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Who can provide antenatal care? The views of obstetricians and midwives

Who can provide antenatal care? The views of obstetricians and midwives Abstract Objective: To describe the types of antenatal services in NSW maternity hospitals and examine the views of midwives and obstetricians about who can provide adequate routine antenatal care. Measurements: A mail-out questionnaire to nursing unit managers (NUMs) explored the types of antenatal services available in their hospitals. The questionnaire for 196 midwives and 114 obstetricians asked whether they believed six providerlservice types could provide adequate antenatal care either alone or in conjunction with an obstetrician. Findings: 80% of hospitals had GPs providing antenatal care, 53% had obstetricians and 3% had visiting midwives; 33% had a public antenatal clinic, 28% a shared care program with GPs and 26% midwives’ antenatal clinics. Midwives were more likely than obstetricians to rate the following as able to provide adequate care alone: hospital antenatal clinic (4.7 times more likely); independent midwife (42.9~); and community midwives as an outreach hospital service (17x). Obstetricians were 8.2~ more likely than midwives to rate private obstetricians as being able to provide adequate care. Midwives were more likely to perceive that independent midwives (24.7~ more likely) and community midwives as an outreach hospital service (15 . 3 ~ more likely) were able to provide adequate care either alone or in conjunction with an obstetrician. Elizabeth Campbell Hunter Centre for Health Advancement, New South Wales Rob Sanson-Fisher University of Newcastle and Hunter Centre for Health Advancement, New South Wales n 1989, a ministerial review of obstetric services in New South Wales (NSW)’ identified that the system was “failing to effectively use the skills of general practitioners (GPs) and midwives in the care of women who have low to moderate risk factors in their pregnancy” and recommended that additional shared-care arrangements involving GPs and midwives in the provision of antenatal care be introduced in metropolitan and selected rural hospitals.’ These included the introduction of midwives’ clinics, appointment of visiting midwives (independent midwives) to public hospitals and an accreditation process for practitioners to provide antenatal care.l The 1988 National Health and Medical Research Council’s (NHMRC) ‘Guidelines for Antenatal Care’, which states that “antenatal care can be provided by staff of a hospital antenatal clinic or by obstetricians, GPs or independent midwives on a shared care basis”, supports the involvement of a range of practitioners in providing antenatal care and the availability of varied models of care.’ Submissions by women to the ministerial review of birthing services invictoria report the importance for women to be able to choose the care-giver that best suits their needs given the range of possible option^.^ Clearly, collaboration between providers is necessary for the efficient provision of antenatal care.4 The more recent NHMRC document ‘Options for Effective Care in Childbirth’S continues to reiterate these issues. In New Zealand, legislative changes in 1990 established independent midwifery within the New Zealand health system. The health minister at the time believed these changes enabled pregnant women and their VOL. families greater choices in using childbirth services. This allowed midwives to admit women to hospital, referral and prescribing rights6 Australian midwives do not as yet have prescribing rights and, as independent practitioners, are not integrated into the health system. Changing the way pregnancy care is provided has also been the focus of maternity service reform in the United Kingdom described in the Changing Childbirth Report.’ Despite these recommendations and the need for provider groups to collaborate in the provision of antenatal care services, debate continues about who should provide Central to the debate among some Australian obstetricians have been issues of professional territory and a purported lack of evidence demonstrating that proposed models involving shared care or midwife care in Australia are as safe and efficient as those established services involving obstetricians and d o not attract an increase in litigation.1° Two studies from the United Kingdom and one from Canada have explored practitioners’ attitudes about changes in antenatal care including midwife and GP involvement.”-” These studies demonstrated that there were differences in views about midwives providing care, particularly where the midwives were more likely to be in favour of midwife involvement than the GPs and obstetricians. A recent Scottish study demonstrated that routine care involving specialist obstetricians for low-risk women showed “little or no clinical or consumer benefit” when compared to care given by GPs and midwives.I4 In Australia, there is much debate but little research data on what provider groups Conclusion: Most NSW hospitals have GPs providing care, but midwives’ clinics and independent midwives are less available. While midwives and obstetricians hold similar beliefs about GPs providing care, substantial differences emerged about the midwife’s role. Such disparity in opinion may be central in providing options and consistency in care for women. (Aust N 2 J Public Health 1998; 22: 471-5) Correspondenceto: Ms Maggie Haertsch, Faculty of Medicine and Health Sciences, Hunter Centre for Health Advancement, Locked Bag 10. Wallsend NSW 2287. Fax: (049) 246 209. 22 NO. 4 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Haertsch et al. think about whose role it is to provide routine antenatal care. There is also little data on the extent to which the call to implement shared care models, visiting midwives and midwives’ clinics has been adopted into the NSW maternity services. This study has two aims: to describe the current types of antenatal care services available in public and private maternity hospitals in rural and urban NSW; and to examine the views of two key provider groups, midwives and obstetricians, about who can provide adequate routine antenatal care. The study specifically examines whether the groups perceive that GPs -with or without training in obstetrics, independent midwives, community midwives based at a hospital and hospital antenatal clinics - are perceived to be capable of providing adequate routine antenatal care either on their own or in conjunction with an obstetrician in a shared care arrangement. Perceptions are also sought about whether obstetricians are capable of providing routine antenatal care. Table 1: Number of hospitals for which Nursing Unit Managers (NUMs) responded by level of hospital and geographical location. Hospital Levela NUMs completed the questionnaire Geographical locationb Urban Rural Rural Major Other Level 2. 