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| Journal of the New Zealand Medical Association,
30-March-2012, Vol 125 No 1352
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Final-year medical students’ perceptions of
maternity care in general practice
Hanna Preston, Dawn Miller
Maternity care workforce shortages are a problem in New
Zealand. There is a shortage of both midwives and specialist obstetricians in
some regions1 and a
dramatic decline in the number of GPs providing full maternity care means that
most women do not have the choice of a GP obstetrician (GPO).
Since the changes to maternity care legislation in the
1990s, and the introduction of the lead maternity carer (LMC) model of care,
midwives can practice independently in New
Zealand.1 The LMC has overall clinical and
budgetary responsibility for a woman’s primary maternity
care.1
Midwives now provide at least 80% of LMC
services.2 Women
choose their LMC, who can be either a midwife, GPO or obstetrician. An
increasing number of women experience difficulties finding a suitable
LMC,3 especially in rural
areas.4 The government has allocated funding
for training and retraining of GPs in maternity
care.5 This raises
the question: are the future doctors of New Zealand interested in providing
maternity care?
There are no known New Zealand studies investigating medical
students’ views about providing maternity care as part of general
practice. Reasons for declining GP maternity services identified in a review of
research from Canada, USA, parts of Europe and Australia include: interference
with lifestyle and interruption of office routine, fear of litigation and costs
of malpractice insurance, insufficient training and insufficient numbers of
cases to retain
competency.6
A recent New Zealand study investigating factors that
influence trainee interns (TIs), and junior doctors when considering career
choices found that interest in a specialty and lifestyle were the two most
important factors for those considering general practice as a
specialty.7 Having
personal experience in a specialty, reports from others in a specialty and
having individual role models most influenced career
decisions.7 With only 54 GPOs identified in
2006 by the Royal New Zealand College of General
Practitioners,8 opportunities for students to
gain any personal experience or exposure to this role could be limited.
This study aimed to investigate TIs’ perceptions about
the provision of maternity care in general practice in New Zealand, their
possible role as future GPs in that service, and the factors that influence
this.
MethodsThis study surveyed TIs enrolled at the Dunedin (n=69),
Christchurch (n=72) and Wellington (n=86) Schools of Medicine, University of
Otago, for the year November 2009 - November 2010. TIs are final-year medical
students in their sixth year of training. Those surveyed included 12 TIs from
the 2008-2009 TI class who were still completing their final quarter, giving a
total of 227 students. Twenty TIs had completed the Rural Medical Immersion
Programme (RMIP) as fifth-year students, undertaking that year of their medical
course in a rural setting.
Students were invited by email to participate in an
online questionnaire. Two reminder emails were sent at 1 week intervals after
the initial invitation. All emails included a hyperlink to the questionnaire,
and a Participant Information Sheet. The second reminder email included the
introduction of $50 vouchers as spot prizes to randomly selected TIs, to
encourage participation.
The questionnaire was delivered through the online
programme SurveyMonkeyTM and included ten
questions and additional demographic data. It could be completed and submitted
online. Maternity care periods were defined as: prenatal care (preparation for
pregnancy), early pregnancy care (pregnancy testing, management of complications
of early pregnancy), antenatal care (monitoring and support throughout
pregnancy), postnatal care, shared care (seeing pregnant women on alternate
antenatal visits to midwife’s visits and postnatally), and full obstetric
care (through pregnancy, labour, delivery, and postnatally). Full obstetric care
is also described as full maternity care. Quantitative results were analysed
using the statistical analysis options available through SurveyMonkey.
Ethics approval for this study was granted by the
University of Otago Human Ethics Committee.
ResultsResponse rate and
representativeness—115 surveys were completed giving a response
rate of 50.7%. Fifty-four TIs were on their Elective, a 3-month module
encouraging other medical experience in New Zealand or overseas. Students on
elective were less likely to have access to their university email to complete
the questionnaire. Response rates were highest in Dunedin, and lowest in
Wellington, ranging from 46.5% to 55%.
The demographic characteristics of the respondents are shown
in Table 1. Respondents could identify with more than one ethnic group. The
‘Other’ ethnicity category includes two counts of ‘New
Zealander’ and a further two as ‘Wellington’ and
‘Waikato’. There was a slight over-representation of TIs who were
younger and of New Zealand-European ethnicity.
Table 1. Demographic characteristics of
respondents
General Practice and its role in maternity
care—TIs were asked what maternity care services GPs who are
interested and trained in maternity care should be offering. Prenatal and
postnatal care had the highest levels of support, at 94.8% and 92.1%
respectively. Most TIs also thought early pregnancy care (88.7%) and antenatal
care (89.6%) should be offered.
