The plasticity of professional boundaries: a case study of collaborative care in maternity services

A case study of twenty-nine midwives and nine obstetricians working in a regional, public sector Australian hospital demonstrates the plasticity of professional boundaries within a post-welfare state. Driven by new discourses of globalisation, marketisation, managerialism and consumerism, professional boundaries in health care are being blurred, reordered and reconstituted. Government policies that call for a new interdisciplinarity between maternity professionals may be seen as responses to the above pressures. However, there remain considerable barriers to achieving collaborative models including conflicting interpretations of risk, of women's bodies and of childbirth; the veto power of decision-making retained by obstetricians; questions of professional accountability; and diversity over appropriate styles of micro-interaction. Collaboration demands a new egalitarianism to eclipse the old vertical system of obstetric dominance and this means that midwives need to create a distinctive professional specialty, or new object of knowledge. Midwives' skill in 'emotion management' could provide this speciality in addition to their rational-technical knowledge and thus elevate midwifery to an equivalent professional status with obstetrics but as yet neither obstetrics nor midwifery have realised its professionalising potential <br />

Workforce trends in specialist and GP obstetric practice in Victoria

<b>OBJECTIVE:</b> To provide a contemporary picture of the general practitioner and specialist obstetric workforce in Victoria. <br /><br /><b>DESIGN, PARTICIPANTS AND SETTING</b>: Postal census by questionnaire of all 317 Fellows and 961 Diplomates on the Victorian database of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in September 2003. <br /><br /><b>MAIN OUTCOME MEASURES: </b>Sex, age and geographical distributions and patterns of retirement from and recruitment to the GP and specialist obstetric workforce in Victoria. <br /><br /><b>RESULTS:</b> 244 Fellows (77.0%) and 652 Diplomates (67.8%) participated. The average age of Diplomates was 42 years; only 20% were involved in procedural obstetrics. Of GPs practising procedural obstetrics, 56% intended to cease within 7 years. Two-thirds of specialist obstetricians continued to practise obstetrics. Among those ceasing obstetrics, almost half had done so since 2000. Among Fellows ceasing obstetric practice, there is a peak in the 50-60-years age group, but cessation of obstetric practice occurred across all age groups. <br /><br /><b>CONCLUSION:</b> The proportion of GPs involved in procedural obstetrics has fallen markedly over the past decade, with half of those ceasing practice in the 40-50-years age group. New GPs entering the workforce with the Diploma and overseas doctors are unlikely to meet the procedural workforce shortfall. Attracting the large cohort of doctors aged 40-50 years back to obstetric practice must be a priority. Given the pattern of retirements from obstetrics, there will be insufficient numbers of specialists to maintain current levels of service. The reasons include non-participation in obstetrics by new graduates and international medical graduates, the inadequate number of new graduates, and the predominance of women among specialists aged under 40 years, whose work output tends to be affected by family commitments.<br />

The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review

<b>Objective</b>: To determine whether the levonorgestrel-releasing intrauterine device (LNG-IUS), licensed at present for contraceptive use, may reduce menstrual blood loss with few side effects. If effective, surgery could be avoided with consequent resource savings. <b>Methods</b>: A systematic review addressing the effectiveness and cost effectiveness of the LNG-IUS for menorrhagia was undertaken. <b>Results</b>: Five controlled trials and five case series were found which measured menstrual blood loss. Nine studies recorded statistically significant average menstrual blood loss reductions with LNG-IUS (range 74%&ndash;97%). Another showed reduction in menstrual disturbance score. The LNG-IUS was more effective than tranexamic acid, but slightly less effective than endometrial resection at reducing menstrual blood loss. In one study, 64% of women cancelled surgery at six months, compared with 14% of control group women. In another, 82% were taken off surgical waiting lists at one year. No cost effectiveness studies were found. <b>Discussion</b>: Small studies of moderate quality indicate the LNG-IUS is an effective treatment for menorrhagia. Costs may be less than for tranexamic acid in primary and secondary care. Although its use may reduce surgical waiting lists, cost effectiveness assessment requires longer follow up. <b>Conclusion</b>: Effectiveness and cost effectiveness relative to other treatments and the effect on surgical waiting lists can only be established in larger trials measuring patient-centred outcomes in women with menorrhagia.<br />

Procedural trained, procedural remain : the first report from 'A census of doctors who have been awarded the Graduate Diploma in Rural General Practice (GDRGP)'