3 [n=78) Level 4. 5. 6 (n=38) Private (n=21) ~~ Total (n=137) Notes: (a) Based on the NSW Department of Health classification system. l5 (b) Rural and remote areas classification system based on population densitx l7 did not respond were sent a duplicate questionnaire. Obstetricians who did not respond were not able to be contacted again. Measures Hospital survey of delivery suite NUMs Method Sample and procedure To address the first aim, nursing unit managers (NUMs) NUMs in the delivery suites from public and private maternity hospital across NSW were contacted by mail during July 1995 and asked to complete a questionnaire and return it using a reply-paid envelope. A follow-up mail out was conducted for non-respondents three weeks after the initial posting. The hospitals (n=144) were those identified as having conducted births and supplied data to the 1990 Midwives Data Collection. The public hospitals ranged from being classified as Level 2 to Level 6 in the NSW Department of Health cla~sification.’~ Level one hospitals are local hospitals with no births; Level 2 are small isolated hospitals staffed by GPs and midwives; Level 3 are country district and smaller metropolitan hospitals; Level 4 are country base or metropolitan district hospitals; Level 5 are country base or metropolitan district hospitals and may have regional perinatal centres; and Level 6 are special obstetric hospitals (supra regional). Although hospitals are classified by location, they are also classified according to the types of services available such as theatre facilities, neonatal services and specialist obstetricians and anaesthetists. Specialist obstetricians usually provide care in all hospitals except Level 2 and 3 hospitals. The higher the level of hospital, the better equipped that hospital is in being able to provide care for women and babies with complications and emergencies. To address the second aim, surveys were conducted of 250 midwives and 250 obstetricians randomly selected using a numerical sequence for the NSW alphabetical membership lists of the Australian College of Midwives Incorporated and Royal Australian College of Obstetricians and Gynaecologists; respectively. A sample size of 250 was calculated allowing for 80% power and a=0.05, with a worst case of 50% non-consent rate. The resulting samples of 1 14 and 196 enabled the detection of differences of 17% or more at the p=0.05 level between the two groups. Midwives and obstetricians were contacted by mail, requesting their completion of an anonymous questionnaire. Midwives who The surveys asked about the types of antenatal care services available: whether obstetricians, GPs and independent midwives provided care and if the hospital had an antenatal clinic, a midwives’ clinic and a shared care program with GPs. Practitioner surveys The surveys explored midwives’ and obstetricians’ views about who can adequately provide routine antenatal care. Respondents were asked to indicate whether they thought that six provider/ service types could provide antenatal care using the following scale: ‘yes’ (can provide adequate routine antenatal care); ‘only in conjunction with an obstetrician’; ‘no’ (cannot provide adequate routine antenatal care); and ‘don’t know’. The provider types were: hospital antenatal clinic, general practitioner with training in obstetrics; general practitioner; independent midwives; community midwives as an outreach hospital service; and private obstetricians. Midwives and obstetricians were asked the year in which they qualified and if they were currently providing antenatal care. Results Response rates and sample characteristics Of the 144 hospitals in which delivery suite NUMs were surveyed, seven were excluded because they no longer provided maternity services in NSW. Of the remaining 137 hospitals, completed questionnaires were received from the delivery suite NUMs of 133 (97%). Table 1 provides information on the number of hospitals for which delivery suite NUMs provided information, by level and by rural and remote areas classification system based on population density. l 6 Of the hospitals for which NUMs provided information, 42 (3 1 %) of maternity hospitals were in urban regions, 41 (31%) in rural major regions and 50 (38%) in rural other and rural remote regions of NSW. Practitioner surveys Of the 250 questionnaires sent to midwives, 196 (78%) completed questionnaires were returned. Of the 250 obstetricians sent VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 22 NO. 4 Who can provide antenatal care?The views of obstetricians and midwives Table 2: NSW maternity hospitals and the type of antenatal care services they provide. Type of service % Hospitals % Hospitals % Hospitals %Total Level 2,3 Level 4,5,6 Private (n=133) (~75) (n=38) (n=20) Antenatal clinics GPs Shared care GPs Midwives clinics guishing feature between public antenatal clinics and midwives clinics is professional group which takes the primary care role. Obstetricians’and midwives’ views of who can provide adequate antenatal care The proportions of the midwife and obstetrician samples nominating each response option for the six items were examined. As, at most, 2% of either group nominated the ‘don’t know’ option for any item, this was combined with ‘no’ for the purposes of further analysis. Table 3 shows the proportions of each group who nominated ‘Yes, alone’, ‘Only in conjunction with an obstetrician’ and ‘NoDon’t know’ for each item. The data were analysed to examine whether the provider groups differed on two questions: i) their perception of who can provide care alone; and ii) and their perception of who can provide antenatal care either on their own or in conjunction with an obstetrician? Midwife and obstetrician ratings of who can provide adequate routine antenatal care on their own ?? Independent midwives 0 Private obstetricians 20 questionnaires, seven were unable to be contacted and a further 22 excluded themselves from participating because they did not practice obstetrics. This left an eligible sample of 221 obstetricians, of whom 114 (52%) completed questionnaires. The midwives’ sample had been qualified in midwifery from one to 36 years (median 11 years) and 89 (51%) were currently providing antenatal care. Obstetricians had been qualified in obstetrics from 2 to 49 years (median 19 years) and 106 (98%) were currently providing antenatal care. Types of hospital services Table 2 shows the types of services by hospital classification. The proportion of hospitals with obstetricians, GPs and midwives providing antenatal care as primary care giver was examined. Of the 133 hospitals, 80% (n=106) have GPs providing care either as GP obstetricians and 28% (n=37) have GPs provide care in a shared antenatal