Shared care with a midwife was supported by 80.7% of TIs and
55.7% thought such GPs should provide full maternity care (including care in
pregnancy, labour/delivery and postpartum). Comments showed one reservation
about providing maternity care was the impact on GPs’ workload (11
comments). Almost all TIs thought that pregnant women should have the option of
having their GP involved in antenatal and postnatal care (98.3%), with 79.1%
believing that women should have access to full maternity care with a GP.
Exposure to maternity care in general
practice—More than half (56.5%) of respondents had seen a GP
practicing antenatal and postnatal care and 25.2% had seen a GP practicing full
maternity care. This exposure to general practice maternity care was mainly as a
medical student (70.1%), but also within the community (14.9%), and family
(10.4%). Of the 13 respondents who undertook the Fifth Year RMIP, ten (76.9%)
had seen antenatal and postnatal care, and six (46.2%) had seen full maternity
care being practiced by a GP.
Our future GPs—A future career in
urban general practice is being considered by 70.2% of respondents, and 56.1%
are considering practicing as a rural GP. More than 90% of all respondents would
consider (respondents who answered ‘yes’ or ‘maybe’)
providing prenatal, early pregnancy, antenatal, and postnatal care if practicing
as a GP (Figure 1), with more than 70% answering ‘Yes’ to providing
these services. Eighty-nine point five percent would consider providing shared
care with a midwife. While 64.0% of respondents would consider providing full
maternity care if practicing as a GP, almost half of that group (45.2%) stated,
‘Yes’, they would like to provide this service.
Results were similar for the subgroup of respondents who
indicated an interest in general practice as a career (urban or rural). The main
differences however were in regard to TIs’ interest in providing full
maternity care in their general practice. Those TIs who had seen a GP practicing
full maternity care were most likely to consider providing full maternity care
in their general practice (82.8%) (Figure 1). Those TIs considering rural
general practice as a career were also more interested to provide full maternity
care (68.3%) (Figure 1).
Figure 1. Pregnancy care respondents would
consider providing if practicing as GP
 Respondents were asked to rate the importance of eight
professional and lifestyle issues related to maternity care in general practice
on a 3-stage scale of ‘not important’ to ‘very
important’ (Figure 2).
Figure 2. Importance of professional and
lifestyle issues if practicing maternity care in general practice.
 Although all issues presented were considered
‘important’ or ‘very important’ by the vast majority,
issues most popularly rated ‘very important’ were: postgraduate
training in obstetrics, peer support from medical and midwifery colleagues,
hospital support and adequate funding. For the 73 TIs who indicated they would
consider providing full maternity care the issues most popularly rated
‘very important’ also included continuity of care for their general
practice patients, in addition to the above four issues identified by all
respondents.
Flexible hours and the ability to work part-time was a big
consideration for most respondents. This was valued highly both during training
and once practicing, with only 2.6% indicating it was not important once
practicing The main reasons given from those who commented were family
commitments (14 comments), and to have a balanced lifestyle (4 comments). Gender
differences were present ‘during training’, but these disappeared
‘once practicing’ (Figure 3).
Figure 3. Importance of part-time work/flexible
hours by gender (male n=50, female n=65).
 Awareness of training
options—Awareness of two postgraduate training options was
investigated: the Postgraduate Diploma of Obstetrics and Medical Gynaecology
(PGDipOMG), and the Certificate of Women’s Health. While most respondents
had heard of the PGDipOMG (82.5%), only 25.4% were aware of the Certificate in
Women’s Health. Many indicated they would consider (‘yes’ or
‘maybe’) undertaking these courses in the future, with 73.4% (n=109)
respondents showing interest in the PGDipOMG, and 52.8% (n=106) in the
Certificate of Women’s Health.
DiscussionThis is the first study of TIs’ interest in maternity
care in general practice in New Zealand. A moderate response rate (50.7%) was
achieved, which was similar for each of the three Otago Schools of Medicine. The
timing of the survey may have influenced the response rate, as it was sent out
in the first week of the TI year when students are busy fitting into their new
roles.
One-quarter of TIs invited to participate were on their
elective period, which is generally completed overseas. A proportion of these
students would not have had internet access to complete the questionnaire.
Students on elective were less likely to have accessed, or
may have been unable to access, their university email to complete the
questionnaire. Considering the response rate, bias may be present as those
interested in general practice as a career or with views on maternity care in
general practice may have been more likely to respond. These are the main
limitations identified in this study. Although slight over-representation of
younger TIs, and NZ European ethnicity was observed, these differences were
small.
