A Victorian perspective
Almost 30 per cent of Australian women deliver their babies in the country and 57 per cent are cared for by general practitioners1, but the future of rural maternity units is quite uncertain.
Over the past 30 years that I have been practising in Wodonga, initially as the only specialist obstetrician in Victoria northeast of Melbourne, (in solo practice for the first ten years), I have witnessed the continual decline in rural maternity units and the numbers of procedural GPs who remain committed to maternity care. The numbers of specialist obstetricians in the country has also dwindled to critical numbers.
When will Australian politicians understand that there is a real workforce crisis in the bush? Predicted by Professor Alastair MacLennan in 1993 in his article, Who will deliver the next generation?2, nothing effective has been done by successive governments to address this issue.
In my 30 years in rural Victoria, there has been the closure of 88 rural maternity units, leaving only 39 still managing some maternity care.3 This is in the face of the government-stimulated (‘one for your country’) increase in the numbers of deliveries in most areas. The loss of expertise of rural generalist doctors and midwives is a national disgrace!
Most of the GP obstetricians are now over 50 years old. As substantial retirement occurs after this age, the workforce will be terminally depleted within ten years, without a major training and retention program. A parallel program is needed for midwives, who share the same age profile.
Is there time left to stop the continued annual decline, or is it too late? Should we all give up? Being an eternal optimist, I believe the crisis can be averted, but only if all governments have a genuine commitment to make it happen.
Unfortunately, most State governments have advisors who are city-based, academic midwives promoting midwife-led maternity care. Not only will midwife-led maternity care be a failure in the country, it has the potential to displace even more GPs, as demonstrated in New Zealand3 where 1500 GPs were displaced by midwives.
The most effective, sustainable and safe model of care is collaborative maternity care, which is even more valid in the rural setting. An open, communicative team of midwives, GPs and specialist obstetricians is the model of care that is vital for the survival of quality rural maternity care.
Medical support not only means having a trained GP obstetrician, but also a doctor available for anaesthetic services and neonatal support, and a roster of capable midwives available in both the maternity unit and the nursery.
Without the certainty of medical supervision on-site, most rural women elect to travel to the nearest maternity unit that can offer this care. Only a minority of women risk being transferred in labour when complications become apparent, especially when in the country the nearest maternity unit is often over an hour away.
I believe all rural towns of 20,000 or more should be able to provide intrapartum maternity care. Maternity services can exist in smaller rural towns, but only with the dedication and commitment of a generalist. There are models which have worked and we should learn from their success. Crystal Brook in rural South Australia is such a model (see the following article on page 28). The cooperation and facilities established in Crystal Brook have ensured the future of this small maternity unit.
So, now we know the problem, how do we implement a solution? It is critical to act now and not procrastinate for another ten years. By then, the remaining small maternity units will be closed down and will not re-open because experienced staff are needed to mentor new recruits. In the rare instance like Seymour, Victoria, where a unit did re-open, the staff did not disperse and were ready to take up their roles.
We are already promoting medicine as a career to Australian country students through rural medical schools, but now we need to facilitate postgraduate training aimed at producing procedural generalists, including intrapartum care, anaesthetics and neonatal care.
We can train a GP to be capable of managing about 90 per cent of all obstetrics patients in one year of advanced training. This awards the GP with a DRANZCOG Advanced and, once qualified, this doctor should be able to work independently, preferably with a senior colleague as a mentor for the first few years.
There is still opposition to the GP trainees in metropolitan teaching hospitals in favour of Integrated Training Program (ITP) trainees. This opposition should be addressed by RANZCOG, affirmatively promoting GP obstetrics and supporting GP training in operative procedures. It is only five years ago that RANZCOG invited the first GP obstetrician, Dr Jeff Taylor, to represent his rural colleagues as an observer on Council. More still needs to be done Australia-wide with the recruitment, training, re-training and support of rural GP obstetricians.
Although all metropolitan teaching hospitals should be training more GP obstetricians, there are very few GPs involved in intrapartum care in the city, so there is no role model for the trainees to identify with. Training in a rural position would equip them with the necessary skills, confidence and courage!
In Wodonga, we have trained several GPs capable of performing caesarean sections. Some have replaced retiring GPs here, while others have set up practice in small rural towns and continue to do operative obstetrics. Unfortunately, most rural maternity units that have specialist obstetricians have no GPs doing intrapartum care, so the opportunity to train young doctors is diminished. The solution is to fund a DRANZCOG position in large rural maternity units with specialist obstetricians or GP obstetricians available and willing to train and support the new recruit.