care arrangement, 53% (n=69) have obstetricians providing care and 26% (n=35) have midwives provide care in midwives clinics and 4% (n=4) have midwives practice as independent midwives. Midwives may provide some care in public antenatal clinics however, in this capacity, the care given is primarily the responsibility of doctors, while midwives may take booking-in interviews, check urine and co-ordinate consultations. The role of the midwife in public antenatal clinics may vary between hospitals. The distin- For each of the service types, the associations between practitioner group (midwives or obstetricians) and the perception of whether the service can provide adequate routine antenatal care alone (yes or no) were tested using chi-square analyses. Odds ratios were calculated comparing the differences in perceptions held by midwives and obstetricians where they rated each type of antenatal care service as being capable of providing care on their own which is shown in Table 3, column 3. Significant differences between the practitioner groups were found on four of the six types of service/provider @<0.01).Odds ratios show that midwives were significantly more likely than obstetricians to rate hospital antenatal clinics (4.7 times more likely); independent midwives (42.9 times more likely); and community midwives as an outreach hospital service (17 times more likely) as being able to adequately provide care on their own. The table also shows that the obstetrician sample was 8.2 times more likely than midwives to rate private obstetricians as being able to adequately provide care. Table 3: Midwives’and obstetricians’ views of who can provide adequate routine antenatal care. Midwives Yo(n= 196)’ Type of service Yes, alone Only in conjunction with an obstetrician No/ don’t know Obstetricians Yo(n= 114)2 Yes, alone Only in conjunction with an obstetrician No/ don’t know Can providers give care alone?3 Odds ratio Can providers be involved in care?4 Odds ratio (95% CI) (95% C ) I Antenatal clinic GP with training in obstetrics GP Independent midwife Community midwife as an outreach hospital service Private obstetrician ~~~~ NIA N/A 4.7(2.7-8.1) 1 .l (0.6-2.0) 1 .35 (0.7-2.6) 42.9 (20.8-88.6) 17 (9.2-30.5) 8.2(1.1-63.4) 1.3 (0.3-5.8) 0.35(0.06-1.3) 0.75(0.4-1.2) 24.7(5.7-1 07) 15.3 (4.5-52.5) N/A Sample size ranges between 187and 196 due to missmg data Sample size ranges between 108and 1 14 due to missing data (Yedconjunction with obstetrman and No, Don’t Know) (Yes and conjunction w nh obstetrician“o, Don’t Know) gl t Not signgnlficant differences between prowders N/A Not applrcable ‘ VOL. 22 NO. 4 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Haertsch et al. Midwife and obstetrician ratings of who can be involved in providing adequate antenatal care either on their own or in conjunction with an obstetrician. For each of the service types, the associations between practitioner group (midwives or obstetricians) and the perception of whether the service can be involved in providing adequate routine antenatal care (yes or no) were tested using chi-square analyses. Odds ratios were calculated comparing the differences in perceptions held by midwives and obstetricians where they rated each type of antenatal care service as being capable of providing care either on their own or in conjunction with an obstetricians which is shown in Table 3, column 4. Significant differences between the practitioner groups were found on two of the five types of service/ providers @<0.01). Odds ratios show that midwives were significantly more likely than obstetricians to rate independent midwives (24.7 times more likely) and community midwives as an outreach hospital service (15.3 times more likely) as being appropriate to be involved in providing care. Years since qualification was examined for both the midwife and obstetrician samples to determine if the more recently qualified practitioners held more liberal views about antenatal care providers other than those who were obstetricians. Chi-squares were performed using three cut points: 10, 15 and 20 years since qualifying. The midwife sample showed no difference in the views with the exception of their views about GPs at the 20-year cut point. Midwives who qualified within the past 2 0 years (79% of the sample), were 3.9 times less likely (95% CI = I .6-9.4) to believe that GPs without training in obstetrics can provide care alone compared to midwives who qualified at least 20 years ago. Differences within the obstetrician sample were also found at the 20-year cut point only. Obstetricians who qualified less than 20 years ago (51% of the sample) believed that the following three practitioner groups can provide care alone compared with those obstetricians who qualified within the past 20 years: GPs without training in obstetrics (6.2 times more likely; 95% CI 1.5-25.8), independent midwives ( 1 1.9 times more likely; 95% CI 2.1-66.4) and community midwives as an outreach hospital service (5.6 times more likely; 95% CI 1.7-19.0). There were no differences between the obstetrician sample on their views about who can be involved in care. Overall, comparing midwives and obstetricians views who qualified within the last 20 years, there were still differences about independent midwives and community midwife as an outreach hospital service being involved in antenatal care. Obstetricians were 22.7 times less likely (95% CI 5-100) and 13 times less likely (95% CI 3.65-47.6) than midwives to hold the view that independent midwives and community midwives respectively can be involved in antenatal care. There were no differences within the midwife and obstetrician samples for those who were currently practising and those who provided antenatal care. Discussion Despite recommendations in the Sheannan report six years previously,’ there were relatively few hospitals which provided midwives’clinics (26%), shared antenatal care programs with GPs (28%) and independent midwives accredited to use hospitals (3%). Although the report did not specify which rural hospitals should provide shared care arrangements with GPs and midwives, the data demonstrates that these options were still not available in all Level 4, 5 and 6 hospitals. Services where midwives were the primary care giver, such as midwives’ clinics and visiting midwives accredited to use the hospital facilities, were the least available options particularly in Level 2 and 3 hospitals. These hospitals were mainly located in rural areas. Options for antenatal care for women who live in rural areas were generally limited to GPs with few public antenatal clinics, midwives clinics, obstetricians and no independent midwives accredited to the Level 2 and 3 hospitals. Midwives were employed within those hospitals primarily to provide intrapartum and postpartum care. There was a limited