of 2012. ²²

Despite a growing body of literature on post-residency obstetrics training for family medicine residents, critical gaps remain in understanding how FMOB curricula should be designed to prepare providers for the clinical and contextual complexities of caring for patients in underserved communities.^{23 -25} A clear understanding of FMOB training from could inform scalable models that better prepare FMOBs for the clinical and contextual realities of underserved maternity care. Therefore, we conducted a qualitative investigation among faculty and graduates engaged in obstetrics training in an urban residency program to: (1) examine FMOB training needs; (2) identify barriers and facilitators to training across rural and urban contexts; and (3) explore provider-perceived unmet maternity care needs.

Methods

To address our study aims, we purposefully solicited provider perceptions, perspectives, and experiences of FMOB training during the implementation phase of the PROMOTE OB program (PRimary care Obstetrics and Maternal Outcomes Training Enhancement). Recognizing a growing national need for trained FMOBs, University A’s family medicine residency program developed and implemented PROMOTE OB as an advanced, dedicated obstetrics track beginning in 2021. ²⁶ PROMOTE OB aims to prepare FM residents for independent practice in maternity care with a specific focus on addressing provider shortages in medically underserved communities. Supplemental Appendix 1 provides a detailed description of PROMOTE OB’s structure, rotations, and scope.

We led focus group discussions with (1) FMOB faculty, (2) non-OB FM graduates, (3) FMOB graduates, (4) obstetrics and gynecology (OB/GYN) faculty and fellows, and (5) maternal fetal medicine (MFM) faculty and fellows. FMOB refers to family physicians who provide prenatal, intrapartum, and postpartum care including deliveries; non-OB FM physicians do not provide obstetric care. All participants were recruited from the university’s health system. The study team coordinated with departmental administrators to purposively sample former graduates and then-current faculty via email and invite them to focus group discussions. During recruitment, participants were made aware of the risks, benefits, and expectations of participation. Focus groups were conducted by university qualitative research staff. Our protocol was determined exempt by the university’s Institutional Review Board (Protocol #850669).

A discussion guide (Supplemental Appendix 2) was developed based on a review of the literature and team expertise in maternal care, medical education, and qualitative methods. Questions were open-ended and explored participants’ backgrounds, roles in their organizations, experience with FM and obstetrical care, training needs/deficits, patient barriers, suggestions for improvement, and specific details about the populations served by their organizations. Focus groups were conducted using video conferencing software. At the beginning of focus groups, we obtained informed consent verbally from all participants. Following completion of focus groups, we also asked participants to voluntarily self-report demographic and other relevant information via a REDCap survey, included in Supplemental Appendix 2. Items included age, race, and ethnicity, which were not mutually exclusive (ie, check all that apply), gender, education and employment history, and clinical practice experience and characteristics. Focus groups were audio recorded, lasting approximately 60 min, and transcribed verbatim by DataGain, a third-party transcription service. Research staff then reviewed transcripts for accuracy and to remove any potentially identifying information.

We used a grounded theory-based approach to analyze the data inductively, code it systematically, and identify emerging themes. ²⁷ First, to develop a codebook, members of the research team conducted an open reading of transcripts from focus group discussions with FMOB residents and faculty, OB faculty and fellows, and MFM faculty and fellows. This process, referred to as open coding, was used to explore the early data line by line to reach a consensus on emerging topics, identify and address discrepancies, and merge similar topics into categories. Preliminary codes were refined as new data emerged until a final codebook was approved by the team to begin coding (Supplemental Appendix 2). Then, individual team members met regularly to code transcripts using NVivo software and make notes of topics emerging from the data. Discrepancies in coding were resolved through group discussions until consensus was reached. During analysis, we noted when themes reflected role-specific dynamics but did not differentially weight views of OB/GYN, MFM, FMOB, or non-OB FM participants. For example, former FM residents suggesting training needs, be they FMOB or non-OB graduates. Training and professional distinctions are reported below to highlight how professional perspectives shape FMOB training realities.

Results

Sample Characteristics

Seven focus groups were conducted with a total of 40 participants. Focus groups were organized homogeneously by area and level of practice: former FMOB residents (n = 1), FMOB faculty (n = 1), former FM residents (non-OB; n = 2), FM faculty (non-OB; n = 1), MFM faculty and fellows (n = 1), and OB/GYN faculty and fellows (n = 1). Among the 37 who provided demographic attributes, the vast majority identified as female (81.1%), White (73.0%), and were physicians (MD or DO; 94.6%). 16.2% of respondents identified as Black or African American, and 13.5% Asian or Asian American. One in 10 (11.1%) also reported Hispanic or Latino ethnicity. Our sample was nearly evenly divided between family medicine physicians and obstetrics and gynecology physicians, 51.4% versus 48.6% respectively. At the time focus groups were held, all obstetricians and gynecologists were actively delivering babies, compared to a third of family medicine physicians (33.3%). Most participants (86.5%) were working primarily in an urban area.

Focus Group Themes

Analysis yielded a set of 5 main thematic domains representing consensus patterns across groups: (1) FMOB training needs and curriculum gaps; (2) collaborative care teams in residency; (3) preparing FMOBs to address structural barriers to care, (4) navigating cultural barriers to care; and (5) responding to unmet patient needs in underserved settings. We summarize emergent patterns for each theme using subtheme categories to present the range of responses. Where perspectives differed by participant role, we highlight those distinctions explicitly. Select representative quotes are included below, with additional responses provided for each theme in correspondingly labeled Tables 1 to 5.

