the obstetrics and gynaecology workforce in australia
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AMWAC 1998.6 i
Australian Medical Workforce Advisory Committee
THE OBSTETRICS AND GYNAECOLOGY WORKFORCE IN AUSTRALIA
SUPPLY AND REQUIREMENTS
1997 - 2008
AMWAC Report 1998.6
August 1998
AMWAC 1998.6 ii
Australian Medical Workforce Advisory Committee 1998 ISBN 0 7313 4096 5 This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgement of the source. Reproduction for purposes other than those indicated above requires the written permission of the Australian Medical Workforce Advisory Committee. Enquiries concerning this report and its reproduction should be directed to: Executive Officer Australian Medical Workforce Advisory Committee c/- New South Wales Department of Health Locked Mail Bag 961 NORTH SYDNEY NSW 2059 Telephone: (02) 9391 9933 E-mail: amwac@doh.health.nsw.gov.au Internet: http://amwac.health.nsw.gov.au Suggested citation: Australian Medical Workforce Advisory Committee (1998), The Obstetrics and Gynaecology Workforce In Australia, AMWAC Report 1998.6, Sydney Publication and design by Australian Medical Workforce Advisory Committee. Printing by Copybook, Sydney.
AMWAC 1998.6 iii
CONTENTS Abbreviations vi List of Tables and List of Figures viii Terms of Reference of AMWAC and the AMWAC Obstetrics and Gynaecology Workforce Working Party xi Membership of AMWAC xii Membership of the AMWAC Obstetrics and Gynaecology Workforce Working Party xiii Introduction, Guiding Principles and Methodology 1 Part A: The Specialist Obstetrics and Gynaecology Workforce 5 Summary of Findings and Recommendations 6 Description of the Current Obstetrics and Gynaecology Workforce 19
The Number of Practising Obstetrics and Gynaecology Specialists 19 Distribution of the Obstetrics and Gynaecology Workforce 20 Age Profile 22 Gender Profile 26 Hours Worked 27 Practice Profiles 31 Services Provided 32
Training Arrangements 34 Summary of Main Characteristics of the Specialist Obstetrics and
Gynaecology Workforce 39
Adequacy of the Current Obstetrics and Gynaecology Workforce 41 Obstetrics and Gynaecology Specialist:Population Ratio 41 Public Hospital Vacancies 45 Provider Shortages 45 Consultation Waiting Times 45 Survey of Divisions of General Practice 46 Professional Satisfaction 47 Conclusions on Adequacy of the Current Obstetrics and
Gynaecology Workforce 47 Projections of Requirements 48
AMWAC 1998.6 iv
Female Population 48 Fertility Rate 49 Birth Rate 50 Cancer of the Cervix, Ovary and Uterus 52 Trends In Utilisation 53 The Impact of Changes in Technology 55 Specialists’ Perceptions of Factors Affecting Workforce Requirements 55
Projections of Supply 56
Additions and Losses to the Obstetrics and Gynaecology Workforce 56 Female Participation in the Workforce 56 Provision of Services in Rural and Remote Areas 57 Substitution of Services 57
Balancing Supply Against Requirements 62
Requirement Trends 62 Supply Trends 64 Projected Balance 65
Recommendations 71 Part B: The Sub-Specialist Obstetrics and Gynaecology Workforces 73 Introduction 74 Characteristics of the Obstetrics and Gynaecology Sub-specialist Workforce 77
Number of Practising Sub-specialists in Obstetrics and Gynaecology 77 Distribution of the Sub-specialist Workforce 77 Age Profile 79 Gender Profile 81 Hours Worked 82 Practice Profiles 84 Training Arrangements 84 Obstetrics and Gynaecology Sub-specialist:Population Ratios 87
AMWAC 1998.6 iv
Appendices Appendix A: Rural, Remote and Metropolitan Areas Classification 90 Appendix B: RACOG/AMWAC Survey of Fellows of the Royal Australian
College of Obstetricians and Gynaecologists 92 Appendix C: AIHW National Medical Labour Force Survey 1995 111 Appendix D: Service Provision and Requirements of Obstetrics and
Gynaecology 116 Appendix E: RACOG Obstetrics and Gynaecology Training Program 119 Appendix F: General Practitioners Providing Obstetrics and Gynaecology
Services 123 Appendix G: AMWAC Survey of Divisions of General Practice 131 Appendix H: Data on Midwives 137 Appendix I: AIHW National Hospital Morbidity Data for Obstetrics and
Gynaecology 145 References 161
AMWAC 1998.6 v
ABBREVIATIONS ABS Australian Bureau of Statistics ACT Australian Capital Territory AHMAC Australian Health Ministers' Advisory Council AIHW Australian Institute of Health and Welfare AMWAC Australian Medical Workforce Advisory Committee AN-DRGs Australian National Diagnostic Related Groups Aust Australia CREI Certificate of Reproductive Endocrinology and Infertility CSCT Certificate of Satisfactory Completion of Training in Women’s
Reproductive Health DHFS Commonwealth Department of Health and Family Services DRACOG Diploma of the Royal Australian College of Obstetricians and
Gynaecologists FRACOG Fellow of the Australian College of Obstetricians and
Gynaecologists FRACP Fellow of the Royal Australian College of Physicians FTE Full time equivalent GONC Gynaecological Oncology GP General Practitioner HIC Health Insurance Commission HMO Hospital Medical Officer
(also known as Career Medical Officer or CMO) ICD-9 International Classification of Diseases, Ninth Revision ITP Integrated Training Program MBS Medicare Benefits Schedule MDC Medical Diagnostic Category MDS Minimum Data Set MFM Maternal Fetal Medicine
AMWAC 1998.6 vi
MRACOG Member of the Royal Australian College of Obstetricians and Gynaecologists
NASOG National Association of Specialist Obstetricians and Gynaecologists NSW New South Wales NT Northern Territory O&G Obstetrics and Gynaecology O&GULT Obstetrical and Gynaecological Ultrasound OS Overseas Pop Population Qld Queensland RACGP Royal Australian College of General Practitioners RACOG Royal Australian College of Obstetricians and Gynaecologists RRMA Rural, Remote Metropolitan Areas classification SA South Australia Spec Specialist SPR Specialist:Population ratio SRAC Specialist Recognition Advisory Committee SSPR Sub-specialist:Population ratio Tas Tasmania Terr Territory TRD Temporary Resident Doctor UK United Kingdom UROG Uro-gynaecology Vic Victoria VMO Visiting Medical Officer WA Western Australia
AMWAC 1998.6 vii
LIST OF TABLES 1. Obstetrics and gynaecology specialists to population, by State/Territory 2. Distribution of obstetrics and gynaecology specialists, by State/Territory and
geographic location (RACOG data), 1998 3. Age profile of the total obstetrics and gynaecology specialist workforce, by
State/Territory and gender (RACOG data), 1998 4. Age profile of the total obstetrics and gynaecology specialist workforce, by
State/Territory, gender and major age group (RACOG data), 1998 5. Age profile of obstetrics and gynaecology specialists, by State/Territory and
gender (RACOG data), 1998 6. Age profile of obstetrics and gynaecology specialists, by State/Territory and
major age group, 1998 7. Specialists and sub-specialists in obstetrics and gynaecology average hours
provided per week, annual labour supply hours by State/Territory, 1998 8. Specialists and sub-specialists in obstetrics and gynaecology average hours and
annual hours worked, by gender and age group, 1998 9. Hours worked by specialists in obstetrics and gynaecology, by geographic
location, 1997 10. Obstetrics and gynaecology services attracting Medicare benefits provided by
specialists, 1986-87 to 1996-97 11. Accredited obstetrics and gynaecology training positions, by hospital and
State/Territory, 1998 12. RACOG trainees, by year of training, age group and gender, 1998 13. RACOG trainees, by full time and part time status, age group and gender, 1998 14. Obstetrics and gynaecology trainees, by State/Territory and gender, 1998 15. Obstetrics and gynaecology specialists in training average hours worked, by
gender and age, 1995 16. Obstetrics and gynaecology specialists in training average hours worked, by
State/Territory, 1995 17. Obstetrics and gynaecology trainees, by gender, 1992 to 1998 18. Specialists in obstetrics and gynaecology to female population ratio, by
State/Territory 1998 (number per 100,000 population) 19. Specialists in obstetrics and gynaecology to female population ratio, by
State/Territory and geographic location, 1998 20. Obstetrics and gynaecology average waiting time (days) for a standard first
consultation and an urgent procedure, by private rooms/public outpatients department and State/Territory, 1997