opportunity for these midwives to give antenatal care, even though these hospitals provide services for low-risk women. Differences in the views of the two practitioner groups were evident on the types of services that involved midwife care or public antenatal clinics. The majority of midwives (86%) believed that antenatal clinics could provide adequate antenatal care alone. Just over half the obstetricians sampled shared this view. The remaining obstetricians believed that antenatal clinics could provide adequate antenatal care if there was an obstetrician involved. Hospital antenatal clinics could potentially be staffed by a range of providers including trainee obstetricians, general practitioners with training in obstetrics and midwives. The survey instrument listed antenatal clinic but did not define the practitioners who would provide care. The largest differences were seen in the beliefs regarding the participants’ own professional groups. There was 100% agreement by obstetricians that they could provide antenatal care alone whereas a minority of midwives (7%) believed that obstetricians could not provide adequate antenatal care alone. A large majority of midwives believed that both independent midwives (82%) and community midwives (75%) could provide adequate antenatal care alone yet only a small proportion of obstetricians believed this. Independent midwives are self-employed private practitioners who have more autonomy than community midwives working as an outreach hospital service. The registration requirements and educational qualifications are no different with either position. Although the conclusions are tentative, the data suggests that obstetricians may be more in favour of community midwives than independent midwives providing care alone. The reverse appears to be true for midwives, who favoured independent midwifery over community midwifery. The majority of obstetricians believed that midwife care needed to include the care given by an obstetrician. These views are similar to those reported in a study from the UK which sought the views of obstetricians about midwifery practice concluding that obstetricians perceived that midwives need a lot of support and that obstetricians were not prepared to be excluded from care of low-risk women.’* Almost one fifth of the obstetricians in the current study indicated they believed that midwives should not provide antenatal care even if an obstetrician was involved. These differing views about the midwife’s role in antenatal care are consistent with a Canadian study where the views of obstetricians and family physicians were in agreement when exploring the pros and cons of midwifery as it was being introduced into the health system in the province of Quebec.13 These physicians believed that midwifery was not necessary. Midwives and obstetricians had similar views about GPs providing care. Both groups believed that GP involvement required GPs to have training in obstetrics and those without the training VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 22 NO. 4 Who can provide antenatal care?The views of obstetricians and midwives needed to provide care in conjunction with an obstetrician, if at all. The study had a strong representation of maternity hospitals in NSW, however, the conclusions may be limited by the representativeness of the samples of obstetricians and midwives. The list from which the obstetrician sample was drawn represented all obstetricians accredited as specialist obstetricians in NSW and, of those sampled, 98% were currently providing antenatal care. Medicare data indicates that there were 255 obstetricians attending more than five births or caesareans in 1992 in NSW” so while the obstetrician sample therefore appears to represent almost half of the practising obstetricians, the response rate was only 52% and, although similar to other studies involving questionnaires mailed to professional groups, this self selection may present a significant bias. The midwife sample, while a good representation of the College members with a high consent rate, may be less representative of practising midwives in NSW. The NSW Nurses Registration Board is the body which accredits midwives to practice. Based on the number of practising midwives in NSW, it was estimated that approximately 35% of practising certified midwives were members of theAustralian College of Midwives in NSW.18 There is thus some uncertainty about how well the views expressed by the sample generalise to all practising midwives. Although 5 1% of the midwives in the study were currently practising in antenatal care, most of the sample would be practising in other areas of midwifery such as delivery suite or postnatal care given that only 4% of members of the Australian College of Midwives NSW Branch are retired or not employed.” There are also potential limitations of the instrument used to assess midwives’ and obstetricians’ views. The questions do not describe to the fullest extent the variety of possible shared care options and may not have provided enough detail to ensure that all practitioners had a shared perception of the questions’ meaning. Practitioners may have had difficulty in the interpretation of definitions such as antenatal clinic and what ‘training in obstetrics’ with regard to GPs providing care. GPs may have undertaken various short shared care courses or a more comprehensive Diploma in Obstetrics. Definitions of shared G P care, midwives’ clinics visiting midwives and the extension of antenatal services to the community are explored in the Shearman report.’ Obstetricians can and in a small number of practices do, provide antenatal care in conjunction with a midwife.20.2 1 Alternatively, GPs can provide antenatal care in conjunction with a midwife. New models of antenatal care have since emerged since the study was planned. grams may help promote collaborative practice. Such programs have been running in at the University of Newcastle with fourth year medical students and students undertaking the Graduate Diploma of Midwifery since 1994. The outcome of this type of educational model is yet to be evaluated, but could prove to be one of a number of useful strategies to assist interprofessional collaboration and ultimateiy quality care. Acknowledgments The authors gratefully acknowledge the contribution of Dr Sally Redman in obtaining the funding for this project, Dr Max Brinsmead for his assistance with reviewing the manuscript and Dell Horey for her practical support. We also thank the practitioners who participated in the study. This research was funded by the General Practice Evaluation Program. Ethics approval for the study was obtained from the University of Newcastle. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Who can provide antenatal care? The views of obstetricians and midwives