Table 1.

FMOB Training Needs and Curricular Gaps (Theme 1) Identified from Focus Groups with FMOB, OB/MFM Faculty, Graduates, and Fellows in Philadelphia, 2022 to 23.

Sub-theme	Participant quote
Standardization of the training program	“So, two people may have graduated with a 100 deliveries, but one may have a lot of experience with managing severe preeclampsia during labor, but another person might have been at an institution where they had to pass those cases off to OB. So, I guess just a little bit of standardization so that everybody leaves with the same, similar experience at least.” (Non-OB FM graduate) “I think that residents who plan to practice obstetrics should be like, the minimum experiences that they’re exposed to should just include a certain number of deliveries that someone has established is appropriate to feel comfortable in independent practice without having to seek external experiences.” (Non-OB FM graduate)
Mentorship and role modeling	“I think for me I don’t know, everything always comes down to mentoring and role modeling. Like me, almost everything I do is because of me seeing someone who I respect doing it and wanting to incorporate some element of that in my life. [..]” (Non-OB FM faculty) “[..]specific mentorship where you can help a resident see how they can get from where they are, to where they might want to be. Because I think that that’s the sense I get a lot of the time, and I talk with residents who are making decisions about choosing OB as just sort of feeling overwhelmed by the possibilities and just because maybe there’s not a specific credential and etc., they don’t know what to shoot for and they don’t know how to get there, and so helping people to really create a path for themselves, I think can be really influential.” (FMOB faculty) “I think education of the attendings over here could probably be optimized related to like what the goals are for the family medicine residents and like the expectations, and yeah, and then like a more of like an assigned mentorship type thing for when they’re there for somebody who’s like actually preparing to improve them and things.” (MFM faculty)
Cultural competency and bias training	“I have not taken care of any of these specifically, but I recall one resident, who took care of someone who was experiencing, like who had issues with domestic violence at home. . .so that’s another high-risk group that I could think of. And then also, patients who may, say, identify as trans, I feel like the experience with that in our residency is also variable. So, some residents might feel comfortable with taking care of those groups of patients whereas other residents might not. And I guess, fortunately, and unfortunately they tend to self-select, because by word of mouth or based on the interest of the resident they might just be going towards a resident who has that experience anyway, or wants that experience, and may seek out a mentor who has experienced treating those patients, but yeah, so those two groups.” (Non-OB FM graduate) “I think some cultural differences, and just like, the patient and – the culture of the patient and the physician being different has led to, you know, some people – different communities will kind of, you know, agree with you, with your management, but then they won’t really get any of the treatment and just kind of like understanding cultural competency I think is important for, you know, that as well.” (FMOB graduate)
Exposure to OB triage management	“I think I had between 135-140 deliveries at the end of my residency, but I agree that it is so much more important than the catching a baby is the management of labor, and triage evaluations knowing, you know, who is safe to send home, versus who needs to be monitored or admitted. I think that that does get often sort of overlooked by trainees who get really obsessed with this number, and I think, so for myself going through the training program.” (FMOB faculty) “I think emphasizing more education around the triaging process would be really amazing because often times as the resident, you’re the first-person kind of answering a Family Care patients’ call with the symptom in pregnancy that they’re concerned about, and, or you’re the first person seeing the patient in the perinatal evaluation center. And sometimes, you know, when you first start out as a resident, you don’t have any context on what are common complaints. What could I expect if the person’s calling me and saying, they’re having concern for leakage of fluid, what do I really need to think about? So having more of an educational framework around the triage process before you’re jumping in and handling the phone, I think could just instill more confidence.” (FMOB faculty)
Other procedural- and content-specific training	“Now that I’ve experienced it myself, I feel like looking back I was not equipped to provide answers to certain questions that I had myself during my postpartum period. For example, lactation education, so we as a part of OR rotation I think maybe, I don’t remember if it was a part of my - a part of the curriculum when I was an intern, but anyway, we have a breastfeeding group where, you know, one of the attendings and a lactation consultant lead a group of women who are trying to breastfeed or want to breastfeed.” (Non-OB FM graduate) “I felt comfortable with vaginal deliveries. You know, managing complications, high risk – well, I think like, some places, we’ll kind of call them more high-risk patients. Based on our patient population, I saw a lot of things like preeclampsia, you know, abruptions, et cetera, which I think is also important to see if you’re gonna be practicing by yourself and being able to recognize it. And so, I think having some basic ultrasound skills is kind of important too.” (FMOB graduate) “I also think basic ultrasound skills, especially in terms of term patients for things like position, fluid, that will help them triage patients through like the perinatal evaluation center would be helpful.” (MFM faculty)

Table 5.

Responding to Unmet Provider-Perceived Patient Needs in Underserved Settings (Theme 5) Identified from Focus Groups with FMOB, OB/MFM Faculty, Graduates, and Fellows in Philadelphia, 2022 to 23.