To quote Dr Mike Moynihan, President of the Rural Doctors Association of Victoria (RDAV):
‘The Victorian State Government has provided a small number of training positions for GP proceduralists in larger hospitals, but these are proving totally inadequate to maintain the rural GP proceduralist workforce. Also, lack of recognition of the GP procedural workforce in Victoria, means there is very little interest in rural medicine as a career among doctors training in Victoria’s four regional training programs.’4
I have also witnessed a change in culture with younger doctors. No longer will they work unsafe hours and devote their lives to their work; their lifestyle and families have more importance to them. I admire their decision, but this does not help women who choose to or have to deliver their babies in the country. The solution to this paradigm shift is to work as a group, even if they are in independent medical practices. They need to establish an agreed roster, especially as most rural women do not have, or do not use, their private health insurance.
An essential part of rural maternity care is the patient-held maternity record. In Wodonga, we have been using this record for over 25 years, so we have a generation of women who have had documented shared care with the GP in their local town. The record is completed by all who attend a woman: the GPs, midwives and obstetricians. It records all the pathology and ultrasound results and documents an agreed birth plan. One of the many benefits, particularly for women who live a long distance from a regional maternity unit, is that it reduces the time spent travelling to a specialist O and G.
There is a need for a standardised, Australian maternity record (like Australia-wide medication records), but the insistence by State Departments of Health that their own non-medical and cumbersome documents are to be used continues to be a frustration. It is difficult to quickly extract essential information from the State Health Department records in an emergency situation.
There is criticism that there is lack of public antenatal clinics in the country, but this is, or can be, addressed by doctors seeing patients in their rooms, provided an agreed standard of care is achieved. Trainees can also gain experience by joining the doctor at their practice. Annual clinical meetings can be arranged to update all the people involved in antenatal care, (doctors and midwives), so that audit is robust and in-service education is provided. Attendance at these meetings could be a condition of approval to be able to do antenatal care.
In Wodonga, ten per cent of women choose midwife-led care, but all must have a medical consultation during their pregnancy and all are supervised by a GP at delivery. This model of care has the support of all the doctors and midwives. We do not support home birthing because of poor outcomes and, fortunately, no midwife currently undertakes home birth in this region.
There needs to be a quality locum service available to both specialist and general practitioner obstetricians to allow them to take leave without adding to the burden of extra work for their colleagues. Fortunately, this is now available for all rural obstetricians through the Specialist Obstetrician Locum Scheme (SOLS) and is arranged through RANZCOG.
The establishment of rural schools of medicine has been a highly successful innovation by the Australian Federal Government. Rural scholarships, such as the John Flynn Scholarship, have enabled many rural students to enter university and encouraged them to return to practise in the country when they have completed their training. Sending students to the country may assist the future numbers of doctors who will be working in rural centres, but they will not necessarily be attracted to consider obstetrics, unless there are motivated mentors to encourage and support them. There need to be more rural training posts in obstetrics for young doctors to be able to learn from existing, experienced GPs or obstetricians.
Although the promotion of telemedicine is good for ongoing education, it is not much help for an acute emergency such as fetal distress or a postpartum haemorrhage. If a maternity unit is going to be safe, experienced doctors who can be immediately available are required. However, televideo conferencing facilities established in rural maternity units would be a valuable resource, in the same way that they are appearing in rural emergency departments. Televideoconferencing facilities established in rural maternity units would be a valuable resource, in the same way that they are appearing in rural emergency departments.
In summary, the future survival of rural maternity units depends upon an infusion of new, young doctors to take over from the retiring, sometimes burnt-out, but highly experienced current doctors. The annual attrition of the ageing doctors is making many rural maternity units perilously close to sudden collapse. Without a comprehensive national program to attract young doctors into obstetrics and train them to be confident and competent, small to medium rural towns will not be able to sustain maternity care in rural Australia. The Government must act now to make these training positions attractive, or rural obstetrics will not survive.
- MacLennan AH. Who will deliver the next generation? Med J Aust. 1993; 159: 261-263.
- Robson S, Bland P, Bunting M. An anonymous survey of provincial, rural and remote obstetricians’ long-term practice intentions; implications for the provision of specialist obstetric services outside metropolitan areas in Australia. ANZJOG 2005; 45(5): 395-8.
- Mourik P. The New Zealand Experience. O&G Magazine Vol 12 No 4 Summer 2003.
- Moynihan M. RDAA Report 2007.