GPs Continue To Walk Away From Childbirth Care

21 June 2002

Obstetrics-Qualified GPs Continue To Walk Away From Childbirth Care

New Zealand general practitioners with specialised training in obstetrics are continuing to walk away from childbirth care as midwives dominate as lead maternity carers.

President Dr Helen Rodenburg of the GP’s professional body, the Royal New Zealand College of General Practitioners, said a snap workforce survey showed fully 20 percent of the remaining GPOs were planning to stop offering a childbirth service this year, and a further 14 percent would stop by 2005.

Only five percent said they would continue indefinitely.

Concerned by the trend, and further contractual changes that come into effect on 1 July, the college conducted the survey of members on 10 June. More than 130 General Practitioner Obstetrics (GPOs) had replied by the following Friday.

“At this rate, there will soon be no GPs left in this specialised area, which seriously reduces women’s choice,” Dr Rodenburg said. “While any GP can help during pregnancy, we have serious concerns about patient safety during the intrapartum period” (during labour and the whole birth period).

“The college believes the general practitioner with specialised training in obstetrics has a distinctive and valuable role to play in maternity care. Particularly so for women who suffer from other health problems - both related and unrelated to pregnancy, and during the intrapartum period in areas without specialists on site.”

In addition, she said, many women continue to request GPOs services as lead maternity carers ahead of both midwives and specialist providers.

The respondents to the workforce survey delivered 3726 babies during 2001, 64 percent of them in the North Island.

As part of the survey, GPOs were asked why they had stopped providing LMC care. Paramount among the answers was the effect of Section 88 of the New Zealand Public Health and Disability Act 2000, which covers the arrangements relating to payments. Twenty-eight percent of those who had stopped cited financial reasons.

Many cited “total demoralisation”. They were “fed up” with the politics of maternity and the lack of support for GPOs, and the lack of recognition of the special skill set in the combination of medical knowledge and the holistic overview of a woman, her family and health care needs.

Other reasons were:

- Section 88, that exemplified the lack of a national strategy, which resulted in poor policies;

- Financial, with GPOs citing financial viability, no financial incentives, funding reduced to unsustainable levels for the amount of time and commitment involved, the impact on the practice and with no recognition or recompense for being constantly on call;

- The stressful working environment, some noting the deteriorating relationships with midwives as a result of the politics of maternity care, and the extra pressure of having to work without peer support;

- Personal reasons, with the family disruption noted from increased administration and bureaucracy;

- Complete frustration about the future.

Preliminary results of the questionnaire sent to GPOs on 10 June -

Assessment of GPOs who are providing maternity care

The “Assessment of General Practice Obstetricians who are providing maternity care” questionnaire was sent through the College networks to gather information about those currently providing intrapartum care, that from the onset of labour through the actual birth period. The main purpose was to determine the actual status of the GPO workforce.

This followed RNZCGP concern that the Section 88 Maternity Notice (of the New Zealand Public Health and Disability Act 2000 due to take effect on 1 July will further decrease GP involvement in maternity care because it fails to recognise the distinctive role of the GPOs and further imposes single referral guidelines when the College believes separate GPO guidelines should be acceptable.

Response rate:

The questionnaire was sent on Monday 10 June and by Friday 14 June (132) responses had been received. Responses have continued to arrive at the College since then. Due to the response and gaps in some areas, or missing information, the College will continue to identify the status of the GPO workforce to try and establish precise figures to ensure it can properly support GPOs.

The College is grateful to those GPOs who responded so promptly to the survey.

Question 1 - Do you currently still provide intrapartum care?

a) YES

60% of GPOs (n79) still provide intrapartum care. The total deliveries recorded for this group was 3,726. The average number of deliveries was 54, with a maximum of 300 and a minimum of 2.

b) NO

40% of GPOs who responded are no longer providing intrapartum care.

Question 2 - If you answered YES to question 1

a) HOW MANY DELIVERIES DO YOU PERFORM EACH YEAR?

In 2001 there were a total of 3,726 births delivered by GPOs who responded to the questionnaire.

b) HOW LONG DO YOU INTEND TO CONTINUE TO DELIVER INTRAPARTUM CARE?

Of the respondents who currently provide intrapartum care, 60% identified how long they will continue. While most intend to stop, 14% indicated they will “keep a watching brief’ before making any decisions and 5% stated they will continue indefinitely.

Intrapartum Care - continue or not to continue

Discontinue

2002 Discontinue

2003 Discontinue

2004 Discontinue

2005 Discontinue

2010 Discontinue

2015 Continue

Indefinitely Uncertain

% % % % % % % %

20 5 8 1 4 1 5 14

c) HOW WILL THE NEW SECTION 88 NOTICE INFLUENCE YOUR DECISION TO CONTINUE PROVIDING MATERNITY CARE?

The following responses are from the 60% currently providing intrapartum care:

- Definitely influence the decision to stop providing care: (26%)

REASON: GPOs feel unsupported by Section 88 and strongly believe they are not treated fairly by the present and proposed system. There are no incentives and no will to stay in the proposed system. One GPO commented, “This is a major factor, the last straw, and I am sick of doing charity work for the good. I fear a worsening situation.”