Sub-theme	Participant Quote
Social determinants of health	“[. . .]there’s just a dearth of mental health providers as it is. And then pregnancy is such a short window time frame, where like if you need – if someone needs mental health services, they’re going to have like a three month – or like however – the intake period to actually be seen. And it’s just not – it’s not acceptable.” (Non-OB FM graduate) “I think we all had a couple of or I could think of like one or two patients I took care of at some point that were either patients who were positive for HIV or hepatitis B, and you kind of like learned along the way with one of our attendings who specializes more in that, but like having a more formal curriculum about that might be helpful.” (Non-OB FM graduate) “[. . .] I don’t know where she’s living or if that’s funded. Certainly, paid for all of her gas across the country and back. So I do think there’s an opportunity for funding above and beyond what [program funder] is doing through these grants to allow people to have - and maybe there is, and I just don’t know about it, but even just for the cost of housing and transportation.” (FMOB faculty) “Housing instability. I mean, it just – it runs the gamut. Like job insecurity. Like it’s just – all of the things.” (Non-OB FM graduate)
Substance use and stigma	“And then I think patients with substance use disorder is another, you know, really important group. I think that that probably applies in our location as well as in, you know, some rural areas as well, given the weight of the opioid epidemic as well as other substance use disorders. [..] we are actively again, working on the curriculum from making sure residents feel trained to be able to do that independently.” (FMOB faculty) “[. . .]Several patients with just issues with chronic depression or higher-level issues that just prohibit them from functioning well. And drugs, alcohol can be a big – pretty big barrier.” (FMOB graduate)
Postpartum support	“I think the complexity of managing, like postpartum complications from chronic diseases, and that bridge from being postpartum to being kind of a person with normal post pre pregnancy physiology. And I think that family medicine can be an important role in bridging that gap in terms of utilizing dyad visits as a tool to one engage both parties and like care. And I think in a way that we don’t have access to, because we don’t see the baby as well. And so I think that family medicine can really have a really impactful role there in terms of bridging that care as people go from the immediate postpartum period, to then transitioning to managing some of their chronic medical conditions after pregnancy.” (MFM faculty)
Health literacy and patient education	“And then a lactation consultant, I don’t think many people do that or have one before delivery, but I think it’d be actually nice starting in like the third trimester or something to have a lactation consultant talk with the patient.” (Non-OB FM graduate) “So in our hospital we have a fairly robust in-house lactation team, so there’s lactation consultants, like IBCLC is their certification, that see every single patient and, you know, assess whether they would like to receive breastfeeding support. So patients do get that support, but because it is done by - because they’re so accessible lactation consultants.” (FMOB faculty)
Immigration-related barriers	“ . . . the vast majority of my patients are uninsured because of being undocumented. And so, it is difficult to – like, if there’s a specialist or a consult or like, something that they need that’s not within our system, it’s almost impossible to get that to happen. So, I guess that like, for instance, something that comes up is if they need like, a fetal echocardiogram for some reason, there’s just – it’s like, basically impossible if they – and plus, they pay like, $400 in cash for it to be done at like, the one place that will do it for cash.” (FMOB graduate)
Rural and underserved communities	“Coming from [Urban Health System], all I had ever heard is like, it’s really hard to do OB, it would be really hard to do OB, really hard to do OB. And then, coming out like, past west of the Mississippi, it’s not super hard to do OB out here if you’re family medicine. You know, you have to be willing maybe to go where and when I wanna go, but it’s not as hard to do OB.”(FMOB graduate) “Resource management is definitely different. And I agree, I actually think the community versus academic is a bigger distinction than rural versus urban. But like, for instance, we refer every single person to get a anatomy scan with that, with MFM. Yeah, maternal fetal medicine and like if you’re in a community hospital, like you see maternal fetal medicine, if it’s like, well, it’s interesting, there’s a really fascinating thing in obstetrics. So like working where we work, like we worked so closely with MFM. that we both over utilize them from a resource standpoint relative to what you would do. But we also we also hold onto patients much, much longer knowing that they are there for backup. So in a community center you get someone who - if someone goes into a high risk bucket and you’re the only family medicine doctor there, you’re probably referring them to OBGYN. Or maternal fetal medicine like, like that. You’re like this person is going there and yes, that resources more limited but like they will then manage that pregnancy. Whereas here, you know, we do all of the things with maternal fetal medicine, providing consultation notes and imaging, but like we manage ante-partum patients on the floor.” (non-OB FM faculty) “When I practiced in New Orleans, we took call in [local town 1] and the family medicine folks took call in [local town 2]. [Local town 2’s name] sounds as country as it actually is. And with Louisiana and Mississippi taking turns being the number one places for maternal mortality. What distinctly struck me, excuse me, was part of this confluence of these states that have very poor maternal outcomes are often the ones that have the most restrictive abortion laws. So you have patients who might have access to care differently if they have the opportunity to, but they very rarely do, the poverty is extreme like, you know, to imagine families making under $50,000 for a family of four or six and then they’re going to these hospitals that are incredibly racist in many ways, structurally and otherwise, and then the hospitals themselves are very low resourced.” (OBGYN faculty)

Table 2.

Building Collaborative Care Teams in Residency (Theme 2) from Focus Groups with FMOB, OB/MFM Faculty, Graduates, and Fellows in Philadelphia, 2022 to 23.