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Publisher
Wiley
Copyright
Copyright © 1998 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1998.tb01416.x
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To describe the types of antenatal services in NSW maternity hospitals and examine the views of midwives and obstetricians about who can provide adequate routine antenatal care. Measurements: A mail-out questionnaire to nursing unit managers (NUMs) explored the types of antenatal services available in their hospitals. The questionnaire for 196 midwives and 114 obstetricians asked whether they believed six providerlservice types could provide adequate antenatal care either alone or in conjunction with an obstetrician. Findings: 80% of hospitals had GPs providing antenatal care, 53% had obstetricians and 3% had visiting midwives; 33% had a public antenatal clinic, 28% a shared care program with GPs and 26% midwives’ antenatal clinics. Midwives were more likely than obstetricians to rate the following as able to provide adequate care alone: hospital antenatal clinic (4.7 times more likely); independent midwife (42.9~); and community midwives as an outreach hospital service (17x). Obstetricians were 8.2~ more likely than midwives to rate private obstetricians as being able to provide adequate care. Midwives were more likely to perceive that independent midwives (24.7~ more likely) and community midwives as an outreach hospital service (15 . 3 ~ more likely) were able to provide adequate care either alone or in conjunction with an obstetrician. Elizabeth Campbell Hunter Centre for Health Advancement, New South Wales Rob Sanson-Fisher University of Newcastle and Hunter Centre for Health Advancement, New South Wales n 1989, a ministerial review of obstetric services in New South Wales (NSW)’ identified that the system was “failing to effectively use the skills of general practitioners (GPs) and midwives in the care of women who have low to moderate risk factors in their pregnancy” and recommended that additional shared-care arrangements involving GPs and midwives in the provision of antenatal care be introduced in metropolitan and selected rural hospitals.’ These included the introduction of midwives’ clinics, appointment of visiting midwives (independent midwives) to public hospitals and an accreditation process for practitioners to provide antenatal care.l The 1988 National Health and Medical Research Council’s (NHMRC) ‘Guidelines for Antenatal Care’, which states that “antenatal care can be provided by staff of a hospital antenatal clinic or by obstetricians, GPs or independent midwives on a shared care basis”, supports the involvement of a range of practitioners in providing antenatal care and the availability of varied models of care.’ Submissions by women to the ministerial review of birthing services invictoria report the importance for women to be able to choose the care-giver that best suits their needs given the range of possible option^.^ Clearly, collaboration between providers is necessary for the efficient provision of antenatal care.4 The more recent NHMRC document ‘Options for Effective Care in Childbirth’S continues to reiterate these issues. In New Zealand, legislative changes in 1990 established independent midwifery within the New Zealand health system. The health minister at the time believed these changes enabled pregnant women and their VOL. families greater choices in using childbirth services. This allowed midwives to admit women to hospital, referral and prescribing rights6 Australian midwives do not as yet have prescribing rights and, as independent practitioners, are not integrated into the health system. Changing the way pregnancy care is provided has also been the focus of maternity service reform in the United Kingdom described in the Changing Childbirth Report.’ Despite these recommendations and the need for provider groups to collaborate in the provision of antenatal care services, debate continues about who should provide Central to the debate among some Australian obstetricians have been issues of professional territory and a purported lack of evidence demonstrating that proposed models involving shared care or midwife care in Australia are as safe and efficient as those established services involving obstetricians and d o not attract an increase in litigation.1° Two studies from the United Kingdom and one from Canada have explored practitioners’ attitudes about changes in antenatal care including midwife and GP involvement.”-” These studies demonstrated that there were differences in views about midwives providing care, particularly where the midwives were more likely to be in favour of midwife involvement than the GPs and obstetricians. A recent Scottish study demonstrated that routine care involving specialist obstetricians for low-risk women showed “little or no clinical or consumer benefit” when compared to care given by GPs and midwives.I4 In Australia, there is much debate but little research data on what provider groups Conclusion: Most NSW hospitals have GPs providing care, but midwives’ clinics and independent midwives are less available. While midwives and obstetricians hold similar beliefs about GPs providing care, substantial differences emerged about the midwife’s role. Such disparity in opinion may be central in providing options and consistency in care for women. (Aust N 2 J Public Health 1998; 22: 471-5) Correspondenceto: Ms Maggie Haertsch, Faculty of Medicine and Health Sciences, Hunter Centre for Health Advancement, Locked Bag 10. Wallsend NSW 2287. Fax: (049) 246 209. 22 NO. 4 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Haertsch et al. think about whose role it is to provide routine antenatal care. There is also little data on the extent to which the call to implement shared care models, visiting midwives and midwives’ clinics has been adopted into the NSW maternity services. This study has two aims: to describe the current types of antenatal care services available in public and private maternity hospitals in rural and urban NSW; and to examine the views of two key provider groups, midwives and obstetricians, about who can provide adequate routine antenatal care. The study specifically examines whether the groups perceive that GPs -with or without training in obstetrics, independent midwives, community midwives based at a hospital and hospital antenatal clinics - are perceived to be capable of providing adequate routine antenatal care either on their own or in conjunction with an obstetrician in a shared care arrangement. Perceptions are also sought about whether obstetricians are capable of providing routine antenatal care. Table 1: Number of hospitals for which Nursing Unit Managers (NUMs) responded by level of hospital and geographical location. Hospital Levela NUMs completed the questionnaire Geographical locationb Urban Rural Rural Major Other Level 2. 