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FUTURE PRACTICE OF GRADUATES OF THE NEW ZEALAND DIPLOMAS OF OBSTETRICS AND MEDICAL GYNAECOLOGY ' And

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Diploma of Obstetrics (DipObs) introduced at University of ... Paediatrics. 43 (12.9) 33 (9.8) O&G specialist/trainee. 19 (5.7) 7 (2.1) Sexual health clinic ... – PowerPoint PPT presentation

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Title: FUTURE PRACTICE OF GRADUATES OF THE NEW ZEALAND DIPLOMAS OF OBSTETRICS AND MEDICAL GYNAECOLOGY ' And


1
FUTURE PRACTICE OF GRADUATES OF THE NEW ZEALAND
DIPLOMAS OF OBSTETRICS AND MEDICAL GYNAECOLOGY
. And the impact on pregnancy care in New
Zealand Dawn Miller and Don Wilson
University of Otago Helen Roberts University
of Auckland
2
Background
  • Diploma of Obstetrics (DipObs) introduced at
    University of Otago in 1977 and Auckland
    University in 1972
  • To provide postgraduate training in womens
    health and obstetric care (particularly suitable
    for GPs)
  • In the 1990s, changes in legislation
    (particularly the increasing autonomy of midwives
    and introduction of LMCs) and associated funding
    changes for maternity care led to decline in
    number of GP practising intrapartum obstetrics 1-
    4

3
Background contd
  • In 2003
  • 1) DipObs became Diploma of Obstetrics and
    Medical Gynaecology (DipOMG)
  • 2) Certificate in Womens Health introduced, open
    to midwives, nurses and other health
    professionals.
  • Auckland University now developing DipOMG web
    based teaching

4
DipOMG is a one year course - 6 month
clinical attachment in OG - four distance
taught papers - two residential papers (2 to
3 days each) (plus log book, assignments,
MCQ and OSCE assessments) Certificate in Womens
Health is a 6 month course - three distance
taught papers - one residential
(plus assignments, MCQ assessments) Individual
papers - (CME credits)
5
Distance taught papers
  • OBGX 712 contraception, preconceptual
    counselling, early pregnancy care (normal
    complications of early pregnancy)
  • OBGX 713 antenatal and intrapartum care
    including complications of pregnancy puerperium
    newborn
  • OBGX 715 well women, screening STIs menstrual
    disorders pelvic pain vulval disorders
    menopause
  • OBGX 716 adolescent gynae TOP infertility
    urogynaecology gynaecological cancers violence,
    abuse

6
Aims
  • To determine
  • Future practice of graduates of DipObs, DipOMG or
    Certificate in Womens Health
  • Reasons for undertaking this postgraduate study
  • Usefulness in the graduates practice of medicine
    or midwifery

7
Methods
  • All University of Otago DipObs (n246), DipOMG
    (n23) or Certificate in Womens Health (n15)
    graduates since 1992 were identified from the
    University graduate database.
  • All University of Auckland DipObs or DipOMG
    graduates from 1996 to 2006 (n304) were
    identified from the Auckland University graduate
    database.
  • All graduates (n588) were medically qualified.
  • The NZ Medical Council provided contact details
    for graduates who were listed on the New Zealand
    Medical Register (n477).

8
Methods contd
  • Questionnaire developed by the academic staff in
    Depts of Womens Health at Otago and Auckland
    Universities and trialed with OG staff and GPs
    at both sites.
  • All questionnaires were coded prior to mailing
    and sent with reply-paid return-addressed
    envelope.
  • A further questionnaire was sent to
    non-responders after 3 weeks. Twenty five
    questionnaires remained as return-to-sender.