21. Australian female population estimates and projections, 1997 to 2006 22. Total fertility rate, by State/Territory, 1976, 1986 and 1996 23. Total births, by State/Territory, 1996 24. Total births, by State/Territory, 1996 25. Incidence of cancer of the cervix among women aged 20 to 74 years, by
State/Territory
AMWAC 1998.6 viii
26. Age standardised rates for incidence of cancer of the cervix, ovary and uterus, selected years 1983 to 1994, with projections to 1999
27. Projected increases in utilisation for obstetrical and gynaecological procedures, 1998 to 2018
28. Summary of obstetrics and gynaecology services attracting Medicare benefits; by provider, selected years 1986-87 to 1996-97
29. Obstetrics and gynaecology Medicare services, by provider and State/Territory, 1995-96
30. Distribution of obstetrics and gynaecology Medicare service providers, by geographic location, 1995-96
31. Projected requirements for obstetrics and gynaecology services (in full time equivalent hours per week) for selected indicators, 1995 to 2009
32. Projected supply of obstetrics and gynaecology services, high, low and average retirement rates, by FTE hours worked per week, 1999, 2004 and 2009
33. Projected obstetrics and gynaecology supply and requirements (FTE hours), 0.4% growth per year, 1998 to 2004
34. Obstetrics and gynaecology graduate output needed to move projected supply into balance with projected requirements, 0.4% growth per year, (in FTE hours), 1998 to 2009
35. Estimated obstetrics and gynaecology graduate output required to move projected supply into balance with projected requirements, 0.4% growth per year, (in FTE hours), by selected graduate outputs, 1998 to 2009
36. Distribution of obstetrics and gynaecology first year advanced trainee positions, by State/Territory, 1999 to 2002
37. Number of obstetrics and gynaecology sub-specialists, by sub-specialty, State/Territory and gender, 1998
38. Distribution of obstetrics and gynaecology sub-specialists; by geographic location, 1998
39. Age profile of obstetrics and gynaecology sub-specialists, by State/Territory and gender, 1998
40. Age profile of obstetrics and gynaecology sub-specialists, by State/Territory, gender and major age group, 1998
41. Sub-specialists in obstetrics and gynaecology average hours worked per week and annual labour supply hours, by State/Territory, 1998
42. Sub-specialists in obstetrics and gynaecology average hours and annual hours worked, by gender and age group, 1998
43. Sub-specialists in obstetrics and gynaecology average hours worked per week, by geographic location of main job, 1997
44. Obstetrics and gynaecology sub-specialty trainees, by year of training, gender and major age group, February 1998
45. Obstetrics and gynaecology sub-specialty trainees, by State/Territory and gender, February 1998
46. Sub-specialists in obstetrics and gynaecology female population: population ratio, by State/Territory, 1997
AMWAC 1998.6 ix
LIST OF FIGURES 1. Obstetrics and Gynaecology Specialists supply (Average Attrition Rates) vs
Demand Projections working a 60 hour week, incorporating the current intake of 58 trainees per year.
2. Obstetrics and Gynaecology Specialists supply (Average Attrition Rates) vs Demand Projections - Birth Rates and Fertility Rates - working a 60 hour week, incorporating the current intake of 58 trainees per year.
AMWAC 1998.6 x
TERMS OF REFERENCE OF AMWAC AND THE AMWAC OBSTETRICS AND GYNAECOLOGY WORKFORCE WORKING PARTY The Australian Health Ministers' Advisory Council (AHMAC) established the Australian Medical Workforce Advisory Committee (AMWAC) to advise on national medical workforce matters, including workforce supply, distribution and future requirements. AMWAC held its first meeting in April 1995. AMWAC Terms of Reference 1. To provide advice to AHMAC on a range of medical workforce matters, including:
- the structure, balance and geographic distribution of the medical workforce in Australia;
- the present and required education and training needs as suggested by population health status and practice developments;
- medical workforce supply and demand; - medical workforce financing; and - models for describing and predicting future medical workforce
requirements. 2. To develop tools for describing and managing medical workforce supply and
demand which can be used by employing and workforce controlling bodies including Governments, Learned Colleges and Tertiary Institutions.
3. To oversee the establishment and development of data collections concerned
with the medical workforce and analyse and report on those data to assist workforce planning.
Obstetrics and Gynaecology Workforce Working Party Terms of Reference The AMWAC Obstetrics and Gynaecology Workforce Working Party was established as a sub-committee of AMWAC and was asked to provide a report to AMWAC on the optimal supply and appropriate distribution of obstetrics and gynaecology specialists and sub-specialists across Australia, including projections for future requirements. The Working Party held its first meeting on 5 August 1997 and presented its report to the AMWAC meeting of August 1998. The report was accepted at the October 1998 AHMAC meeting.
AMWAC 1998.6 xi
MEMBERSHIP OF AMWAC Independent Chairman Professor John Horvath Physician, Sydney Members Mr Eric Brookbanks Assistant Secretary, Business and Temporary Entry
Branch, Commonwealth Department of Immigration and Multicultural Affairs
Ms Meredith Carter Director, Health Issues Centre Dr William Coote Secretary General, Australian Medical Association Mr Michael Gallagher First Assistant Secretary, Higher Education Division,
Commonwealth Department of Employment, Education, Training and Youth Affairs
Dr Susan Griffiths General Practitioner, Minlaton, South Australia Assoc. Prof. Jane Hall Director, Centre for Health, Economics, Research and
Evaluation, University of Sydney Dr Richard Madden Director, Australian Institute of Health and Welfare Mr Ronald Parker Secretary, Tasmanian Department of Community and
Health Services Professor Nick Saunders Dean, Faculty of Medicine, Monash University, Melbourne Dr Robert Stable Director General, Queensland Department of Health Dr David Theile Surgeon, Brisbane (former President, Royal Australasian
College of Surgeons) Dr Lloyd Toft Chairman, Medical Board of Queensland Mr Robert Wells First Assistant Secretary, Office of the National Health and
Medical Research Council, Commonwealth Department of Health and Family Services
AMWAC 1998.6 xiii
MEMBERSHIP OF THE AMWAC OBSTETRICS AND GYNAECOLOGY WORKFORCE WORKING PARTY Chairman Professor Ross Kalucy President, Medical Board of South Australia Members Dr John Bates Gynaecologist, Perth Mr Maurie Breust Executive Director, Strategic Planning and
Development, North West Adelaide Health Service Dr Lawrence Brunello President, Royal Australian College of Obstetricians
and Gynaecologists Ms Dell Horey Consumer representative, Maternity Alliance, New
South Wales Dr Alan Sandford Senior Medical Adviser, Manager Health Workforce
Section, Public Health and Development Division, Department of Human Services Victoria
Dr Geoff Westwood Director of Medical Services, Alice Springs Hospital Ms Anastasia Ioannou Senior Policy Officer, AMWAC This report was written by Ms Anastasia Ioannou, Senior Policy Officer, AMWAC. The Working Party would also like to acknowledge the assistance of the following people in preparation of the report: - Professor John Horvath and Mr Paul Gavel (AMWAC) for helpful editorial
comments; - Mr John Harding and Mr Warwick Conn (AIHW) and Ms Angela Tirrizzi and Ms
Emma Gilbert (RACOG) for assistance with data collection; - Chairs of the RACOG sub-specialty committees and Professors of Obstetrics
and Gynaecology for helpful comments on particular aspects of the specialty; - Dr David Molloy, National Association of Specialist Obstetricians and
Gynaecologists (NASOG) for providing comments on the draft report; - Dr Kathy Innes and Dr Mark Henschke for providing data on general practitioner
(GP) provision of obstetrics and gynaecology services;
AMWAC 1998.6 xiv
- Mr Dean Carson (Centre For Rural Health) for data collection through the National Rural General Practitioner Survey;
- Ms Patricia Brodie (New South Wales Health Department) for editorial comment on the summary of trends in midwife numbers; and,
- Dr Derrick Bui, Medical Management Trainee, Victorian Department of Human Services for assisting with RACOG data collection.