Sub-theme	Participant quote
Experiences with different obstetrics care models and practice settings	“I just think that overall, the exposure that we had working so closely with OB, I think that’s not really the norm. And I think in general, hopefully it’s still the way, but the OBs at [Health System] were really much more open to having us be very involved in their care and with their delivery. So, I think more so than a lot of other programs out there, we got more first-hand training with the OB Department than most other family medicine OB residents get.” (FMOB graduate) “[In a low-resourced clinical setting] the staffing of whatever that particular place is changes every six months [. . .] But because we’re doing training in an ivory tower inside of a town of like six ivory towers, it’s less likely that we would – inside of our good training there, would have access to like, oh, that stuff didn’t happen because – and everybody around us would talk about that stuff is just sort of completely not acceptable. But it’s happening in lots of places and if we don’t get exposure to those sort of atypical below standard approaches, then we don’t have a way to sort of consider, or deal with, or find solutions to those things. To the point of just sort of like having some empathy for what might happening, and then also saying, okay, well, how would you approach that conversation?” (Non-OB FM graduate) “I felt like I derived so much value from managing labor and looking at tracings, and then kind of knowing what problems to anticipate during the actual catching the baby phase, and something that I really valued also was that we have the ability to see the OB team, so not family medicine, but the OB services tracings as well.” (FMOB faculty)
Availability of ancillary staff	“Yeah, I think that’s why the midwives are – perspective, was so helpful though because we do such crazy things at [Health System], which is wonderful, I felt very prepared, but then also seeing like, oh yeah, sometimes babies just come out, you know? I think that was like, a really wonderful perspective. And to know that, you don’t have to always do everything for a baby to come out. There are going to be women who that’s not appropriate and you’re kind of remembering that there are people who just have babies. But I think it’s a really helpful thing too.” (FMOB graduate)
Inter- and multidisciplinary collaboration	“So where I used to work, we had 17 live interpreters on staff at all times, and we also had perinatal advocates from the populations that were most present in our clinic, that would be there through every prenatal visit and also on the labor floor too. And we had our live interpreters on call knowing the patients through each visit and also on the labor floor. So we created a continuity model of language and culture through prenatal care and on the labor floor, which, [Interviewee 3] I don’t know if you’ve ever witnessed, but it’s a really beautiful thing.”(FMOB faculty) “There’s absolutely no way I’d be able to manage the patients I see if it weren’t for social work and nursing outreach. We have a family resource center. We have just dozens of people who can actually help to kind of manage the psychosocial needs of the patients. We’re lucky enough to have that.” (FMOB graduate)

Table 3.

Preparing FMOBS to Address Identified Structural Barriers to Care (Theme 3) from Focus Groups with FMOB, OB/MFM Faculty, Graduates, and Fellows in Philadelphia, 2022 to 23.

Sub-theme	Participant quote
Transportation and parking	“But transportation cannot be understated [. . .] on days when I have access to a person who can use a Lyft account to get patients to their appointment, I just see every single patient. And on days when I don’t have that access, I see a third of the patients. So functional transportation cannot be underestimated even just getting from - and as was stated, the prenatal care may be happening at a community center, but all of the ultrasounds and testing and delivery is happening centralized at a hospital that I don’t even know where to park for.” (FMOB faculty) “ So parking for sure, where to park and the cost of parking and the time it takes to park, is a reason that people will either not come to appointments, leave appointments early, or sometimes after an appointment if they need to go get blood work, decide that they will forego that because of the time it would add onto their parking and the cost that it would add onto their parking[ . . .] (FMOB faculty)
Lack of insurance coverage	“I think there is probably silence because there’s so many, we could all dish out the 20 million reasons. I mean, there’s patient level issues, there’s provider level issues, there’s health system level issues, there’s neighborhood level issues. So, from a patient level issue, it’s no insurance, it’s having availability to take off of work, it’s having the finances from a provider level, it’s having the appointments, having access to care.” (MFM faculty) “[. . .] for people who have preeclampsia, or for people who have substance use. . .like how do we engage people long enough in the postpartum period. Making sure that insurance coverage goes through like that full year as opposed to cutting it off at like six weeks or however long.” (Non-OB FM graduate)
Work-life and family challenges	“I mean, they have a pace of visits that’s higher than most conditions, so they’re being seen monthly or even more frequently and so, I’m sure that’s a huge burden in terms of employment and transportation and cost. Then some of the tests are very long. If you’re getting like, a test for diabetes takes hours. And the antenatal testing is the surveillance testing that takes a lot of time as well. So I think it’s just a huge amount of time.” (Non-OB FM faculty) “Like how many patients we’ve had who couldn’t go to antenatal testing, because they had an hourly job, and they couldn’t miss work or they would lose their job.” (Non-OB FM graduate) “When patients have to go for their ultrasounds or for their, you know, increased level of monitoring, that [Interviewee 1] was talking about called antenatal testing, they do not allow children at those visits [. . .] I think not pictured here in the data is all the patients who would have come, but knew that they would get turned away and so don’t ever show up because they know they’re not going to be allowed to enter with their kids. And so they just register as a no-show for unknown reasons, but it’s childcare. (FMOB faculty) “I’d love to see some childcare options for patients to attend appointments because it’s really hard to go to your – to take care of yourself when you have like six other little kids that you need to also figure out what to do with your visits.” (Non-OB FM graduate)
Working within a fragmented care system	“I had a patient recently where the notification system to say, you have an upcoming appointment, it didn’t give enough detail. And this patient was getting prenatal care at one site and getting antenatal testing for high-risk condition at another site. And all of those notifications came in on one text thread without a specific address, time, date. So just the new platforms that are texting patients about their appointments, but not providing information. Unfortunately, this family shared that they would like drive to one of their provider locations and be told like, “No, that’s not this appointment.” And just so the platforms of patient notification are really confusing.” (FMOB faculty) “But the process to get the charity care is just like, so convoluted that like – and my patients, my pregnant patients, aren’t allowed to like, get their lab work or their initial ultrasounds done a lot of the time until they like, bring in – it’s like going to the DMV and it’s like, oh, you brought this, this, and this document, but you didn’t bring this bullshit. And so, like, yeah, sorry. Like, try to try to call us, but you can’t call us, so like, make another appointment to come back to get it. So, I guess they sort of go hand in hand, but the – like, the social risks and the medical risks. And be really different, but I guess there’s overlap.” (FMOB graduate)

Table 4.