3 [n=78) Level 4. 5. 6 (n=38) Private (n=21) ~~ Total (n=137) Notes: (a) Based on the NSW Department of Health classification system. l5 (b) Rural and remote areas classification system based on population densitx l7 did not respond were sent a duplicate questionnaire. Obstetricians who did not respond were not able to be contacted again. Measures Hospital survey of delivery suite NUMs Method Sample and procedure To address the first aim, nursing unit managers (NUMs) NUMs in the delivery suites from public and private maternity hospital across NSW were contacted by mail during July 1995 and asked to complete a questionnaire and return it using a reply-paid envelope. A follow-up mail out was conducted for non-respondents three weeks after the initial posting. The hospitals (n=144) were those identified as having conducted births and supplied data to the 1990 Midwives Data Collection. The public hospitals ranged from being classified as Level 2 to Level 6 in the NSW Department of Health cla~sification.’~ Level one hospitals are local hospitals with no births; Level 2 are small isolated hospitals staffed by GPs and midwives; Level 3 are country district and smaller metropolitan hospitals; Level 4 are country base or metropolitan district hospitals; Level 5 are country base or metropolitan district hospitals and may have regional perinatal centres; and Level 6 are special obstetric hospitals (supra regional). Although hospitals are classified by location, they are also classified according to the types of services available such as theatre facilities, neonatal services and specialist obstetricians and anaesthetists. Specialist obstetricians usually provide care in all hospitals except Level 2 and 3 hospitals. The higher the level of hospital, the better equipped that hospital is in being able to provide care for women and babies with complications and emergencies. To address the second aim, surveys were conducted of 250 midwives and 250 obstetricians randomly selected using a numerical sequence for the NSW alphabetical membership lists of the Australian College of Midwives Incorporated and Royal Australian College of Obstetricians and Gynaecologists; respectively. A sample size of 250 was calculated allowing for 80% power and a=0.05, with a worst case of 50% non-consent rate. The resulting samples of 1 14 and 196 enabled the detection of differences of 17% or more at the p=0.05 level between the two groups. Midwives and obstetricians were contacted by mail, requesting their completion of an anonymous questionnaire. Midwives who The surveys asked about the types of antenatal care services available: whether obstetricians, GPs and independent midwives provided care and if the hospital had an antenatal clinic, a midwives’ clinic and a shared care program with GPs. Practitioner surveys The surveys explored midwives’ and obstetricians’ views about who can adequately provide routine antenatal care. Respondents were asked to indicate whether they thought that six provider/ service types could provide antenatal care using the following scale: ‘yes’ (can provide adequate routine antenatal care); ‘only in conjunction with an obstetrician’; ‘no’ (cannot provide adequate routine antenatal care); and ‘don’t know’. The provider types were: hospital antenatal clinic, general practitioner with training in obstetrics; general practitioner; independent midwives; community midwives as an outreach hospital service; and private obstetricians. Midwives and obstetricians were asked the year in which they qualified and if they were currently providing antenatal care. Results Response rates and sample characteristics Of the 144 hospitals in which delivery suite NUMs were surveyed, seven were excluded because they no longer provided maternity services in NSW. Of the remaining 137 hospitals, completed questionnaires were received from the delivery suite NUMs of 133 (97%). Table 1 provides information on the number of hospitals for which delivery suite NUMs provided information, by level and by rural and remote areas classification system based on population density. l 6 Of the hospitals for which NUMs provided information, 42 (3 1 %) of maternity hospitals were in urban regions, 41 (31%) in rural major regions and 50 (38%) in rural other and rural remote regions of NSW. Practitioner surveys Of the 250 questionnaires sent to midwives, 196 (78%) completed questionnaires were returned. Of the 250 obstetricians sent VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 22 NO. 4 Who can provide antenatal care?The views of obstetricians and midwives Table 2: NSW maternity hospitals and the type of antenatal care services they provide. Type of service % Hospitals % Hospitals % Hospitals %Total Level 2,3 Level 4,5,6 Private (n=133) (~75) (n=38) (n=20) Antenatal clinics GPs Shared care GPs Midwives clinics guishing feature between public antenatal clinics and midwives clinics is professional group which takes the primary care role. Obstetricians’and midwives’ views of who can provide adequate antenatal care The proportions of the midwife and obstetrician samples nominating each response option for the six items were examined. As, at most, 2% of either group nominated the ‘don’t know’ option for any item, this was combined with ‘no’ for the purposes of further analysis. Table 3 shows the proportions of each group who nominated ‘Yes, alone’, ‘Only in conjunction with an obstetrician’ and ‘NoDon’t know’ for each item. The data were analysed to examine whether the provider groups differed on two questions: i) their perception of who can provide care alone; and ii) and their perception of who can provide antenatal care either on their own or in conjunction with an obstetrician? Midwife and obstetrician ratings of who can provide adequate routine antenatal care on their own ?? Independent midwives 0 Private obstetricians 20 questionnaires, seven were unable to be contacted and a further 22 excluded themselves from participating because they did not practice obstetrics. This left an eligible sample of 221 obstetricians, of whom 114 (52%) completed questionnaires. The midwives’ sample had been qualified in midwifery from one to 36 years (median 11 years) and 89 (51%) were currently providing antenatal care. Obstetricians had been qualified in obstetrics from 2 to 49 years (median 19 years) and 106 (98%) were currently providing antenatal care. Types of hospital services Table 2 shows the types of services by hospital classification. The proportion of hospitals with obstetricians, GPs and midwives providing antenatal care as primary care giver was examined. Of the 133 hospitals, 80% (n=106) have GPs providing care either as GP obstetricians and 28% (n=37) have GPs provide care in a shared antenatal