AMWAC 1998.6 1
INTRODUCTION, GUIDING PRINCIPLES AND METHODOLOGY Introduction In preparing this report, the Working Party’s aim has been to promote appropriate obstetric and gynaecology services throughout Australia. The main objective of the Working Party has been to promote an optimal supply and distribution of specialist obstetricians and gynaecologists, including projections for future supply and requirements to the year 2008. Obstetrics and gynaecology is a ‘fused’ profession in the sense that specialists are licensed to undertake specialist treatments in both obstetrics and gynaecology. In addition, there are five associated sub-specialties, namely maternal fetal medicine, uro-gynaecology, obstetrical and gynaecological ultrasound, gynaecological oncology and reproductive endocrinology and infertility. This report attempts to accommodate the subdivisions within the obstetrics and gynaecology workforce by presenting information on the total workforce and the sub-specialist workforce. To this end the report is provided in two parts: • Part A: The Specialist Obstetrics and Gynaecology Workforce • Part B: The Sub-Specialist Obstetrics and Gynaecology Workforce Part A includes a description of the total workforce, an assessment of the adequacy of the total workforce and projections of total workforce supply and requirements to 2008. Part B provides a summary of the main characteristics of each of the five sub-specialist workforces. The report also examines obstetric services provided by general practitioners (GPs) and midwives and most of this examination is detailed in appendices H and J respectively. Guiding Principles In compiling this report, the Working Party adopted the following guiding principles: • the Australian community should have available an adequate number of trained
obstetric and gynaecology specialists, appropriately distributed to provide the obstetric and gynaecology services it requires;
• there should be high standards of training leading to qualification which ensures high quality of practice;
• the working life of specialists should be embedded within a process of continuing education and quality assurance;
• challenges to the provision of a good standard of care in obstetrics and gynaecology need to be identified and addressed;
• Australians should have access to a good standard of obstetric and gynaecology services including related sub-specialty services, irrespective of geography and economic status. In achieving this, convenience to the patient must be balanced against the quality of services that can be distributed to meet that convenience;
• the guiding principles should apply equally to private and public sectors.
AMWAC 1998.6 2
The Working Party defined an obstetric and/or gynaecology specialist as:
A qualified specialist who is conducting obstetric and gynaecological consultations, obstetrics and gynaecology assessments/procedures and medico legal consultations in obstetrics and gynaecology medicine, including being in a full time or part time academic position relating to obstetrics and gynaecology. The definition includes specialists in salaried positions and private practice.
An obstetrician provides medical care before, during and after childbirth. Gynaecologists diagnose, treat and aid in the prevention of disorders of the female reproductive system.
This definition does not include registrars in training or registrars who have completed their training but have not successfully passed their final examination for specialty recognition. Methodology The approach of the Working Party has been to analyse existing data sources and to undertake consultation with relevant persons and organisations in order to make informed comments on the factors affecting the current and future requirements for obstetric and gynaecology services. In estimating workforce numbers, establishing a profile of the workforce and assessing its adequacy, the main sources of data were: 1. Royal Australian College of Obstetricians and Gynaecologists (RACOG) RACOG keeps a variety of data, principally on the number of Fellows and training posts and age and gender information of Fellows and trainees. A survey of the 954 members was conducted in 1997 with a response rate of 53%. A summary of the findings of the survey is provided in Appendix B. The profile and projections of the workforce has been based on the March 1998 RACOG figures of Australian active Fellows/Members, both specialist and sub-specialist. 2. Australian Institute of Health and Welfare (AIHW) The principle AIHW data source is the annual Medical Labour Force Survey. The Medical Labour Force Survey presents national labour force statistics for registered medical practitioners, principally through a survey collected as part of the annual renewal of registration. The survey data used in this report is for 1995. A summary of the key findings for the obstetrics and gynaecology workforce are included in Appendix C. 3. Commonwealth Department of Health and Family Services (DHFS) Medicare
AMWAC 1998.6 3
provider database Medicare provider statistics define medical practitioners according to the predominant services billed to Medicare. The Medicare statistics include all practitioners who have billed Medicare for at least one service during a financial year. The major deficiency with the use of Medicare data for workforce planning purposes is that it does not provide data on practitioners who are salaried obstetricians and gynaecology specialists/sub-specialists in the public hospital system and who do not render services on a fee for service basis. Medicare data thus excludes services rendered free of charge to public hospital patients, to Veterans' Affairs patients and to compensation cases. 4 Casemix data on hospital activity The AIHW National Hospital Morbidity database (ICD-9-CM groupings) has been used as a key source of data on service trends. The data is sourced from the AIHW Australian hospital morbidity database for all patients in public and private hospitals in Australia from 1993-94 to 1996-97. 5. AMWAC Survey of Divisions of General Practice To assist the Working Party in its assessment of the adequacy of the workforce AMWAC administered a mailed survey of each Division of General Practice. Of a possible 122 Divisions, 77 responded (63.1%). The results of the survey are summarised in Appendix I. 6. Sources of data on the non specialist workforce. Obstetrics and gynaecology services can also be provided by non-specialists, mainly GPs, principally in rural and remote areas, and midwives. In order to gain an insight into the use of non-specialists and the types of services provided by non specialists the Working Party also examined the following data sources: AIHW, Nursing Labour Force Survey 1995
This survey presents national labour force statistics for registered nurses, principally through a nurse labour force survey conducted by each State/Territory nurses board on behalf of the Institute. The survey data used in this report is for 1995. The National Rural General Practitioner Survey conducted by the Centre for Rural
Health at Moe The survey was conducted in 1996 and collected information in regards to rural GPs working in obstetrics and gynaecology. The majority of respondents were qualified in either the Diploma of the RACOG (DRACOG) or the Certificate of Satisfactory
AMWAC 1998.6 4
Completion of Training in Women’s Reproductive Health (CSCT). The response rate of the survey was approximately 70% (2,100). 7. Australian Bureau of Statistics The Australian Bureau of Statistics (ABS) population data and projections are used as the sole source on population data. In making its population projections ABS uses four different series. The population projections in this report are based on Series A/B, where constant fertility and low overseas migration are assumed (ABS 1994 and ABS 1997). It should also be noted that where population data is provided in this report it relates to female population only. 8. Rural, Remote Metropolitan Areas classification Wherever possible, distributional data has been interpreted using the rural, remote and metropolitan areas classification (RRMA) developed by the Commonwealth Departments of Health and Family Services and Primary Industries and Energy (DPIE & DHSH 1994). A summary of the RRMA classification is provided in Appendix A: Rural, Remote and Metropolitan Areas Classification. Key Assumption The Working Party would like to emphasise that the projections on supply and requirements are based on the existing national health structure. If there is a change to the national health structure the Working Party recommends the supply requirements and projections be reviewed. The Working Party also assumed that the current length of the RACOG training program would remain unchanged and that the majority of candidates would complete the program within this time frame. In addition, the Working Party has assumed that the pattern of workforce participation of the current workforce provides a suitable basis on which to project future workforce requirements.