New Zealand is in the midst of a maternity workforce
shortage.1 Rural areas in particular are short
of midwives and obstetricians1,2 and the number
of active GPOs throughout the country is now very
small.9 In addition to GPOs withdrawing from
maternity care it is thought there will also be ongoing issues of recruitment of
GPs into maternity care.10 Currently those
doctors who do undertake the PGDipOMG no longer do so with the intention to
practice intrapartum maternity
care.11
Our study has revealed that despite this, final year medical
students (TIs) not only expect that interested and trained GPs should provide
maternity care, but that of those TIs considering general practice as a future
career most have an interest in providing antenatal care and shared care, and
over half have some interest in providing full maternity care in their future
practice (Figure 1). This suggests that the recruitment difficulties are not
simply due to a lack of interest, but that other factors are responsible.
Those students who had completed the RMIP in their fifth
year of training were both more likely to be considering rural general practice
as a future career, and to be considering providing full maternity care in this
role (Figure 1). This finding is encouraging given the particular shortage of
maternity care providers in rural areas in New Zealand.
The study shows that the RMIP is successful in meeting two
of its goals: to encourage interested students to pursue a career in rural
medical practice;12 and to utilise the large
range of rural community clinical learning experiences which are not available
to students in tertiary teaching hospitals,12
including increased exposure to primary maternity care.
Personal experience in a specialty has been shown to have
the biggest influence on career decisions for TIs and junior
doctors.7 This was consistent with our findings
that those students who reported having seen a GP practicing full maternity care
were most likely to consider providing full maternity care if they were to
become a GP (Figure 1). This is encouraging, but also raises the concern that
with the number of GPOs continuing to fall, fewer and fewer students will
experience a GP practicing maternity and the numbers who will consider it as a
future career path will dwindle.
To combat the maternity workforce shortage, one governmental
response has been to allocate money for training and refresher courses for GPs
in maternity care.5 Whether this strategy will
be effective is uncertain. Currently doctors still complete the PGDipOMG, but
not with the intention to practice GP
obstetrics.11 In Australia it has been shown
that of those GPs who enrol in the Diploma with the intention to practice
maternity care, most decide during or after training not to pursue procedural
obstetrics.13 Thus
despite the high level of awareness of the PGDipOMG among TIs and their
potential interest to enrol in it, this may not be sufficient to increase the
number of GPs providing maternity care. Other areas also need targeting.
Our results suggest that although future doctors are likely
to value training opportunities, improvements to overall working conditions such
as availability of both peer and hospital support, and adequate funding will
also be required for TIs to practice maternity care in general practice.
Part-time and flexible hours were highly valued both by men and women (Figure
3), due to a desire for family time and life balance.
Overall these findings are similar to studies by
Wiegers,6 and an Australian study of GPOs and
obstetricians in Victoria, Australia.13 The
Victoria study identified the themes: clinical issues, lifestyle and indemnity
as key areas to address to recruit doctors into maternity care. New Zealand
health professionals work within a unique medicolegal legislative environment
compared to other OECD countries so indemnity issues are unlikely to be as
important.
ConclusionThis study has shown that most TIs believe GPs should
provide maternity care and women should be able to access maternity care from
their GP. TIs show an interest in providing a range of maternity care services,
including shared care with midwives and providing full maternity care, if
practicing as a GP in the future.
The main factors that could influence their becoming
involved in providing maternity care in general practice are: personal
experience of GPs providing maternity care, adequate training, professional and
peer support, adequate funding for maternity care, and a practice model that
supports professional practice and lifestyle options.
Competing interests: None
declared.
Author information: Hanna Preston, Trainee
Intern, Dunedin School of Medicine, University of Otago, Dunedin; Dawn Miller,
Senior Lecturer in Women’s Health, Department of Women’s and
Children’s Health, Dunedin School of Medicine, University of Otago,
Dunedin
Acknowledgements: This research was a
Health Sciences Divisional Summer Scholarship project funded by the Health
Sciences Division, University of Otago, Dunedin, New Zealand. The researchers
also thank the administrators at the Otago University Schools of Medicine:
Jillian Tourelle, Carol Milnes and Alice Jay.
Correspondence: Dawn Miller, Senior
Lecturer in Women’s Health, Department of Women’s and
Children’s Health, Dunedin School of Medicine, PO Box 913, Dunedin, New
Zealand. Fax: +64 (0)3 4747620; email: dawn.miller@otago.ac.nz
References:
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