care arrangement, 53% (n=69) have obstetricians providing care and 26% (n=35) have midwives provide care in midwives clinics and 4% (n=4) have midwives practice as independent midwives. Midwives may provide some care in public antenatal clinics however, in this capacity, the care given is primarily the responsibility of doctors, while midwives may take booking-in interviews, check urine and co-ordinate consultations. The role of the midwife in public antenatal clinics may vary between hospitals. The distin- For each of the service types, the associations between practitioner group (midwives or obstetricians) and the perception of whether the service can provide adequate routine antenatal care alone (yes or no) were tested using chi-square analyses. Odds ratios were calculated comparing the differences in perceptions held by midwives and obstetricians where they rated each type of antenatal care service as being capable of providing care on their own which is shown in Table 3, column 3. Significant differences between the practitioner groups were found on four of the six types of service/provider @<0.01).Odds ratios show that midwives were significantly more likely than obstetricians to rate hospital antenatal clinics (4.7 times more likely); independent midwives (42.9 times more likely); and community midwives as an outreach hospital service (17 times more likely) as being able to adequately provide care on their own. The table also shows that the obstetrician sample was 8.2 times more likely than midwives to rate private obstetricians as being able to adequately provide care. Table 3: Midwives’and obstetricians’ views of who can provide adequate routine antenatal care. Midwives Yo(n= 196)’ Type of service Yes, alone Only in conjunction with an obstetrician No/ don’t know Obstetricians Yo(n= 114)2 Yes, alone Only in conjunction with an obstetrician No/ don’t know Can providers give care alone?3 Odds ratio Can providers be involved in care?4 Odds ratio (95% CI) (95% C ) I Antenatal clinic GP with training in obstetrics GP Independent midwife Community midwife as an outreach hospital service Private obstetrician ~~~~ NIA N/A 4.7(2.7-8.1) 1 .l (0.6-2.0) 1 .35 (0.7-2.6) 42.9 (20.8-88.6) 17 (9.2-30.5) 8.2(1.1-63.4) 1.3 (0.3-5.8) 0.35(0.06-1.3) 0.75(0.4-1.2) 24.7(5.7-1 07) 15.3 (4.5-52.5) N/A Sample size ranges between 187and 196 due to missmg data Sample size ranges between 108and 1 14 due to missing data (Yedconjunction with obstetrman and No, Don’t Know) (Yes and conjunction w nh obstetrician“o, Don’t Know) gl t Not signgnlficant differences between prowders N/A Not applrcable ‘ VOL. 22 NO. 4 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Haertsch et al. Midwife and obstetrician ratings of who can be involved in providing adequate antenatal care either on their own or in conjunction with an obstetrician. For each of the service types, the associations between practitioner group (midwives or obstetricians) and the perception of whether the service can be involved in providing adequate routine antenatal care (yes or no) were tested using chi-square analyses. Odds ratios were calculated comparing the differences in perceptions held by midwives and obstetricians where they rated each type of antenatal care service as being capable of providing care either on their own or in conjunction with an obstetricians which is shown in Table 3, column 4. Significant differences between the practitioner groups were found on two of the five types of service/ providers @<0.01). Odds ratios show that midwives were significantly more likely than obstetricians to rate independent midwives (24.7 times more likely) and community midwives as an outreach hospital service (15.3 times more likely) as being appropriate to be involved in providing care. Years since qualification was examined for both the midwife and obstetrician samples to determine if the more recently qualified practitioners held more liberal views about antenatal care providers other than those who were obstetricians. Chi-squares were performed using three cut points: 10, 15 and 20 years since qualifying. The midwife sample showed no difference in the views with the exception of their views about GPs at the 20-year cut point. Midwives who qualified within the past 2 0 years (79% of the sample), were 3.9 times less likely (95% CI = I .6-9.4) to believe that GPs without training in obstetrics can provide care alone compared to midwives who qualified at least 20 years ago. Differences within the obstetrician sample were also found at the 20-year cut point only. Obstetricians who qualified less than 20 years ago (51% of the sample) believed that the following three practitioner groups can provide care alone compared with those obstetricians who qualified within the past 20 years: GPs without training in obstetrics (6.2 times more likely; 95% CI 1.5-25.8), independent midwives ( 1 1.9 times more likely; 95% CI 2.1-66.4) and community midwives as an outreach hospital service (5.6 times more likely; 95% CI 1.7-19.0). There were no differences between the obstetrician sample on their views about who can be involved in care. Overall, comparing midwives and obstetricians views who qualified within the last 20 years, there were still differences about independent midwives and community midwife as an outreach hospital service being involved in antenatal care. Obstetricians were 22.7 times less likely (95% CI 5-100) and 13 times less likely (95% CI 3.65-47.6) than midwives to hold the view that independent midwives and community midwives respectively can be involved in antenatal care. There were no differences within the midwife and obstetrician samples for those who were currently practising and those who provided antenatal care. Discussion Despite recommendations in the Sheannan report six years previously,’ there were relatively few hospitals which provided midwives’clinics (26%), shared antenatal care programs with GPs (28%) and independent midwives accredited to use hospitals (3%). Although the report did not specify which rural hospitals should provide shared care arrangements with GPs and midwives, the data demonstrates that these options were still not available in all Level 4, 5 and 6 hospitals. Services where midwives were the primary care giver, such as midwives’ clinics and visiting midwives accredited to use the hospital facilities, were the least available options particularly in Level 2 and 3 hospitals. These hospitals were mainly located in rural areas. Options for antenatal care for women who live in rural areas were generally limited to GPs with few public antenatal clinics, midwives clinics, obstetricians and no independent midwives accredited to the Level 2 and 3 hospitals. Midwives were employed within those hospitals primarily to provide intrapartum and postpartum care. There was a