AMWAC 1998.6 5
PART A:
THE SPECIALIST OBSTETRICS AND GYNAECOLOGY WORKFORCE IN AUSTRALIA
AMWAC 1998.6 6
SUMMARY OF FINDINGS AND RECOMMENDATIONS This report describes the current specialist obstetrics and gynaecology workforce, assesses the adequacy of that workforce, and projects workforce supply and requirements to the year 2008. Obstetrics and gynaecology, with an estimated 1,049 specialists, is one of the largest single specialties in Australia (only the psychiatry and anaesthesia workforces are noticeably larger). However, the specialty is one of the more difficult to examine and assess and there are several reasons for this: 1. Obstetrics and gynaecology is a complex profession to analyse in that specialists
can practice obstetrics, gynaecology or a mixture of both, and even some of the obstetrics and gynaecology sub-specialists continue to practice general obstetrics and gynaecology. There also appears to be a tendency for older specialists to do less obstetrics work. All this makes it difficult to assess who is doing what and the level of service that is being provided.
2. The above issue is further complicated by the variable contribution of some
service provision through the provision of obstetrics services by GPs and midwives. Assessment of services trends is further compounded by the general absence of national data collections that allow the separation of data by service provider. Reliable data on the trends in GP and midwife numbers has also been difficult to obtain.
Nevertheless the Working Party has attempted to provide information and estimates to overcome these data shortcomings. The report concludes that there is a slight shortage in the current workforce, perhaps due more to maldistribution than any widespread general shortages. The Working Party also concluded that the current level of trainee intake will need to be maintained for projected supply to be adequate to meet estimated future requirements. Obstetrics and gynaecology trainee intake was dramatically boosted in 1995 (from 208 trainees in 1994 to 282 trainees in 1995) and has been maintained at this level in 1996, 1997 and 1998. As a result, no short term measures have been recommended by the Working Party to temporarily boost specialist supply because it is recognised that shortages should begin to improve once the higher number of trainees commence making a contribution to the workforce from 2001 onwards. In projecting workforce supply, there were two key factors identified that would influence the future level of trainee intake. The first is the significant number of specialists aged 55 years and over, 32.0% (336) of the workforce; and therefore likely to proceed through to retirement in the next five to ten years. Average retirement age for this
AMWAC 1998.6 7
workforce is estimated at 63 years and only 7.0% (74) of the current workforce are aged 65 years and over. The other key supply factor is that 55.3% of current trainees are female. This is one of the highest levels of female trainee participation in any specialty and has potentially significant implications for lifetime workforce contribution, given that estimates based on current participation patterns suggests that female lifetime participation in obstetrics and gynaecology is 74% of that of male lifetime participation. This trend is projected to continue and has been factored into the supply projections. Notwithstanding the future uncertainties considered above, the Working Party anticipate that actual requirements are not expected to grow by much, only an estimated 0.4% per annum. This estimation was arrived at following examination of eight requirement trend indicators, including fertility rate, birth rate and service growth trends. As indicated above, the results of the projection analysis indicate that first year trainee intake should be maintained at the current level. Future workforce requirements have indicated that first year trainee intake be 58 so that no significant shortfall emerges in the workforce. However, the Working Party was advised by RACOG that a more practical intake is around 55 trainees. Accordingly, a training program intake of 55 first year trainees has been recommended for the next four years. It should be noted however, that on present indications it is unlikely that this level of intake will need to be sustained indefinitely and as such the Working Party has recommended that before the level of trainee intake for 2003 is determined the workforce should again be reviewed, that is by the end of 2000 to allow sufficient time to recruit the 2003 intakes. In particular, the Working Party acknowledged that the higher level of trainee intake of 58 may cause some difficulties for RACOG in terms of available trainers and the accumulation by trainees of necessary clinical experience. Hence, the recommended first year trainee intake of 55 per year for the next four years, which is in fact similar to the intake over the period 1995 to 1997. Description of the Current Obstetrics and Gynaecology Workforce There were various data sources used to identify the current obstetrics and gynaecology workforce. The total workforce numbers were derived from 1998 RACOG and were supplemented by data from the 1997 RACOG/AMWAC survey of College Fellows. The 1995 AIHW Medical Labour Force Survey was used for comparison. Number of Practising Consultants in Obstetrics and Gynaecology The current size of the practising obstetrics and gynaecology workforce is estimated
to be 1,049 and was based on RACOG figures, as of March 1998. The workforce consists of 951 obstetrics and gynaecology specialists. In addition,
there are an estimated 98 sub-specialists, some of whom also provided obstetrics
AMWAC 1998.6 8
and gynaecology services. RACOG records further show that 502 specialists consider their predominant clinical
practice to be in obstetrics (although time was also spent in gynaecology) and 79 Fellows consider their predominant area of clinical practice to be in gynaecology. 370 Fellows have indicated to the College that they spend roughly the same amount of time in obstetrics and gynaecology.
There are five sub-specialties within obstetrics and gynaecology. The Working Party
identified 10 maternal fetal medicine specialists, 13 uro-gynaecologists, 23 obstetrical and gynaecological ultrasound specialists, 24 gynaecological oncology specialists and 28 reproductive endocrinology and infertility specialists, as of February 1998. Specialists can also contribute to these sub-specialty areas.
The number of sub-specialists is relatively small, making up approximately 9.3% per
cent of the profession. The main characteristics of the sub-specialists workforce are outlined in part B of this report.
Geographic Distribution Using three data sources (RACOG, AIHW and Medicare) the total specialist
obstetrics and gynaecology to population ratio (SPR) is estimated to range from 1:6,954 to 1:7,547 or (13.3 to 14.4 specialists per 100,000 female population 15 years and over).
RACOG data estimates the national SPR to be 1:6,954 female population. The
RACOG data shows Victoria and South Australia have the highest SPR and Tasmania and the Northern Territory the lowest SPRs. Other States/Territories, with a SPR better than the national average are New South Wales and the Australian Capital Territory. The SPRs in Queensland and Western Australia are noticeably lower than the national average. AIHW and Medicare data show a similar pattern.
77.5% of specialists and sub-specialists had their primary practice in a capital city
(64% of the female population), 7.2% in other metropolitan areas (7.5% of the female population) and the remaining 15.3% in rural and remote centres (28.5% of the female population).
Sub-specialties are generally located in the metropolitan areas and capital cities.
Only obstetrics and gynaecology ultrasound sub-specialists are represented in rural centres.
Age Profile The RACOG data indicated that the average age of the workforce was 51.1 years.
The largest five year age group was aged between 51 and 55 years (19.4%), followed by the 46 to 50 year age group (17.5%), 7.0% (74) of the workforce was
AMWAC 1998.6 9
aged over 65 years and 32.0% (336) of the workforce was aged over 55 years. Currently, 48.6% (510) of the total obstetrics and gynaecology workforce was aged
less than 50 years, and 17.2% (180) were aged over 60 years. The workforce is predominantly (51.4%) over 50 years of age (539).
Tasmania has a noticeably older workforce with 29.2% (7) of specialists aged over
60 years. Victoria also has a higher proportion of specialists aged over 60 years, 19.0% (54). Queensland has the youngest age structure with 51.2% (87) of its workforce aged under 50 years of age. The Northern Territory has a high proportion of younger specialists, although the actual number is small, 50.0% (4).