Navigating Cultural Barriers to Care (Theme 4) Identified from Focus Groups with FMOB, OB/MFM Faculty, Graduates, and Fellows in Philadelphia, 2022 to 23.

Sub-theme	Participant quote
Discrimination, stigma, and bias	“When you have, you know, a racially discordant provider, or someone from like a different background who, you know can’t fully like understand your experience, even if they can be empathetic.” (Non-OB FM graduate) “I would say – I am in the suburb of [Western City]. It’s a mostly affluent white suburban area. And there – for our patients, we have a large Spanish-speaking population, a large immigrant population, and for our patients who are not white suburban people, implicit bias on the labor floor is a huge barrier. They face a lot of racism and discrimination from our nurses and things like that, and that is definitely a barrier for them.” (Non-OB FM graduate)
Hesitancy to engage with healthcare systems	“[. . .] but for a subset of sort of higher need populations and higher risk populations, I’ll just put out my personal view that I don’t think virtual care has been an adequate point of access for the resources that we try to offer, such as behavioral, insurance, financial, and all the other things that we tend to try to pile into a visit at the health center. And there’s just less to access to that with the virtual care. So we would think that virtual care improved access and it maybe did, but I personally don’t feel that it improved high quality access for our highest need patients.” (FMOB faculty) “And even though in short, most patients would be eligible for insurance there’re first of all, some who may not know that they are and then also for patients who are not documented getting into the health centers can potentially have a wait, etcetera, so there’s still the insurance aspect that is a barrier for patients.” (OB faculty)
Patient-provider language and identity-based discordance	“Or even understanding the context in which people kind of come to the appointments. Like, we’re saying, you know, people make assumptions like, especially – yeah, and I don’t know. I think it’s on our labor floor too. It’s like, the nurses are predominantly like, very much white, and it can be really hard when the Spanish-speaking patients come in and they don’t always use the interpreter and things like that.” (Non-OB FM graduate) “I forget patients of limited English proficiency as well. So that’s another area where I think there’s actually again, a pretty high volume of patients in our hospital who have recently come to the US, or who have limited English proficiency as well as now, a more re and influx of refugees from Afghanistan and, you know, we’ll see from where else continues. And so I think that that’s another area that we have not historically had specific structured curriculum around, you know, the use of an interpreter in-person versus written consent, and the use of an interpreter outside of the process for signing consent forms. But actually, to make sure that people are understanding what they, you know, want to need, and also beyond that actually creating an affirming birth experience for people who are getting care, not in their native language, the things that we value for any other patients, how we could make that more similar for patients of limited language proficiency. So those would be sub-specialty populations. I think about.” (FMOB faculty)

Theme 1: FMOB Training Needs and Curriculum Gaps

Standardization of the Training Program

Many participants noted wide variation across FMOB tracks and called for clearer expectations around procedural competencies and minimum delivery volumes. They emphasized clearer minimum competencies would better prepare residents to manage real-world scenarios independently, including in rural or low-resource settings.

Mentorship and Role Modeling

Participants expressed the importance of all residents having an assigned mentor who could model the role of a practicing FMOB. Mentorship was described as more than advice: residents valued seeing FM faculty provide obstetric care in supportive, collaborative environments. FM faculty were vocal about the need for role modelling, including a non-OB faculty member who commented, “You have to have FM faculty who are doing obstetrics.” Participants added that mentorship broadens residents’ sense of feasible career models, including rural practice options. One FMOB faculty member, when asked about what factors would influence to practice FMOB in a rural setting, responded, “I wanna say mentorship, I think helping people to you see the options out there, because I do think people can be sort of limited by how they see the practice looking at [University Hospital 1]. And if you can see yourself doing 24-hour shifts, for example, then that alone is enough to sort of deter people from conceptualizing a career in OB because they don’t see that there are models where people don’t do that.” Formalized mentorship would give residents exposure to working in a collaborative setting with OBs, midwives, and FMs, allow them to better integrate within the workflow, and help guide them throughout the program. Participants frequently discussed how structured mentorship during residency also influenced whether FM residents pursued OB after graduation.

Cultural Competency and Bias Training

Providers emphasized FMOBs must be equipped to deliver respectful and responsive care to diverse patient populations. Some reported insufficient exposure to caring for specific populations (eg, patients with substance use disorders, LGBTQ+ patients). They recommended structured cultural humility training to reduce disparities and improve trust.

Exposure to Obstetrics Triage Management

Several participants noted confidence in managing triage scenarios post-graduation was directly tied to structured exposure during residency. A standardized curriculum on common triage presentations was widely recommended to support readiness for call-based or inpatient OB roles. As 1 FMOB faculty member explained, “Having more of an educational framework around the triage process before you’re jumping in and handling the phone, I think could just instill more confidence. Not that it was necessarily a struggle to kind of learn by doing with attendings there and being extremely supportive, but I don’t know if that could just be an opportunity for some more standardized curricular development around common triage issues.”