<b>Aims &amp; rationale/Objectives :</b> To document the practice of initial cohorts receiving the Graduate Diploma in Rural General Practice<br /><b>Methods :</b> With the co-operation of the National Rural Faculty (NRF) of Royal Australian College of General Practitioners (RACGP), a census by questionnaire was conducted on 279 graduates. The response rate was 70%.<br /><b>Principal findings :</b> The target doctors are young (65% &lt; 40 years old). Under half (42.3%) have completed Advanced Rural Skills terms in &gt;1 discipline. Of the total 272 posts recorded from 174 respondents, the most popular advanced skill is anaesthetics, followed by obstetrics. The ARSP increased confidence in 96.3% of respondents. Two thirds of doctors trained in a procedural skill remain practicing procedural General Practice.<br /><b>Discussion :</b> The GDRGP was the qualification developed to recognise competency gained as a result of a series of rural training initiatives begun within the RACGP Training Program in 1992. Its delivery has continued under the new GPET Training Program. Outcomes from the range of initiatives leading to the GDRGP are currently emerging in an environment which has seen significant changes within vocational training, and within the context of a rising focus on indemnity. Doctors who undertook this training have mostly retained procedural practice. In addition, RACGP rural initiatives successfully achieved increase confidence prior to rural work in advanced areas of practice, with &gt;95% reporting an increase.<br /><b>Implications : </b>Changes within vocational training were accelerated without analysis of existing initiatives such as the GDRGP. Funding for the GDRGP was, as a result, withdrawn prematurely. These changes also saw the entrant of a second College with an interest in rural procedural practice. This research show that the GDRGP offers, and offered, a clear vocational pathway that will guide a doctor to a career as a rural doctor, and provide them with the advanced skills they need to practice confidently in the bush. It is important to capitalise on past success before deconstructing professional concepts of practice further.<br /><b>Presentation type :</b> Paper <br />

Use of complementary and alternative medicines by a sample of Australian women during pregnancy

<b>Background</b>: The use of complementary and alternative medicines (CAM) is growing in Australia, with women higher users than men. Yet, only a few Australian studies have explored the use of CAM during pregnancy.<br /><b><br />Aims</b>: To explore the use of CAM, the types of CAM practitioners consulted, physical symptoms/complaints for which CAM are used by a sample of pregnant Australian women, and women's perceptions of the efficacy of CAM in treating those complaints.<br /><br /><b>Methods</b>: Three hundred and twenty-one pregnant women, who volunteered for a study exploring women's well-being during pregnancy, completed a self-report questionnaire in their late second/early third trimester.<br /><br /><b>Results</b>: Seventy-three per cent of women had used at least one kind of complementary therapy in the prior eight weeks of pregnancy. Over one-third of the women had visited at least one alternative medicine practitioner during pregnancy. Approximately one-third of the women reported taking CAM to alleviate a specific physical symptom, with 95.7% of these women reporting they either got completely better or a little bit better with use of CAM; one quarter reported planning to use an alternative therapy to assist with labour preparation. Age, number of physical symptoms experienced, income level and level of education were not associated with greater use of CAM (P &lt; 0.05); however, women reporting more physical symptoms were more likely to consult a CAM practitioner.<br /><b><br />Conclusion</b>: Findings highlight the substantial use of CAM during pregnancy and the need to have all health professionals adequately informed about such therapies during this life stage.<br />

Maternity waiting homes in Southern Lao PDR : the unique 'silk home'

The concept of maternity waiting homes (MWH) has a long history spanning over 100 years. The research reported here was conducted in the Thateng District of Sekong Province in southern Lao People&rsquo;s Democratic Republic (PDR) to establish whether the MWH concept would be affordable, accessible, and most importantly acceptable, as a strategy to improve maternal outcomes in the remote communities of Thateng with a high proportion of the population from ethnic minority groups. The research suggested that there were major barriers to minority ethnic groups using existing maternal health services (reflected in very low usage of trained birth attendants and hospitals and clinics) in Thateng. Unless MWH are adapted to overcome these potential barriers, such initiatives will suffer the same fate as existing maternal facilities. Consequently, the Lao iteration of the concept, as operationalized in the Silk Homes project in southern Lao PDR is unique in combining maternal and infant health services with opportunities for micro credit and income generating activities and allowing non-harmful traditional practices to co-exist alongside modern medical protocols. These innovative approaches to the MWH concept address the major economic, social and cultural barriers to usage of safe birthing options in remote communities of southern Lao PDR.<br />

Prevalence and cost of musculoskeletal disorders: a population-based, public hospital system healthcare consumption approach.