Gender Profile Women make up 15.1% of the total obstetrics and gynaecology workforce, and this
compares with women comprising 14.0% of all specialists. In comparison to other specialties obstetrics and gynaecology appears to be one
speciality that is relatively attractive to women. As well as the proportion of women in the specialty being above the national average for specialists, obstetrics and gynaecology has the fifth highest proportion of female specialists of all specialties.
55.3% (156) of the current trainees in obstetric and gynaecology and 43.6% (17) of
the sub-specialist trainees are female; and this is one of the highest levels of female participation in a specialist training program.
The largest proportion of female obstetrics and gynaecology specialists is in the 41
to 45 year age group (29.7%) followed by the 36 to 40 year age group (24.7%) and the 46 to 50 year age group (15.2%).
Hours Worked The average hours worked per week is estimated at 62.0; 42.6 hours per week were
spent in direct patient care and an additional 19.4 hours were worked on call. In 1997, it is estimated specialists worked on average 62.0 hours per week, 64.0 for
males and 54.0 for females. For both males and females, those under 55 years of age averaged around 62.5 hours per week; this declined to 54.1 hours for the 55 to 64 years age group and to 45.8 hours for 65 to 74 years age group. The highest average hours worked per week were 71.2 hours by males aged 45 to 54 years and for females 60.7 hours per week in the 35 to 44 age range.
Average hours worked increase with remoteness from a capital city and range from
an estimated 60.4 hours per week for capital city based specialists to 74.5 hours per week for specialists located in remote areas. The proportion of the workforce on call in small rural and remote areas is higher than in metropolitan and large rural centres.
AMWAC 1998.6 10
There is little difference in hours worked, practitioners on call and average age between metropolitan and large rural centres.
Type of Practice Of the 501 specialists who responded to the RACOG/AMWAC survey, 63.7% were
in a private practice and/or undertaking public hospital work; 15.8% were salaried in a public hospital; 14.2% were in a private practice with no public hospital role; 2.2% were public hospital salaried and in a private practice; 0.6% were salaried in private hospital and in a private practice and/or undertake public hospital role; 0.5% had a university appointment with a public hospital role.
Services Provided The Working Party analysed obstetrics and gynaecology procedures performed on
private and public patients in Australian hospitals for the period 1993-94 to 1995-96. The national hospital morbidity data is outlined in full in Appendix K but notable trends are; between 1993-94 and 1995-96 the overall growth in gynaecological procedures was 7.7% and the overall growth in obstetrical procedures was 11.8%, for the same period.
Proportions of private versus public patients for given procedures varied widely
especially for gynaecological procedures. The overall proportion of gynaecological procedures undertaken on private patients was 51.3%; this ranged from a high of 91.8% for the incision of vagina and cul-de-sac to a low of 33.8% for other bilateral destruction or occlusion of fallopian tubes. Overall, obstetrics procedures were less likely to be performed on private patients than were gynaecological procedures Β (34.9% of obstetrical procedures compared with 51.3% of gynaecological procedures were performed on private patients).
The Working Party also examined services attracting Medicare benefits and found
that over the ten year period, 1986-87 to 1996-97, all obstetrics and gynaecology Medicare services provided by specialists increased by 27.2%. This represents a growth of 2.7% per annum.
For gynaecological items there was an increase of 8.0% in the period 1986-87 and
1996-97 (0.8% growth per annum). During the period 1995-96 and 1996-97, Medicare services provided by obstetrics
and gynaecology specialists for obstetric items increased by 42.7% (growth of 21.3% per annum over the two year period). Only the period 1995-96 to 1996-97 was examined because in 1995-96 ante-natal visits were included in the number of services for the first time.
Confinement services provided by specialists in obstetrics and gynaecology
decreased by 33.0% in the period 1986-87 to 1996-97.
AMWAC 1998.6 11
Training Arrangements In March 1998 there were 282 advanced trainees in obstetrics and gynaecology, the
bulk of whom are in years 1, 2 and 3 of the program (60.1%); reflecting the large increase in annual intake from 1995 onwards.
Women represent 55.3% of current trainees.
In terms of the State/Territory distribution of trainees, the number in Queensland and
Western Australia is noticeably below those States population shares, and conversely South Australia has a noticeably higher proportion of trainees compared to population. The bulk of the trainees are located in New South Wales and Victoria (57.2%/152). These two States share of trainees is roughly in proportion to their respective population shares. Female trainees are well represented in each State/Territory with the highest proportions in Queensland (63.8%), the Australian Capital Territory (60.0%) and New South Wales (58.0%).
There has been a 34.3% increase in the number of trainees during the period 1992
to 1998. Trainee numbers increased dramatically in 1995, with a 35.6% increase on the previous year. Female trainees increased by 85.7% during the period 1993 to 1998.
There were 39 sub-specialist trainees, the majority (79.5%) of whom were aged
under 40 years of age. Females represented 43.6% (17) of sub-specialist trainees. Adequacy of the Current Obstetrics and Gynaecology Workforce Overall, the Working Party concluded that there is some indication of a slight workforce shortage, particularly when public hospital vacancies and consultation waiting times are considered. Waiting times for a standard public patient were found to be noticeably higher for patients in Queensland, Western Australia, Tasmania, South Australia and Northern Territory. However, these regional shortages may relate more to maldistribution of the workforce than any significant shortage in the workforce as a whole, especially as the SPR data indicated that most States/Territories had an SPR above the suggested benchmark. The SPR data also showed that in capital cities/metropolitan areas all States/Territories are currently well supplied with obstetrics and gynaecology specialists, with the exception of the Northern Territory. In rural/remote areas South Australia and Western Australia remain below the national rural/remote SPR. Specialist (including sub-specialist) to Population Benchmarks RACOG has indicated that an acceptable specialist (including sub-
specialist):population ratio (SPR) for females in urban areas is 1:10,000 and for rural areas is 1:15,000. As the majority of the female population (64%) is situated in capital cities/metropolitan areas the national ratio is skewed towards the urban areas
AMWAC 1998.6 12
and is estimated to be 1:12,500. Examining the SPR by State and Territory and RRMA classification for the female
population age ranges indicated that in general capital city/metropolitan areas were well supplied with specialists with the exception of the Northern Territory.
The distribution of specialists in rural/remote areas indicated that generally South
Australia, Western Australia, Queensland and Tasmania fall below the rural RACOG SPR benchmark for the female population. RACOG has recommended that there should ideally be at least two to four specialists (depending on the size of the catchment population) resident in any one location which will allow appropriate cover for those specialists who are in large remote areas. The above analysis of rural/remote SPR levels indicates that these States/Territories may not have appropriate cover.
The Working Party considered that where population size is below the necessary
critical mass to support a resident specialist, or there are no specialists interested in establishing a practice in a community large enough to support a resident obstetrics and gynaecology service, a regular visiting outreach service may become an appropriate form of service delivery.
Consultation Waiting Times The average waiting time for a standard first consultation with a specialist in
obstetrics and gynaecology in his/her private rooms is 16.9 days (standard deviation 18.0) while public patients wait, on average, 31.9 days (standard deviation 48.4). The waiting time in the Australian Capital Territory for a standard first consultation is well above the average for both private and public patients.
For a serious condition, private patients wait less time (2.0 days, standard deviation
4.1) than do patients in public outpatient departments (7.1 days, standard deviation 18.5); with public patients in Queensland and Northern Territory waiting above average times for urgent conditions.
Public Hospital Vacancies The 1997 AMWAC survey of public hospital specialist vacancies found there were
17 obstetrics and gynaecology vacancies (13.5 full time equivalents). There were 6 (4.2 FTEs) vacancies in New South Wales, one (1 FTE) in Victoria, 8 (6.3 FTEs) in Queensland, one (1 FTE) in South Australia and one (1 FTE) in Tasmania. There were no vacancies in Western Australia. In addition, nine vacancies were filled by TRDs; seven TRDs in New South Wales and one TRD in both Queensland and Western Australia.
