Elizabeth Dawson, a family nurse practitioner, works in the labor and delivery unit at South Sunflower County Hospital in Indianola, Miss., Friday, Oct. 20, 2023. Credit: Eric J. Shelton/Mississippi Today

The state’s first fellowship to train family physicians to care for pregnant and postpartum women is poised to start next July.

The proposed fellowship will train two to three family physicians a year in obstetrics, which the medical community hopes will provide rural and underserved areas with prenatal, delivery and postpartum care.

More than half of Mississippi’s counties are considered maternity care deserts, meaning there are no practicing OB-GYNs and no hospitals that deliver babies. For family physicians looking to practice obstetrics, the lack of training programs and difficulty getting affordable malpractice insurance coverage are challenging. 

Aside from two hospitals that have been able to cut through the red tape and use family physicians in maternal care, nearly all pregnancies are handled by OB-GYNs, who are in short supply in Mississippi and mostly practice in urban areas. 

The state is an outlier when it comes to how little it uses family physicians in obstetrics. Across the country, family physicians play a significant role in providing obstetric care to expectant mothers. Neighboring Alabama, for instance, boasts five fellowships in obstetrics for family physicians.

Family physicians deliver babies in more than 40% of U.S. counties, and “are the sole maternity care clinicians delivering babies in 181 (maternity care deserts) … serving more than 400,000 women” nationwide, according to a report by the American Academy of Family Physicians. 

Dr. James Lee Valentine and Dr. Melissa Stephens of EC Health Net, a family medicine residency program in Meridian, are designing the new one-year training program to focus on increasing access to rural maternal care.

“The fellowship will train family physicians to be able to go into some of our rural, underserved communities, and provide obstetric care for these women close to home, who may have limited access and are facing challenges,” Stephens said. 

University of Mississippi Medical Center is home to the only OB-GYN residency in the state, which graduates five or six residents each year. Of those, an average of two residents remain and practice in Mississippi.

On the other hand, a record 37 family physicians graduated in 2023 from residencies in Mississippi – more than any year in the past five years, according to the Office of Mississippi Physician Workforce.

Meanwhile, the state’s maternal and infant mortality rates are worsening. Valentine and Stephens see the fellowship as one way to combat that.

 “These patients sometimes don’t get any (prenatal care) and they show up in the emergency room, delivering … that’s got to change,” Valentine said. “And I’m not saying that we ought to put family practice doctors out there doing all kinds of GYN surgeries and all that, but we got to deliver better prenatal care to our patients in the rural areas.”

The fellowship will set physicians up on three-month rotations between EC Health Net in Meridian, South Sunflower Hospital in Indianola, and Wayne General Hospital in Waynesboro. Valentine and Stephens hope to also add a stint at a larger hospital studying gynecological surgeries.

South Sunflower and Wayne General are the only two hospitals in the state currently using family medicine OBs, despite the bureaucratic challenges. The family physician OBs at these two hospitals are attending the majority of births in their counties.

Dr. Kelvin Sherman, the only practicing family medicine OB at Wayne General, delivers between 180 and 280 babies a year from Wayne County and some neighboring counties. In 2022, 256 babies were born in Wayne County, which has no practicing OB-GYN, alone.  

Sherman, who did his obstetrics fellowship in Alabama, said in his experience, women who are farther from obstetrical care tend not to seek help when experiencing symptoms because they can’t justify the long drive or using the county’s only ambulance. Having a family doctor nearby can make a huge difference in pregnancy outcomes. 

“If they’ve got some place to go that’s 15 minutes away, then maybe they go get something checked on and find out that ‘Yeah, you are in preterm labor, but it’s early and we can stop it, and we can prolong your pregnancy and you can have a healthier baby – a baby that goes home with you rather than having to deliver early a small baby that ends up in the NICU that stays sick a lot in the first few years of life,’” he explained. 

Sherman is breaking ground not only as one of the state’s only family medicine OBs, but also by working closely with a certified nurse midwife, a rarity in Mississippi – a state with no certified midwife program. Opening the doors to certified midwives could increase the amount of care available to women.

Advanced nurse practitioners are also qualified to give prenatal care. But in Mississippi, restrictive and expensive collaboration agreements limit the care nurse practitioners can provide

Sherman’s partnership with the certified nurse midwife is the kind that Wayne General CEO Andrew Porter hopes the new fellowship will facilitate. 

“The FMOB (a family medicine physician who practices obstetrics) can really be a multiplier,” Porter said. “They can be the captain of a ship that has these other providers working under them and it just multiplies the amount of care that can be provided to patients.”