9
Results
  • - 334 of the 477 graduates identified on the NZMC
    register completed the questionnaire
  • - a 70 response rate
  • - 190 (56.9) Otago grads, 144 (43.1) Auckland
    grads
  • 92 of respondents aged 30-49 years old
  • 65 female, 35 male
  • Ethnicity 78.0 NZ European
  • 3.6 Maori
  • 1.8 Pacific Island
    nations
  • 6.0 Asian
  • 3.3 Indian or Sri Lankan

10
Demographics continued
  • 308 (92) doctors lived in New Zealand
  • 21 (6.3) were living in Australia
  • 2 in United Kingdom, 1 in France and 1
    in USA
  • 251 (86) worked in urban practice
  • 40 (14) worked in rural practice
    (n292)

11
(No Transcript)
12
Reasons for enrolling in courseto further
knowledge in. (n334)
13
Clinical Practice (n334)
14
GP intrapartum obstetric care
  • 144 respondents enrolled in the DipObs or DipOMG
    intending to practise intrapartum obstetrics
  • 81 respondents (56.3) have practised intrapartum
    GP obstetrics
  • 6 respondents are still practising intrapartum GP
    obstetrics
  • 2.8 of the GPs surveyed
  • 4.2 of the 144 who enrolled in
    DipObs to practise GP obstetrics
  • 7.4 of those who did practise GP
    obstetrics
  • Of note
  • 3 of these 6 doctors are in urban
    practice
  • 3 are in rural practice (including 1
    in Australia)

15
New Zealand based respondents
  • 309 NZ based respondents
  • 203 respondents currently working in general
    practice in New Zealand
  • 137 NZ based respondents enrolled in
    DipObs/DipOMG to practise intrapartum obstetrics
    in general practice
  • 5 currently practising intrapartum obstetrics in
    general practice
  • 3.6 of NZ based respondents who
    initially enrolled to practise intrapartum GP
    obstetrics
  • 2.5 of those graduates who are working
    in general practice today

16
Enrolled in DipObs/OMG to practise GP obstetrics
vs Year of graduation with
DipObs/OMG (n286)
17
7 respondents commented on the effect of
legislation change in the mid 1990s. 3 expressed
regret at stopping GP obstetrics. My original
intention was to practice intrapartum as well as
antenatal obstetric care. Practically and
politically it became impossible My Obs
(obstetrics) experience was long ago now. I feel
many of my skills and much of my knowledge has
been eroded by not participating in Obs for many
years. General practice is much poorer in the
loss of this experience and women much worse off
without GPs involved in their pregnancy care.
GPs have been excluded from pregnancy care
18
GPs involved in shared care
  • 26 respondents were still involved in shared
    care
  • 12.3 of the 210 DipObs/OMG graduates
    surveyed who are currently in general practice
  • Comments
  • Too much administration required for claiming,
    too many changes over last 10 years
  • Rural midwives unable to afford shared care
    model. (I) provide labour support and emergency
    care for LMCs. (I) support local midwives
  • Legislation means can't do!! LMC difficult to
    delegate pay

19
Early Antenatal Care
  • 198 (90) of 220 primary care practitioners
    surveyed provide early antenatal care

20
Usefulness of the DipObs/OMG, Certificate in
Womens Health
21
Usefulness of course
  • The degree of usefulness of the course, at the
    time it was undertaken, was the same whether
    respondents enrolled to further knowledge about
    womens health, childrens health, family health,
    to practise GP obstetrics or to specialise in
    OG.
  • 76 (33.1) of 229 respondents thought other
    topics should be included, however with major
    curriculum change in 2004, this information may
    no longer be valid

22
On-line course delivery
  • 191 (62.8) of 304 respondents thought a totally
    on-line delivery method for the course would be
    useful.
  • 31 (77.5) of 40 respondents in rural practice
    favoured a web based course.
  • Comment
  • As long as we had regular access to tutors
    online and/or by phone
  • 112 (36.8) did not think on-line delivery would
    be useful
  • Comment
  • There is a lot to be gained from direct
    interaction with others, both students and
    teachers

23
Certificate in Womens Health
  • 9 of the15 graduates in the Certificate in
    Womens Health were identified on the NZMC
    register. (None were listed on the New Zealand
    Register of Midwives or Nursing Council of New
    Zealand.)
  • 7 of the 9 graduates sent a questionnaire
    completed the survey
  • - 78 response rate
  • 6 of the 7 are GPs one an OG registrar.
  • 6 GPs described Certificate training as extremely
    useful, very useful. OG registrar - useful.
  • Comments
  • The Certificate in Womens Health was
    great for general practice. I dont regret
    missing out on the full Diploma as I wont be
    delivering babies unless it is an emergency. I
    wish there had been an equivalent instead of the
    full DCH (Diploma in Child Health) also.