Survey of Divisions of General Practice To gain a GP perspective on the adequacy of the specialist workforce, AMWAC
AMWAC 1998.6 13
surveyed the Divisions of General Practice. The survey found that 55.4% of Divisions considered that a shortage of obstetrics and gynaecology specialists existed in their area, with the remaining proportion predominantly of the view that supply was about right. A greater proportion of rural divisions (61.5%) perceived the supply of specialists to be inadequate than did Divisions located in urban areas (50.0%).
Projections of Requirements Population Over the next ten years, the total Australian female population is expected to
increase at an annual rate of 1.1% per annum. During the same period the female population greater than 15 years will increase approximately by 1.1% per annum, those aged 15-49 years will increase approximately 0.2% per annum, those aged greater than 25 years will increase approximately 1.0%per annum and those ages over 49 years will increase by 2.7% per annum.
Birth Rate There has been a growth in births in Australia from 243,408 live births in 1986 to
253,834 in 1996, this represents a growth of 4.3%, or 0.4% per annum. Future projections indicate that birth rates will remain constant.
Fertility Rate The total fertility rate since 1992 (1.894) has steadily declined, with the fertility rate
for registered births at 1.796 in 1996, the lowest rate on record. The fertility rate is considered to be more likely to fall or remain stable in the longer term, and the age distribution will continue to change in favour of ages over 30 years. It can be assumed that as the mean age of women giving birth to their first child in Australia increases it will in turn increase the likelihood of increased demand for specialist in obstetrics and gynaecology.
Medicare and ICD-9-CM Data Trends Medicare obstetrics and gynaecology services provided by obstetricians and
gynaecologists have shown a 2.7% per annum growth over the period 1986-87 to 1996-97.
ICD-9-CM data on obstetrics and gynaecology have indicated that for gynaecological
procedures there will be overall growth of 14.0% over the next 20 years (1998-2018) or 0.7% per annum. For obstetrical procedures it is forecasted to rise by only 2.2% or by 0.1% per annum in the same period.
The Working Party concluded that the birth rate provided the best indicator of likely
future obstetrics and gynaecology services requirements, that is requirements growth of an estimated 0.4% per annum. This projection trend is the mid point of all the indicators examined. It is lower than most of the population trends, but higher
AMWAC 1998.6 14
than the fertility rate and the incidence of cancer trend. It is actually close to the trend in growth in obstetrics and gynaecology ICD-9-CM national hospital morbidity data
Projections of Supply The average expected age of retirement from the workforce was 63 years.
Examining the age and sex distribution of the specialist workforce shows that the
majority (52.7%) of the workforce is aged over 50 years, 32.0% of the workforce is aged 55 years and over and 18.0% are aged over 60 years. Assuming the average retirement age from the RACOG/AMWAC survey of 63 years, it can be estimated that there could be approximately 200 (21%) specialists intending to retire in the next five years.
RACOG expects trainee graduations over the next seven years to be: 45 in 1998, 21
in 1999, 50 in 2000, 47 in 2001, 57 in 2002, 49 in 2003 and 42 in 2004; that is an average of 48 graduates per year (excluding 1999 graduates).
It is expected that the proportion of women in the workforce will increase; given the
continuing increase in the number of female trainees. Women represent 15.5% the current total workforce, but 55.3% of trainees. In addition, of the 336 specialists aged 55 years and over, only 21 are female.
The expected lifetime hours worked by a female obstetrics and gynaecology
specialist has been estimated at 74.1% of that of a male. In conducting the projection analysis, the expected supply has been adjusted to account for increasing female participation and for the expected lower lifetime workforce contribution.
Contribution of Services by Non-specialist Providers One of the features of obstetrics and gynaecology is the scope for non specialist
providers to provide at least some of the services in obstetrics and minor gynaecological procedures. There are no definitive data sources that enable the level of substitution to be assessed, however Medicare data does provide an indication of the number of services provided by specialists and non specialists.
When private services alone are considered the majority of Medicare obstetrics and
gynaecology services are provided by specialist obstetricians and gynaecologists. In 1996-97, 86.5% of confinements were provided by obstetricians and gynaecologists, 57.2% of obstetric items and 75.3% of gynaecological items. There has been a fall of 5.6 percentage points in the number of obstetric services provided by a GP during the period 1995-96 and 1996-97. Similarly, obstetrics services provided by specialists increased by 5.7 percentage points and confinement items provided by specialists increased by 1.5 percentage points.
AMWAC 1998.6 15
In terms of obstetrics it is clear that there has been a relative decline in the provision of privately provided services by GPs against the backdrop of a falling number of private deliveries overall. In 1986, 23.1% of private deliveries were performed by GPs, in 1996-97, the proportion was down to 13.3%, in other words, a dominant trend has been declining involvement of GPs in private obstetrics. As a consequence the proportion of private deliveries undertaken by obstetrics and gynaecology specialists has risen markedly, to the point that nearly 90% of all private deliveries are undertaken by specialists.
In terms of States/Territories, Queensland and Western Australia show GP
involvement above the national average. In antenatal care South Australia and Northern Territory GP involvement is also above the national average, as is the involvement of GPs in the management of labour in Tasmania and the Northern Territory.
States/Territories with GP involvement below the national average are New South
Wales, Tasmania and the Australian Capital Territory. These figures indicate that there is a predominant role taken by GPs in providing obstetrics and gynaecology services in some of the less populous States/Territories, much of which is likely to be in provincial and rural/remote areas.
Balancing Supply Against Requirements A balance in supply to match a continued growth rate in the requirement indicators
of 0.4% per annum can be achieved by ensuring the same number of graduates currently entering the six year program is maintained; that is a trainee intake of 58 per year.
If trainee intakes remain at around 58 per year, it is expected that there will be no
significant shortfall emerging in the workforce. Notional shortages are expected to peak at 2.9% in 2002 but for requirements and supply to move back towards balance thereafter. It is projected that there will only be 1.6% shortfall in 2008.
Ideally trainee intake should be around 58 per year so that no significant shortfall
emerges in the workforce. However, RACOG has indicated that the initial intake of 58 trainees per year may not be achievable as there are limited potential training positions currently available and an already stretched resource of trainers. Maintenance of trainee intake at this level could also impact on trainees obtaining the necessary accumulated training experience. Accordingly, to accommodate this concern several scenarios based on trainee intake ranging from 50 per year to 58 per year were examined. Notional shortfalls range from a near balanced scenario with a trainee intake of 58 per year to an estimated shortfall of 3.6% with a trainee intake of 50 per year.
AMWAC 1998.6 16
In recognition of RACOGs concern the Working Party has recommended that an intake of 55 trainees per year may be a more practical target to reach. A trainee intake of 55 per year, will produce an estimated workforce shortfall of 2.1% in 2009.
Of course this does not address the issue of maldistribution of the workforce and in
this respect it will be necessary for RACOG and State/Territory health departments to make internal adjustments to the distribution of training positions.
The Working Party recommends that training positions should be increased
proportionately less in the comparatively well endowed state of South Australia, and to a lesser extent Victoria, although it needs to be remembered that Victoria has a significant proportion of older specialists. This is also the case in New South Wales. In particular, emphasis needs to be given to increasing training positions in New South Wales, Western Australia and Queensland.
Given the sensitivity of the assumptions in the projection modelling, it will be
important that obstetrics and gynaecology requirements and supply projections be monitored regularly so that they can be amended if new trends emerge. The Working Party recommends that a review of the specialist obstetrics and gynaecology workforce be undertaken before the level of trainee intake for 2003 is determined, that is by the end of 2000 to allow sufficient time to recruit the 2003 intakes. In this context, it will also be important for AMWAC to continue to monitor the trend in the numbers of non specialist providers.