<b>Objective:</b> To use a population-level, public-hospital approach to compare the prevalence and cost of musculoskeletal diseases (MSD) with other clinical specialties. <br /><br /><b>Methods:</b> A healthcare utilization survey of 4 million individual records over 4 years, from all major public hospitals in the state of Victoria (estimated population 4.8 million residents in 2000/01) from 1997/98 to 2000/01. Main outcome measures were inpatient episodes of care, bed-days, and outpatient clinic encounters. MSD was defined as the combination of orthopedics and rheumatology. <br /><br /><b>Results:</b> After obstetrics, MSD was the most frequent outpatient service, with orthopedics accounting for 9.9% of all visits in 2000/01. The proportion of MSD outpatient encounters (on average 11.6% of the total) was constant over the study period. Among 26 medical specialties, MSD had the sixth highest number of inpatient episodes (6.2% in 2000/01), following renal dialysis (14.6%), general surgery (8.2%), obstetrics (7.6%), gastroenterology (7.1%), and general medicine (6.7%). MSD was the fifth highest consumer of bed-days, occupying on average 7.7% of all beds per annum in the period 1997/98 to 2000/01, behind psychiatry (10.1%), respiratory medicine (8.5%), rehabilitation (8.3%), and general medicine (7.8%). MSD was the third most-costly discipline in 2000/01, with total costs of over A dollars 169 million (9.7% of total inpatient costs that year), behind respiratory medicine (11.6%) and general surgery (11.5%). <br /><b><br />Conclusion: </b>Compared to other diseases, MSD consumes a substantial proportion of healthcare resources in Victorian public hospitals. These data have important implications for allocation of healthcare resources, clinical care pathways, and prevention strategies.<br />

Duly delivered : women's experiences of birth planning

Critically examines the construct of power differentials in the childbirth experiences of forty-two women following the birth of their first child. Detailed data was collected using questionnaires and in-depth interviews with women from a range of localities around the State. The research demonstrated that childbirth processes in Victoria effectively ignore the wishes of pregnant women leading to them suffering significant physical and psychological health consequences.

Assessment of first sexual intercourse in young women with a history of childhood sexual abuse

Women reporting childhood sexual abuse (CSA) that involved actual or attempted penetration may not identify this as their first sexual intercourse. Data were drawn from a population-based, prospective cohort study spanning adolescence to adulthood. CSA prior to age 16 and age of first sexual intercourse with a male were assessed retrospectively. More than half of women reporting CSA in the form of actual or penetrative abuse reported an age of first sexual intercourse at or beyond 16 years. Direct questioning about CSA is needed to accurately ascertain sexual history.<br />

Regime change in Australian maternity hospitals

Contemporary attempts to &lsquo;organise&rsquo; risk and manage uncertainty are remaking many &lsquo;industrial-era&rsquo; institutions &ndash; including maternity hospitals. Health policies are encouraging a shift away from hierarchical, medically dominated structures towards new governance systems and &lsquo;women-centred&rsquo; care, often led by midwives. To understand the resulting contestation, in this article we argue for a wider conceptual frame than a focus on neo-liberal state regulation of the professions. We utilise theories of the &lsquo;second modernity&rsquo;, in particular those concerning socio-cultural changes associated with shifts in risk regimes, to interpret findings from qualitative research studies undertaken in Australian maternity hospitals. Whereas analysis confined to macro or institutional levels emphasises stability and hegemony, we demonstrate that when cultural and interactional levels are examined, considerable fluidity and uncertainty in the identification and negotiation of risk is evident, resulting in new work practices with inevitable shifts in professional identities and allegiances.

Barriers among Danish women and general practitioners to raising the issue of intimate partner violence in general practice: a qualitative study

Thirty-five percent of Danish women experience sexual or physical violence in their lifetime. However, health care professionals are not in the practice of asking about intimate partner violence (IPV) in Denmark. It is currently unknown what hinders general practitioners from asking about partner violence and how Danish women would perceive such an inquiry. This aspect has not previously been explored in Denmark. An exploratory study was conducted to examine what hinders general practitioners (GPs) from asking and what Danish women's views and attitudes are regarding being asked about IPV.

Interventions designed to promote exclusive breastfeeding in high-income countries: a systematic review

Worldwide, women fail to reach the recommended exclusive breastfeeding target of 6 months postpartum. The objective of this study was to present a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding to 6 months in high-income countries.

The transition to motherhood: towards a broader understanding of perinatal distress

A substantial body of research has focused on maternal perinatal mood and wellbeing, with the focus predominantly being on depression, and to a lesser extent, anxiety. Perinatal maternal stress has also been investigated recently, but to a far lesser extent. The present paper questions whether the term 'perinatal distress' accurately captures the range of challenges experienced by women during the perinatal period, when the scope of 'distress' is limited to the experience of depression and anxiety alone.

The intergenerational continuity of breastfeeding intention, initiation, and duration: a systematic review.

In studies investigating predictors of breastfeeding behaviors, it is not uncommon for researchers to adjust for participants' having been breastfed as an infant. This assumes an intergenerational effect of breastfeeding continuity. Our aim was to investigate the veracity of that assumption. Specifically, we sought to summarize and evaluate evidence of associations between breastfeeding in one generation and breastfeeding intentions and behaviors in the second generation.