A GP’s voyage in rural obstetrics and how we went off course.

Part 2

Part 1 looked at the background to the current crisis in GP obstetrics and how changes in the specialist colleges’ viewpoint, GPs’ own expectations and increased litigation contributed to the gradual loss of GP obstetric services in small hospitals all over rural and regional Australia.

As things are now
I became excited when I was unexpectedly invited to take an appointment in obstetrics at the hospital in the early 1990s. I felt honoured to be recognised at last but soon realised they were just scraping the barrel as it was becoming impossible to get GPs onto the dwindling team of obstetricians.

It is common knowledge that procedural GPs today are an endangered species. In our hospital the four doctors who practice obstetrics are all grey haired. ‘Dad’s obstetric army’ remarked one of our number at a meeting. That there are four is a luxury. Casino Hospital has only two, the minimum requirement. The preference is three to keep the service operational. One doctor cannot be on call 24/7 and what if one gets sick? If a doctor retires, it is simple arithmetic that the birth unit will close. Any recruits? Under current conditions most unlikely.

There is an old saying that human memory is as short as a rabbit’s tail. As things change we adjust to the changes, forgetting history unless there are tangible reminders of what went before. Those hospitals in the Northern Rivers area that once provided birth services are our landmarks.

Ballina, a large town with young families did have a busy unit until only one doctor remained. Dr Sue Page used to deliver babies here. Byron Bay had six doctors doing deliveries ten years ago. Five years ago they were reduced to three. It closed birth services last year. Coraki and Kyogle both had active obstetric units. Now labouring women travel to Lismore. The growing town of Maclean had a birth unit, but no more.

These towns are not dying, in fact this whole coastal area is expanding in population, house prices are booming, shops and cafes are buzzing. Many doctors are attracted to this area but none seem willing to work in childbirth.

When a town loses its birth unit the women are cornered into a difficult decision, especially where distance is a tyrant. She can either drive to a larger town that may be hours away, causing disruption to families and may be away for days or weeks waiting for labour. Or, she can choose home birth. As there is no organised home birth service in rural Australia this can be a dangerous option. Nevertheless many women make this choice. That women birth with only their friends to help is not widely acknowledged but truly is quite common. Surprisingly, this type of birth usually goes quite well.
The midwife option

The State should offer all women an opportunity to birth with safety and comfort. If there are no doctors, is there any real reason why competent midwives could not manage a low risk hospital birth unit?

During time spent with the flying doctor service, I was impressed at the clinical efficiency of the nurses who ran the outback clinics, having no choice but to step into the responsibility of the doctor.

Wherever possible, our birth unit tries to give midwives responsibility. As chances of medical succession seem to be very remote under current conditions, midwives need to get ready. It would be tragic for birth units to keep closing for lack of willing medical workforce. In spite of this, the best option continues to be the doctor-midwife team.

Where to from here?
Possibly too late, those GPs still doing obstetrics are being showered with inducements and retention grants to keep working. As far as incentives go for established GP obstetricians, there are many, including grants for re-training and free insurance paid by the hospitals. The inducements are so good that you can earn more doing a day’s training in the city than by working in your practice.

I am being re-trained just as I want to start thinking about retirement. It’s stimulating enough but where’s the sense in it? These things should have happened 15 years ago. It’s confronting as well because the practices in a large obstetric unit reminds me how birth used to be for me all those years ago.

Obstetricians in these hospitals say they can’t even get applications for established diploma training jobs. Many GPs who have completed the diploma don’t return to birth work. It’s not surprising as the training positions are work intensive with responsibility often greater than the skills or comfort zone of doctor. One said it was “like working long shifts at a sausage factory”. What a waste.

The natural birth alternative in hospital
In comparison, the art of ‘low risk birth’ is a relatively new phenomenon for doctors and is a cross between midwifery and medicine. It’s an alternative to the heroic and often violent procedures that we learned was the way of obstetrics. This new art for doctors has the stated intention of not interfering.

Birth has not changed in thousands of years it is true, but the way that we handle it has. The massive social trend towards Caesarian section as a birth choice is widely commented on. Active natural birth as an antidote to this fashion is sought by many thoughtful women. Our little hospital attracts women from faraway, even interstate. I said to one expectant mother: “You realise there is no epidural service or CTG monitoring?” “That” she replied, “is exactly why I am here.”

The birth plans of these women have a common thread:

• hands off, no unnecessary examinations;
• no unnecessary intervention without consultation;
• no separation from baby;
• appropriate ambience to promote labour in relation to light and noise;
• staff involvement to a minimum. For example, doctor or nurse not to announce the sex of the baby. No unnecessary chatter during contractions.
• The water birth alternative sometimes called ‘nature’s epidural’ is a growing attraction.