It should also be noted that whilst RACOG has recently introduced a compulsory six
month rural training placement for trainees, in an effort to improve awareness of rural practice, this scheme will need the continued support of State/Territory health departments in terms of funding and support of suitable rural training positions.
The Working Party would also like the Commonwealth and State/Territory health
departments to consider the establishment of rural cadetships aimed at providing financial assistance to those training in their last year and are interested in remaining and establishing a rural practice. This process coupled with the compulsory experience to rural practice through the training program may help to alleviate some of the geographical maldistribution inherent in the workforce. In the first instance the Commonwealth Department of Health and Family Services and RACOG should jointly examine the feasibility of such a scheme.
AMWAC 1998.6 17
RECOMMENDATIONS The Working Party recommends: 1. There be an increase in the number of funded obstetrics and gynaecology
training positions to maintain trainee intake during the period 1999 to 2002 at 55 per year.
2. That State and Territory health departments undertake negotiations with the
RACOG to ensure intake numbers for first year trainees remain constant at 55 per year to 2002 and distributed as shown below.
Distribution of obstetrics and gynaecology first year advanced trainee positions, by State/Territory, 1999 to 2002
State/Territory
1997
1998
1999
2000
2001
2002
actual intakes
required intake
NSW
18
14
20
20
20
20
Victoria
12
10
14
14
13
12
Queensland
9
5
11
11
11
11
South Australia
5
6
4
4
4
4
Western Australia
5
2
4
4
4
4
Tasmania
0
2
1
1
2
2
ACT
0
3
1
1
1
2
Northern Territory*
0
0
0
0
0
0
Australia
49
42
55
55
55
55
* Trainees to the Northern Territory are on a rotational basis from other States Source: AMWAC
3. State/Territory based obstetrics and gynaecology services working groups,
comprising RACOG and State/Territory department of health representatives, be organised to oversee the funding and establishment of any new training positions.
4. That obstetrics and gynaecology requirements and supply projections be
monitored regularly so that they can be amended if new trends emerge, and that the specialist obstetrics and gynaecology workforce be reviewed before the level of trainee intake for 2003 is decided, that is at the end of 2000.
AMWAC 1998.6 18
5. That this monitoring be coordinated by RACOG and AMWAC and the results incorporated into the AMWAC annual report to AHMAC. AMWAC will provide all necessary support.
6. AMWAC also to continue to monitor the trend in the numbers of non specialist
obstetric and gynaecology providers (general practitioners and midwives). 7. The RACOG and the Commonwealth Department of Health and Family Services
examine the feasibility of establishing a rural obstetric and gynaecology graduate cadetship scheme to encourage graduates from the obstetrics and gynaecology training program to consider rural practice.
AMWAC 1998.6 19
DESCRIPTION OF THE CURRENT OBSTETRICS AND GYNAECOLOGY WORKFORCE As discussed in the introduction, there are a variety of data sources on the numbers, attributes and distribution of obstetrics and gynaecology specialists and sub-specialists in Australia. While each of these data collections has some deficiencies, it is possible to piece together a reasonably accurate and up-to-date profile of the workforce. In establishing the profile of the current obstetrics and gynaecology and sub-specialty workforce the Working Party defined: the number of practising obstetrics and gynaecology specialists; the distribution of the workforce; the age and gender profiles of the workforce; the hours worked; and the services provided.
The Number of Practising Obstetrics and Gynaecology Specialists in Australia Specialists in obstetrics and gynaecology are generally Fellows of the Royal Australian College of Obstetricians and Gynaecologists (FRACOG). Fellows may practice as obstetricians, gynaecologists, or both, or in the sub-specialities of maternal fetal medicine, uro-gynaecology, obstetrical and gynaecological ultrasound, gynaecological oncology and reproductive endocrinology and infertility. The Working Party estimated that in March 1998 the current size of the practising obstetrics and gynaecology workforce was 1,049 which includes both specialists and sub-specialists. This figure was provided by RACOG, and includes members who identified themselves as being a FRACOG and are registered under the National Specialist Qualification Advisory Committee as a specialist or sub-specialist in obstetrics and gynaecology. Of the 1,049, ninety eight (9.3%) were identified as sub-specialists. It is important to note, however, that this is not a strict division of the area of practice because many specialists may provide sub-speciality services and sub-specialists may provide general obstetrics and gynaecology services. RACOG records further show that 502 specialists consider their predominant clinical practice to be in obstetrics (although time was also spent in gynaecology) and 79 Fellows consider their predominant area of clinical practice to be in gynaecology. 370 Fellows have indicated to the College that they spend roughly the same amount of time in obstetrics and gynaecology. Of the practitioners who are sub-specialists, 10 are maternal fetal medicine specialists, 13 uro-gynaecology specialists, 23 obstetrical and gynaecological ultrasound specialists, 24 gynaecological oncology specialists and 28 reproductive endocrinology and infertility specialists. More detailed data on each of the sub-specialist workforces is provided in Part B of the report.
AMWAC 1998.6 20
Distribution of the Obstetrics and Gynaecology Workforce State/Territory Distribution The distribution of the total specialist obstetrics and gynaecology workforce is shown in Table 1. Using three data sources (RACOG, AIHW and Medicare) the total specialist obstetrics and gynaecology to population ratio (SPR) is estimated to range from 1:6,954 to 1:7,547 or (13.3 to 14.4 specialists per 100,000 female population). RACOG data estimates the national SPR to be 1:6,954 female population. The RACOG data shows Victoria and South Australia have the highest SPR and Tasmania and the Northern Territory the lowest SPRs. Other States/Territories, with a SPR better than the national average are New South Wales and the Australian Capital Territory. The SPRs in Queensland and Western Australia are noticeably lower than the national average. AIHW and Medicare data show a similar pattern. Geographic Distribution Table 2 shows the geographic distribution for the total workforce, using 1998 RACOG data. Overall, 77.5% of the workforce had their primary practice in a capital city (64% of the female population), 7.2% in metropolitan areas (7.5% of the female population) and the remaining 15.3% in rural/remote areas (28.5% of the female population) - (8.5% in a large rural centre, 3.4% in a small rural centre, 2.5% in other rural areas and 0.9% in remote areas). The data from the 1995 AIHW survey indicates a similar distribution pattern; 83.7% of specialists had their main job in a capital city or other major urban area, 9.1% in a large rural centre, 4.3% in a small rural centre, 2.3% in other rural areas and 0.6% in remote areas.
AMWAC 1998.6 21
Table 1: Obstetrics and gynaecology specialists/sub-specialists to population, by State/Territory State/ Territory
O&G spec.
and sub-spec.
% of total O&G
spec. and sub-spec.
% of Australian
female pop. >15 years a
O&G
SPR
O&G per
100,000 pop.
Total number of specialists and sub-specialists (RACOG 1998)
NSW
361
34.4
34.0
1:6,879
14.5
Vic.
284
27.1
25.3
1:6,498
15.4
Qld
170
16.2
17.9
1:7,694
13.0
SA
92
8.8
8.2
1:6,515
15.3
WA
92
8.8
9.4
1:7,465
13.4
Tas.
24
2.3
2.6
1:7,852
12.7
NT
8
0.8
0.9
1:7,820
12.8
ACT
18
1.7
1.7
1:6,777
14.8
Australia
1,049
100.0
41.1
1:6,954
14.4
Total number of specialists and sub-specialists (AIHW 1995) b
NSW
309
31.7
34.0c
1:7,904
12.7
Vic.