Other Specific Procedures and Content

Several participants reported insufficient training and exposure in certain areas including: ultrasound skills such as amniotic fluid index (AFI) assessment and biophysical profile (BPP), neonatal management and resuscitation, management of fetal death, lactation education, and postpartum depression. They felt additional exposure would better prepare FMOBs for full-scope maternity care in community settings.

Theme 2: Building Collaborative Care Teams in Residency

Participants described how exposure to a range of care team elements and clinical experiences improved patient outcomes and were linked directly to residency training design.

Experiences With Different Obstetrics Care Models and Practice Settings

Participants noted that variable exposure to collaborative care models in particular rural and underserved settings left some residents unevenly prepared. FMOB graduates said that learning across both high-acuity, specialist-driven care and lower-intervention, midwife-attended births built confidence for the mix of scenarios typical of smaller hospitals with limited backup. In contrast, non-OB FM graduates described limited procedural volume, little continuity, or discouraging feedback that steered them away from obstetrics. Faculty across specialties agreed that training centered on urban, high-acuity care did not reflect rural realities where providers must balance low volume with episodic high-risk events. Short rural electives were viewed as insufficient due to low delivery numbers, and structural barriers (eg, funding and rotation approvals) constrained longer, more geographically diverse placements.

Availability of Ancillary Staff

Midwives, doulas, and lactation consultants were cited as key collaborators whom FMOBs often rely on post-graduation. Participants reported working alongside these providers during residency promotes a team-based care approach and prepares FMOBs to practice in integrated settings. A former non-OB FM resident discussed the benefits of such team composition in their current role and how it could positively influence FMOB patient care, “We have midwives in our clinic, which also gives us a different perspective of prenatal care and labor and all of that, but I agree a doula would be a great addition to the team, especially because I think awareness is increasing in terms of the benefits of having a doula prenatally and postnatally, but we also know that our patients might not have access to that resource.”

Inter- and Multidisciplinary Collaboration

Some participants reported having access to language interpreters, social workers, and lactation consultants in their clinical settings and described these roles as essential for delivering high-quality care to diverse populations including immigrants, refugee, and underserved populations. Language barriers were identified as a major challenge, with interpreters playing a critical role in facilitating communication and ensuring patients understood their care plans. Social workers were valued for their ability to advocate for patients, provide emotional and logistical support, and connect families to community-based resources, filling needs FMOB providers felt unequipped to address alone. Similarly, lactation consultants were seen as key to supporting postpartum patients in areas where residents lacked sufficient training, such as breastfeeding and infant nutrition. Participants emphasized exposure to these roles during residency helps FMOBs develop the collaborative competencies needed for community-based, team-oriented practice.

Theme 3: Preparing FMOBs to Address Structural Barriers to Care

Participants emphasized how FMOBs often care for patients facing persistent structural challenges with limited access to maternity care. Providers said residency should prepare FMOBs to recognize these barriers, respond with empathy, and use practical strategies to help patients navigating them. Equipping residents with tools to identify and mitigate these access issues was seen as integral to delivering holistic, community-based care post-residency.

Transportation and Parking

Providers stressed training should include proactive screening for transportation barriers and familiarity with clinic- or community-based solutions (eg, rideshare support and home-visit models). Participants frequently cited transportation and parking difficulties as significant barriers to care for low-income and rural patients. Challenges like travel distance, public transit, and parking were major contributors to missed appointments.

Lack of Insurance Coverage

Providers described the logistical and clinical challenges of caring for uninsured or underinsured patients. For example, financial barriers often led to delayed or forgone care. Providers noted residency training should include explicit instruction on navigating insurance systems, advocating for coverage, and assisting patients with enrollment or financial assistance programs. Understanding these processes was seen as key to practicing effectively in underserved settings.

Work-Life and Family Challenges

Respondents described how patients’ rigid work schedules, job insecurity, and lack of childcare often prevented patients from attending prenatal visits. Challenges were compounded by appointment frequency, or having to visit multiple providers for specialized procedures like dating ultrasounds. One FMOB graduate noted COVID-19 as an additional compounding factor, “I have a lot of – especially during COVID, a lot of patients who had issues making appointments because of childcare.” Providers emphasized training should prepare residents to assess these barriers, adapt care plans, and advocate for flexible scheduling and co-located services to improve continuity.

Working Within a Fragmented Care System

Providers highlighted how poorly coordinated appointment systems, complex EHRs, and siloed referrals created confusion for patients and disrupted continuity. FMOB residency should include structured training on clinic workflows, co-located services, and patient-centered communication to improve care integration.

Theme 4: Navigating Cultural Barriers to Care

Across groups, participants highlighted that cultural barriers such as discrimination, stigma, and language access challenges remain pervasive in maternity care, and called for training to address these systemic inequities.

Discrimination, Stigma, and Bias

Providers expressed how FMOBs must be trained to recognize and mitigate previous negative experiences to build trust with marginalized patients. One non-OB FM graduate reported how patients fall at the intersection of different types of discrimination, “I think a big barrier is just like the cultural and economic racism that prevents people from being able to engage in the care that they might want to otherwise. Like how many patients we’ve had who couldn’t go to antenatal testing, because they had an hourly job, and they couldn’t miss work or they would lose their job. How many patients I’ve taken care of during pregnancy who were living in a shelter, who were being threatened to be evicted from the shelter, like truly awful things, which obviously would make anybody hesitant to engage in that space.” Residency training should include strategies for fostering inclusive, trauma-informed care.