limited opportunity for these midwives to give antenatal care, even though these hospitals provide services for low-risk women. Differences in the views of the two practitioner groups were evident on the types of services that involved midwife care or public antenatal clinics. The majority of midwives (86%) believed that antenatal clinics could provide adequate antenatal care alone. Just over half the obstetricians sampled shared this view. The remaining obstetricians believed that antenatal clinics could provide adequate antenatal care if there was an obstetrician involved. Hospital antenatal clinics could potentially be staffed by a range of providers including trainee obstetricians, general practitioners with training in obstetrics and midwives. The survey instrument listed antenatal clinic but did not define the practitioners who would provide care. The largest differences were seen in the beliefs regarding the participants’ own professional groups. There was 100% agreement by obstetricians that they could provide antenatal care alone whereas a minority of midwives (7%) believed that obstetricians could not provide adequate antenatal care alone. A large majority of midwives believed that both independent midwives (82%) and community midwives (75%) could provide adequate antenatal care alone yet only a small proportion of obstetricians believed this. Independent midwives are self-employed private practitioners who have more autonomy than community midwives working as an outreach hospital service. The registration requirements and educational qualifications are no different with either position. Although the conclusions are tentative, the data suggests that obstetricians may be more in favour of community midwives than independent midwives providing care alone. The reverse appears to be true for midwives, who favoured independent midwifery over community midwifery. The majority of obstetricians believed that midwife care needed to include the care given by an obstetrician. These views are similar to those reported in a study from the UK which sought the views of obstetricians about midwifery practice concluding that obstetricians perceived that midwives need a lot of support and that obstetricians were not prepared to be excluded from care of low-risk women.’* Almost one fifth of the obstetricians in the current study indicated they believed that midwives should not provide antenatal care even if an obstetrician was involved. These differing views about the midwife’s role in antenatal care are consistent with a Canadian study where the views of obstetricians and family physicians were in agreement when exploring the pros and cons of midwifery as it was being introduced into the health system in the province of Quebec.13 These physicians believed that midwifery was not necessary. Midwives and obstetricians had similar views about GPs providing care. Both groups believed that GP involvement required GPs to have training in obstetrics and those without the training VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 22 NO. 4 Who can provide antenatal care?The views of obstetricians and midwives needed to provide care in conjunction with an obstetrician, if at all. The study had a strong representation of maternity hospitals in NSW, however, the conclusions may be limited by the representativeness of the samples of obstetricians and midwives. The list from which the obstetrician sample was drawn represented all obstetricians accredited as specialist obstetricians in NSW and, of those sampled, 98% were currently providing antenatal care. Medicare data indicates that there were 255 obstetricians attending more than five births or caesareans in 1992 in NSW” so while the obstetrician sample therefore appears to represent almost half of the practising obstetricians, the response rate was only 52% and, although similar to other studies involving questionnaires mailed to professional groups, this self selection may present a significant bias. The midwife sample, while a good representation of the College members with a high consent rate, may be less representative of practising midwives in NSW. The NSW Nurses Registration Board is the body which accredits midwives to practice. Based on the number of practising midwives in NSW, it was estimated that approximately 35% of practising certified midwives were members of theAustralian College of Midwives in NSW.18 There is thus some uncertainty about how well the views expressed by the sample generalise to all practising midwives. Although 5 1% of the midwives in the study were currently practising in antenatal care, most of the sample would be practising in other areas of midwifery such as delivery suite or postnatal care given that only 4% of members of the Australian College of Midwives NSW Branch are retired or not employed.” There are also potential limitations of the instrument used to assess midwives’ and obstetricians’ views. The questions do not describe to the fullest extent the variety of possible shared care options and may not have provided enough detail to ensure that all practitioners had a shared perception of the questions’ meaning. Practitioners may have had difficulty in the interpretation of definitions such as antenatal clinic and what ‘training in obstetrics’ with regard to GPs providing care. GPs may have undertaken various short shared care courses or a more comprehensive Diploma in Obstetrics. Definitions of shared G P care, midwives’ clinics visiting midwives and the extension of antenatal services to the community are explored in the Shearman report.’ Obstetricians can and in a small number of practices do, provide antenatal care in conjunction with a midwife.20.2 1 Alternatively, GPs can provide antenatal care in conjunction with a midwife. New models of antenatal care have since emerged since the study was planned. grams may help promote collaborative practice. Such programs have been running in at the University of Newcastle with fourth year medical students and students undertaking the Graduate Diploma of Midwifery since 1994. The outcome of this type of educational model is yet to be evaluated, but could prove to be one of a number of useful strategies to assist interprofessional collaboration and ultimateiy quality care. Acknowledgments The authors gratefully acknowledge the contribution of Dr Sally Redman in obtaining the funding for this project, Dr Max Brinsmead for his assistance with reviewing the manuscript and Dell Horey for her practical support. We also thank the practitioners who participated in the study. This research was funded by the General Practice Evaluation Program. Ethics approval for the study was obtained from the University of Newcastle.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Aug 1, 1998

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