24
Conclusions
  • DipObs, DipOMG and Certificate in Womens Health
    provide very useful post graduate training in
    womens health, especially for primary care
    practitioners
  • Most doctors used to enrol in the DipObs
    intending to practise intrapartum obstetrics in
    general practice
  • Most doctors now enrol in the DipOMG not
    intending to practise intrapartum obstetrics in
    general practice

25
Conclusions
  • Only a very small number of GPs who
    graduated with the DipObs/DipOMG since the early
    1990s are still providing intrapartum obstetric
    care.
  • And points to ponder....
  • Why?
  • Is this of concern?
  • If so, how can this be improved?

26
References
  • Midwife Occupational Skill Shortage Assessment.
    Wellington Department of Labour 2006.
    Available online. URL http//www.worklife.govt.n
    z/PDFs/jvm-prof-mid-2005.pdf
  • Abel S. Midwifery and maternity services in
    transition An Examination of change following
    The Nurses Amendment Act 1990.
    ResearchSpace_at_Auckland 1997. Available online.
    URL http//hdl.handle.net/2292/1968
  • Notice Pursuant to Section 88 of the New Zealand
    Public Health Disability Act 2000. Wellington
    Ministry of Health 2002. Available online.
    URL http//www.moh.govt.nz/moh.nsf/indexmh/matern
    ity-section88notice
  • Notice Pursuant to Section 88 of the New Zealand
    Public Health Disability Act 2000. Wellington
    Ministry of Health 2007. Available online.
    URL http//www.moh.govt.nz/moh.nsf/indexmh/matern
    ity-section88notice

27
Our thanks to
  • Gaye Ellis, research coordinator, and Amanda
    Phillips, Tony Egan and Caroline Slater in the
    development of the project
  • Andrew Gray for his statistical support
  • Andrew Cullen from the Medical Council of New
    Zealand
  • DipObs, DipOMG and Certificate of Womens Health
    graduates who participated in this survey
  • The University of Otago and the University of
    Auckland who funded this research.

28
Discussion
  • GPs are also withdrawing from intrapartum
    obstetric care in Australia, UK, Canada because
    of
  • lifestyle issues
  • concern about medico-legal liability
  • inadequate compensation
  • insufficient numbers of cases per year5-10

29
  • GP trainees in these countries are also choosing
    not to train in intrapartum obstetrics because
    of
  • concern about interference with lifestyle
  • interruption of regular office routine
  • insufficient training in obstetrics
  • cost of malpractice insurance
  • fear of litigation 7-10

30
Maternity Services Consumer Satisfaction Survey
MOH 200711
  • Access to LMC
  • 19 found it difficult to find an LMC to provide
    maternity care for them
  • 11 reported difficulty with this in 2002 survey
  • Most common reasons
  • LMCs too busy
  • Shortage of LMCs

31
Additional references
  • 5. Wiegers T. General Practitioners and
    their role in maternity care. Health Policy
    20036651-59
  • 6. Reid A, Grava-Gubins I, Carroll J.
    Family physicians in maternity care. Still in the
    game? Canad Fam Physician 200046601-611
  • 7. Chen F, Huntington J, Kim S et al.
    Prepared but not practising Declining pregnancy
    care among recent Family Medicine residency
    graduates. Fam Med. 2006 Jun38(6)423-6
  • 8. Ratcliffe S, Newman S, Stone M et al.
    Obstetric care in Family Practice residences A
    5-Year follow-up survey. J Amer Board Fam Med
    200215(1)20-24
  • 9. Smith L. Should general practitioners
    have any role in maternity care in the future? Br
    J Gen Pract. 1996 Apr46(405)243-7
  • 10. Haertsch M, Campbell E, Sanson-Fisher R.
    Who can provide antenatal care? The views of
    obstetricians and midwives. Aust N Z J Public
    Health. 1998 Jun22(4)471-5
  • 11. Maternity Services Consumer Satisfaction
    Survey Report http//www.moh.govt.nz/moh.nsf/pages
    mh/7699/File/maternity-services-consumer-survey-r
    eport-2007.pdf
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