Hesitancy to Engage With Healthcare Systems

Participants connected patient mistrust to provider behaviors and even institutional histories. They emphasized residents must learn communication techniques that support shared decision-making and build long-term relationships, such as promoting interconception care for women with multiple pregnancies.

Patient-Provider Language and Identity-Based Discordance

Providers cited language barriers, sex/gender mismatches, and cultural misunderstandings as common challenges for patients. FMOB training should include simulation or observation-based training in culturally concordant and inclusive care.

Theme 5: Responding to Unmet Provider-Perceived Patient Needs in Underserved Settings

Participants noted many barriers to FMOB care which were structural or systemic, and therefore viewed as less modifiable. For instance, patient needs that could or should have been addressed (eg, behavioral health, substance user) remained routinely unmet. Nevertheless, they emphasized importance of preparing FMOBs to address both medical and non-medical aspects of maternity care.

Social Determinants of Health

Providers felt social needs were often unaddressed in maternity care. For example, patients often faced barriers accessing mental health services, such as long wait lists and limited availability due to lack of insurance. Participants also often care for patients with housing and employment instability. They advocated for residency training including behavioral health integration, social resource referral, and systems navigation to address the full spectrum of patient needs.

Substance Use and Stigma

Providers frequently cited opioid use disorder and co-occurring conditions in pregnancy. FMOBs reported feeling underprepared to support patients navigating recovery and treatment. As 1 FMOB graduate expressed how lack of training negatively impacted their comfort providing such care, “I’m involved in [our perinatal OUD] clinic, which is for pregnant individuals with substance use disorder. Because I’m one of those providers, I’d say that I’m very uncomfortable when I have to do that because it’s, you’re doing substance use sort of stuff and plus basically prenatal care for high risk obstetrical concerns, which is not really my comfort zone.” Respondents recommended training in MAT during pregnancy, stigma reduction, and linkage to treatment resources.

Postpartum Support

Providers described limited training in lactation troubleshooting, cultural sensitivity around infant feeding practices, and how to screen or counsel for postpartum depression. Participants recommended more robust postpartum training, including linkage to community supports and lactation counseling basics.

Health Literacy and Patient Education

Participants highlighted how many patients lacked a clear understanding of their care plans, especially around labor expectations, fetal testing, and postpartum warning signs. FMOB training should equip residents with tools to assess and address health literacy.

Immigration-Related Barriers

Several participants noted undocumented patients faced limited access to referrals, diagnostic services, and insurance coverage. Residency training should include knowledge of immigrant health rights and safety net systems.

Rural and Underserved Communities

Participants emphasized that FMOBs are essential for sustaining maternity care in rural and underserved areas where communities may depend on only 1 or 2 obstetric providers within a 30 to 50-mile drivable radius. Across all focus groups, participants described how FMOBs can help maintain access, continuity of care, and trust when obstetrics coverage is limited or absent. Two OB/GYN providers, reflecting on their own practice experiences in low-resourced settings in the American South, highlighted challenges such as late entry to care, regional policies and politics, and systemic access barriers. Their personal experiences reinforced the importance of well-prepared providers, including FMOBs, in underserved communities. At the same time, OB/GYN and MFM faculty cautioned that FMOBs practicing in isolation without reliable backup can pose patient safety risks in low-volume hospitals where maintaining procedural competence is difficult. OB/GYN and MFM faculty pointed to other barriers constraining patient access including the economic unsustainability of rural obstetric practice due to low delivery volumes and high malpractice costs, restrictive legal climates, and hospital credentialing policies limiting FMOBs’ ability to practice the full scope of obstetrics.

Discussion

Our qualitative study revealed a range of barriers and facilitators influencing FMOB providers in their training and practice, specifically within under-resourced communities in Philadelphia. During focus group discussions, providers described their own experiences navigating complex unmet needs of family medicine patients receiving maternity care, and how those could inform future FMOB residents’ training. Our findings also shed light on the complex dynamics at play in ensuring equitable access to maternity care. Herein, we discuss our findings in relation to existing literature, organized around the key themes identified: FMOB training needs, barriers and facilitators to FMOB care, and provider-perceived unmet patient needs.

Our analysis supports prior advocacy for standardized FMOB residency programs, mentorship, and exposure to a range of obstetric practices to enhance competence and confidence of FM physicians in obstetric practice.^4,28 Mentorship emerged as a foundational component of residency, with participants describing how having a committed mentor improved skill development, integration within interdisciplinary teams, and overall residency satisfaction. In prior research, structured mentorship has also been shown to reduce burnout and enhance career alignment for FM residents. ²⁹ Participants in our study also called for clearer expectations around procedural competencies, a defined minimum number of deliveries, and more exposure to complex cases such as operative vaginal deliveries or high-acuity triage scenarios. As of July 1st, 2024, the Accreditation Council for Graduate Medical Education (ACGME) updated this competency and required family medicine residents to have “experience with a minimum of 20 vaginal deliveries.” ³⁰ The new requirements further recommend a total of 400 h (or 4 months) dedicated to training on labor and delivery and participation in a minimum of 80 deliveries in order to practice obstetrics post-graduation. Our findings suggest previous ambiguity and shifting expectations may have contributed to variability in training quality and resident preparedness. Based on participant input, we believe an opportunity still exists for ACGME and other professional bodies to outline more specific program requirements or supplemental guidance related to high-acuity cases or other obstetrical related procedures.