South Sunflower in Indianola has three family physician OBs on staff who average about 250 births a year in a county that had 263 live births in 2022. 

Courtney Phillips, CEO of South Sunflower Hospital, poses for a portrait at South Sunflower County Hospital in Indianola, Miss., Friday, Oct. 20, 2023. Credit: Eric J. Shelton/Mississippi Today

The hospital has been using the family medicine OB model since it opened in the 1930s, according to hospital CEO Courtney Phillips. It’s a lifeline today, where the next closest hospital is 30 miles away, and even there, there aren’t enough OB-GYNs to take care of all the deliveries. 

“So, even though the next closest hospital to deliver is 30 miles away, they may have to travel all the way to Grenada if we weren’t here, which is close to 80 miles away,” Phillips explained. 

The family medicine obstetrics model is used sparsely because while family physicians receive an unrestricted license to practice medicine, the problem lies in getting insurance and privileges at a hospital.

 “There’s a big difference between licensure and credentials,” Stephens, a family medicine physician at EC Health Net in Meridian, said.

While the licensure board allows physicians to practice according to their training without restriction, physicians also need to apply for malpractice insurance coverage, which requires proving competence to the malpractice carrier, and then proving competence to get credentialed by the hospital they are joining. Both became difficult in Mississippi after the explosion of liability insurance costs in the 1990s. 

Medical liability premiums skyrocketed across the U.S. at the turn of the century, but particularly in Mississippi – known by 2001 as the “lawsuit capital of the world,” according to a 2011 case study by the American College of Obstetricians and Gynecologists – and affected physicians’ ability to practice specialties like obstetrics or neurosurgery. Mississippi was “perhaps the hardest hit of the ‘red alert states,’” a term used to denote high medical liability regions, the case study said. 

Valentine, who worked in obstetrics throughout the 1980s and had proven his competency to the board through documentation of all the procedures he performed and deliveries he attended, suddenly couldn’t afford his malpractice insurance premium when what he refers to as the “malpractice crisis” hit. 

“My malpractice insurance went up about 180% premium-wise in a year’s time,” he said. “I couldn’t justify losing money to practice OB, and then take the risk on top of that. It was almost like they were trying to push us out.”

As it stands, Mississippi family physicians interested in obstetrics have few options: pursue an official training program in another state – which often results in those physicians deciding to either leave the state altogether or stay in the state and forego obstetrics – or train unofficially in Mississippi but without the guarantee of affordable malpractice insurance or a hospital that will grant them privileges.

South Sunflower Hospital in Indianola, Miss., Friday, Oct. 20, 2023. Credit: Eric J. Shelton/Mississippi Today

South Sunflower, according to Valentine, is able to utilize family physicians in obstetrics affordably because of its highly regarded staff that helps them get coverage and credentials. 

“Places like Indianola, they have a track record,” he said. “Dr. Wade Dowell has been … a champion for family medicine, doing OB and doing general family medicine for years, and so he’s got a track record, and the doctors he’s trained there – they do a good job.”

Valentine and Stephens hope the new fellowship will offer a similar standard that will help family physicians receive credentials and coverage in obstetrics at an affordable rate – though it’s never a guarantee.

“Whether every hospital in the state of Mississippi will recognize that, whether every hospital will open their doors, I don’t know,” said Valentine. “But from the standpoint of being qualified … we want to make sure that our fellowship is substantial enough that when they leave our fellowship, whether it’s one year or two years, they’re ready to practice obstetrics at the level they’re trained to do that.” 

The fellowship is one proposed solution to changing the maternal health landscape of Mississippi. But experts believe programs like it are critical in shifting the pendulum.

“It’s not going to be a cure-all for some of the obstetrics needs, and issues like infant mortality, but it’s a step,” Porter, the Wayne General CEO, said. “It’s people who are acknowledging that we have a crisis here in the state and are trying to do something about it. Here in Waynesboro, Mississippi, and the surrounding area of Meridian, and those in the Delta, we're trying to take the matter into our own hands and come up with some solutions.”

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Sophia, a New York native, covers community health with a focus on women’s and family health care. In 2023, she graduated with a master’s in journalism from Northeastern University, where she served as editor-in-chief of the Boston Scope. Her multimedia work has been recognized by the National Press Photographers Association and the New England chapter of the National Academy of Television Arts and Sciences. She has also worked for the global nonprofit, Girl Rising, and the documentary group, The Disability Justice Project.