- Outcomes will have some effect on decision: (18%)

REASON: GPOs will be dependent on DHBs continuing to fund maternity schemes to enable them to operate in the same way they are now. Issues such as increased administration and lack of support, initiatives or funding for GPOs will further influence their decision to leave. The number of GPOs available in a geographical area to provide backup (ie as GPOs no longer provide maternity care) will have an effect on whether they continue to provide maternity care.

- Have not made a decision yet: (36%)

REASON: Some GPOs have decided to “wait and see’ before they make a final decision about whether to continue providing care or not. If the environment is too difficult, most indicated that they would discontinue.

- Will definitely continue regardless of Section 88: (21%)

REASON: Some GPOs who indicated they would continue were in schemes that support them with administration.

Question 3 - Are you part of a separate contract e.g. Hokianga, MATPRO. If so, can you please indicate which type?

The GPOs who identified maternity contracting arrangements, listed 5 different options:

- SAMCL - 5%

- Southlink - 17%

- MATPRO - 15%

- Wairarapa - 1%

- Fee for service - 20%

Question 4 - Are you a member of a peer group?

a) YES - 85% of GPOs said they were a member of a peer group.

b) NO - 12% of GPOs said they were not a member of a peer group.

Question 5 - If you are no longer a LMC GPO;

a) WHEN DID YOU STOP

The pattern of GPOs who discontinued the provision of LMC care is that it is increasing over time, particularly since 2001. (See graph)

b) WHY DID YOU STOP PROVIDING LMC CARE?

GPOs cited the main reasons for no longer providing LMC care as “total demoralisation”. They were “fed up” with the politics of maternity and the lack of support for GPOs that had taken the enjoyment out of providing maternity care. There was no acknowledgement of their own special skill set, where GPO care combines medical knowledge and an holistic overview of a woman, her family and health care needs.

Section 88

There was a range of personal and professional reasons that cited Section 88 as the main reason for discontinuing LMC Care. Many stated that Section 88 has exemplified the lack of a national strategy and resulted in poor policies. They believe that the purpose has been to force GPOs out of maternity care and that “the inevitable has happened”.

Financial reasons

Of those who stopped providing LMC care, 28% cited financial reasons. (Not financially viable, no financial incentives, funding reduced to unsustainable levels for the amount of time and commitment involved, impact on practice and no recognition or recompense to being constantly on call. One GPO said, “I’m fed up with having to pay the hospital or midwife for services that weren’t delivered and to do it oneself for no payment eg intrapartum”.

Stressful working environment

Others stated that the increasing stressful working environment was a reason for opting out of LMC care. Some noted poor or deteriorating relationships with midwives that have developed as a result of the politics of maternity care, while others stated that the number of GPOs no longer providing obstetric care had put extra pressure on them to work without peer support. This has increased workloads and posed difficulties in shared care relationships. Some were concerned about workforce shortages posing risk to their patients, particularly if there was only midwife cover.

Personal reasons

A number of respondents noted the disruption to their own family circumstances from increased administration and bureaucracy. Some noted that family commitments had taken precedence over maternity care as the pressures of being on call 24 hours a day to respond to deliveries were significant. The irregular hours combined with a lack of personal satisfaction due to multiple stresses was too demanding.

Complete frustration about the future

“I suspect that there are issues around funding and maybe professional jealousy, but I really feel strongly that family medicine includes pregnancy care and generally the first two trimesters are non problematic, and some can easily be done by a GP with Dip Obst and many years experience. I have found that many women seem to have their medical needs ignored by midwives during pregnancy. They have told them not to worry, everything will be normal etc. Just yesterday, I saw a woman who had one week of severe cramps at 23 weeks. Her midwife refused to see her and told her not to worry. She had severe constipation, which I treated.”

“I feel sad that the care has been polarised to either independent midwives or GPs as I very much enjoy involvement in the antenatal and postnatal care and feel shared care to be the preferred option both for the patients and myself. I believe the choice of women has been severely reduced. I also get annoyed with difficulty getting payments when seeing women in the second/third trimester and also having to clear up problems the LMC hasn’t dealt with or ignored, or is “too busy” to deal with in addition to calls when the midwife is uncontactable. Although these may be infrequent, they can be extremely annoying when someone else is being paid to deliver the service.”

6. Are you on the GP email group?

Those providing LMC care or shared care are still keen to remain on a contact list and attend a CME session next year.

Profile of intrapartum care

The geographical profile of GPOs who responded to this survey showed that those providing intrapartum care, from the onset of labour through the actual birth period, are most likely to be in an urban area in the North Island.

During 2001 intrapartum care was delivered by:

- 64% of GPOs in the North Island

- 36% of GPOs in the South Island

- 22% of total deliveries were located in a rural area. (Rural ranking scale)

Urban areas:

- Auckland - 1216

- Wellington - 1114

- Hamilton - 105

- Dunedin - 100

- Christchurch 102

- Whangarei - 30

Provincial towns:

- Hastings - 235

- Masterton - 180

- Gisborne - 125

- Paraparaumu - 60

- Invercargill - 72

- Ashburton - 110

- Nelson - 60

- Dargaville - 22

- Napier - 50

Small towns:

- Takaka - 10

- Hokianga - 10

- Catlins - 20

- Timaru - 20

- Te Awamutu - 10

- Inglewood - 35

- Feilding - 40

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