Residents require structured training in triage, system navigation, and community-based care delivery to manage diverse clinical and logistical challenges. Training should prepare FMOBs not only for technical care delivery but also for healthcare navigation challenges like fragmented appointment systems, insurance complexities, and care coordination across specialties. Exposure to the OB triage process was noted to be critical, as residents are often first to respond to urgent OB complaints (eg, suspected rupture of membranes and abnormal fetal heart rate tracings) yet often lacked the opportunity to do so confidently early in training. In parallel, participants wanted residency programs to expose FMOBs to diverse care settings so residents could develop adaptable workflows accommodating patients’ lived experiences. Having health system-level competencies was described as essential to delivering equitable care in under-resourced communities and to retaining FMOBs in these settings long-term.

Providers identified persistent unmet needs among maternity patients, including mental health, postpartum support, health literacy and education, substance use, and immigration-related barriers. Provider-perceived gaps tended to reflect a broader system failure to integrate behavioral health, social support services, and culturally concordant care into maternity workflows. For example, transportation and insurance were described as structural barriers to FMOB care, supporting prior research demonstrating the adverse effects of logistical and financial obstacles on maternal outcomes.^1,2 For patients from marginalized backgrounds or those with limited English proficiency, discrimination, stigma, and bias were identified as pervasive challenges which disrupted care continuity and trust. And though public insurance is available to many, participants highlighted how undocumented patients face delayed or partial coverage, leading to confusion about eligibility and missed opportunities for early engagement.

The socioecological model provides a conceptual framework for understanding how FMOB training needs and opportunities operate across multiple, interacting levels of influence. ³¹ At the individual level, residents must develop competencies such as procedural skills, confidence in triage, and cultural humility. At the interpersonal and organizational level, residency programs and training infrastructure shape how these competencies are cultivated through mentorship, exposure to collaborative care teams, and structured clinical experiences. At the community level, FMOBs practice within environments where patients face persistent barriers (eg, transportation, health insurance, discrimination, and mistrust) that directly influence maternity care access and continuity. At the policy and societal level, national accreditation requirements, malpractice environments, and the economic sustainability of rural and urban maternity care create enabling or constraining conditions for both training and practice. Importantly, across all levels lie the realities of patient oft-unmet needs and social determinants of health.

Our study advances the FMOB literature by moving beyond a narrow focus on procedural training to present a multilevel framework for residency preparation. Through our inclusion of perspectives from FMOBs, non-OB FM graduates, and OB/MFM specialists, we learned why some residents may opt out of obstetrics and how specialists shape practice environments. Providers also distinguished systemic barriers from those amenable to curricular solutions, highlighted the importance of training across the continuum of maternity care, ambulatory and postpartum services, and emphasized the realities of both urban and rural underserved communities. These contributions underscore the need for FMOB programs to prepare residents not only with clinical competencies but also with the tools to navigate fragmented systems, connect patients with community resources, and deliver inclusive, trauma-informed care.

Limitations

Our study is not without limitations. Our insights here are drawn from a specific context, participants associated with 1 university health system, which likely limits generalizability of findings. While such a focus enables detailed exploration of context-specific challenges, it also limits applicability of our findings to other regions or healthcare settings with different resources, policies, and patient demographics. In addition, we did not collect primary data on patient perspectives of unmet maternity needs, which would have enriched our understanding of maternity care barriers and facilitators. Incorporating patient experiences in future studies is recommended to capture a fuller picture. Despite the fact that our decision to include OB/GYN, MFM, and non-OB FM participants provided valuable insight into both supportive and potentially restrictive forces influencing FMOB training, these perspectives do not directly represent FMOB training realities. However, we believe OB/GYN, MFM, and non-OB FM participants offered important context for understanding how potential gatekeeping and interdisciplinary collaboration could influence implementation of FMOB training programs.

Qualitative analysis is subject to inherent limitations such as potential researcher bias and challenges in generalizing results. To mitigate analytic bias, data collection and coding was led by qualitative researchers not involved in PROMOTE OB instruction or administration. We believe our use of non-affiliated, non-clinical research team members also reduced potential social desirability bias which may have arisen during data collection as some participants were colleagues or involved in FMOB training. Lastly, thematic analysis allows for in-depth exploration of complex issues but the perspectives captured may not represent all possible viewpoints within the broader FMOB and patient communities. Although we sought to mitigate these limitations through rigorous coding and systematic analysis procedures, our conclusions must be interpreted within the context of these methodological constraints.

Conclusion

Our findings highlight the urgent need to invest in FMOB training to expand access to equitable, high-quality maternity care in under-resourced communities. Inter- and multi-disciplinary residency programs must address systemic training barriers residents face by incorporating community-based experiences, mentorship, and education in structural and cultural competency. Policy-level action is also essential because individual programs alone cannot resolve the gaps we identified. Federal investment through Title VII appropriations, workforce development grants, and other funding streams will be critical to expand training infrastructure and effectuate needs-based curriculum development. Future research should include patient perspectives, evaluate targeted supports like insurance navigation and transportation, and examine long-term career outcomes of FMOB trainees. It is only by aligning national policy with the realities of frontline training that we may build and sustain the FMOB workforce our maternal health system so urgently requires.