258
26.5
25.3
1:7,035
14.2
Qld
165
16.9
17.9
1:7,791
12.8
SA
91
9.1
8.3
1:6,547
15.3
WA
89
8.9
10.8
1:8,699
11.5
Tas.
25
2.6
2.6
1:7,460
13.4
NT
11
1.1
0.4
1:2,730
35.8
ACT
26
2.7
1.7
1:4,561
21.9
Australia
974
100.0
100.0
1:7,371
13.6
Total number of specialists and sub-specialists (Medicare 1995-96)c
NSW
339
35.0
34.0
1:7,325
13.7
Vic.
264
27.3
25.3
1:6,990
14.3
Qld
147
15.2
17.9
1:8,898
11.2
SA
77
8.0
8.2
1:7,787
12.8
WA
85
8.8
9.4
1:8,079
12.4
Tas.
*
*
2.6
*
*
NT
*
*
0.9
*
*
ACT
*
*
1.7
*
*
Australia
968
100
100
1:7,537
13.3
Notes: a - 1996 ABS female population figures; b - specialists whose main specialty of practice is obstetrics and gynaecology; c - 1995 ABS female population figures; * - number less than three. Source: RACOG & AIHW
AMWAC 1998.6 22
Table 2: Distribution of the total obstetrics and gynaecology workforce, by State/Territory and geographic location (RACOG data), 1998 State/ Territory
Total
% of Aust
% capital
city
% other
metro
% large
rural centre
% small
rural centre
% other
rural centre
%
remote
NSW/ACT
379
36.1
76.5
10.6
7.1
4.8
1.1
0.0
Vic
284
27.1
82.0
3.2
6.2
3.2
4.9
0.0
Qld
170
16.2
63.5
12.9
21.8
0.6
0.6
0.6
SA
92
8.8
91.3
. .
2.2
1.1
5.4
0.0
WA
92
8.8
85.9
5.4
. .
4.3
0.0
4.3
Tas
24
2.3
66.7
. .
16.7
12.5
4.2
0.0
NT
8
0.8
37.5
. .
0.0
. .
12.5
50.0
Australia
1,049
100.0
77.5
7.2
8.5
3.4
2.5
0.9
Notes: . . - not applicable Source: RACOG 1998 Age Profile The RACOG data indicated that the average age of the workforce was 51.1 years. The largest five year age group was aged between 51 and 55 years (19.4%), followed by the 46 to 50 year age group (17.5%), while, 7.0% (74) of the workforce was aged over 65 years and 32.0% (336) of the workforce was aged over 55 years (Table 3). Table 4 provides a summary of the workforce by major age categories. It shows that for Australia, 48.6% (510) of the total obstetrics and gynaecology workforce was aged less than 50 years, and 17.2% (180) were aged over 60 years. The workforce is predominantly (51.4%) over 50 years of age (539). Tasmania has a noticeably older workforce with 29.2% (7) of specialists aged over 60 years. Victoria also has a higher proportion of specialists aged over 60 years, 19.0% (54), than the national average. Queensland has the youngest age structure with 51.2% (87) of its workforce aged under 50 years of age. The Northern Territory also has a high proportion of young specialists, although the actual number is small, 50.0% (4). The 1995 AIHW data indicated that the average age of the workforce was 51.1 years, with 103 specialists (10.5%) aged 65 years and over (Appendix C).
AMWAC 1998.6 23
Table 3: Age profile of the total obstetrics and gynaecology specialist workforce, by State/Territory and gender (RACOG data), 1998
State/ Terr.
31-35
yrs
36-40
yrs
41-45
yrs
46-50
yrs
51-55
yrs
56-60
yrs
61-65
yrs
66-70
yrs
71 + yrs
Total
Male
NSW
12
26
46
52
77
48
29
22
1
313
Vic.
8
19
30
39
52
35
24
15
1
233
Qld.
5
18
15
34
22
29
13
10
4
150
SA
3
6
9
13
15
13
11
3
0
73
WA
3
7
5
15
17
15
6
4
4
76
Tas.
1
2
4
3
4
2
5
2
0
23
ACT
1
2
3
2
2
4
1
0
1
16
NT
0
1
0
2
1
2
0
1
0
7
Aust.
33
81
112
160
190
148
99
57
11
891
Female
NSW
4
13
14
8
3
1
3
0
2
48
Vic.
5
12
17
7
4
2
1
3
0
51
Qld.
2
6
4
3
3
2
0
0
0
20
SA
2
4
6
2
2
2
0
1
0
19
WA
1
3
5
4
0
1
2
0
0
16
Tas.
0
1
0
0
0
0
0
0
0
1
ACT
0
0
0
0
1
0
1
0
0
2
NT
0
0
1
0
0
0
0
0
0
1
Aust.
14
39
47
24
13
8
7
4
2
158
Total
NSW
16
39
60
60
80
49
32
22
3
361
Vic.
13
31
47
46
56
37
35
18
1
284
Qld
7
24
19
37
25
31
13
10
4
170
SA
5
10
15
15
17
15
11
4
0
92
WA
4
10
10
19
17
16
8
4
4
92
Tas.
1
3
4
3
4
2
5
2
0
24
ACT
1
2
3
2
3
4
2
0
1
18
NT
0
1
1
2
1
2
0
1
0
8
Aust.
47
120
159
184
203
156
106
61
13
1,049
% total
4.5
11.4
15.2
17.5
19.4
14.9
10.1
5.6
1.2
100.0
% female
29.8
32.5
29.6
13.0
6.4
5.1
6.6
6.6
15.4
15.1
Source: RACOG 1998
AMWAC 1998.6 24
Table 4: Age profile of the total obstetrics and gynaecology specialist workforce, by State/Territory, gender and major age group (RACOG data), 1998
State/Terr.
NSW
Vic
Qld
SA
WA
Tas
NT
ACT
Aust
Number of specialist obstetricians and gynaecologists
Male
under 50 years
136
96
72
31
30
10
3
8
386
51-60 years
125
87
51
28
32
6
3
6
338
over 60 years
52
50
27
14
14
7
1
2
167
Total
313
233
150
73
76
23
7
16
891
Female
under 50 years
39
41
15
14
13
1
1
0
124
51-60 years
4
6
5
4
1
0
0
1
21
over 60 years
5
4
0
1
2
0
0
1
13
Total
48
51
20
19
16
1
1
2
158
Total
under 50 years
175
137
87
45
43
11
4
8
510
51-60 years
129
93
56
32
33
6
3
7
359
over 60 years
57
54
27
15
16
7
1
3
180
Total
361
284
170
92
92
24
8
18
1,049
Percentage
Male
under 50 years
43.5
41.2
48.0
42.5
39.5
43.5
42.9
50.0
43.3
51-60 years
40.0
37.3
34.0
38.4
42.1
26.1
42.9
37.5
37.9
over 60 years
16.5
21.5
16.0
19.1
18.4
30.4
14.2
12.5
18.7
Female
under 50 years
81.3
80.4
75.0
73.7
81.3
100.0
100.0
0.0
78.5
51-60 years
8.3
11.8
25.0
21.1
6.2
0.0
0.0
50.0
13.3
over 60 years
10.4
7.8
0.0
5.2
12.5
0.0
0.0
50.0
8.2
Total
under 50 years
48.5
48.2
51.2
48.9
46.7
45.8
50.0
44.4
48.6
51-60 years
35.7
32.7
32.9
34.8
35.9
25.0
37.5
38.9
34.2
over 60 years
15.8
19.1
15.9
16.3
17.4
29.2
12.5
16.7
17.2
% Female
13.3
18.0
11.8
20.7
17.4
4.2
12.5
11.1
15.1
Source: RACOG 1998
AMWAC 1998.6 25
With respect to the specialist workforce of 951, the data shows that the largest five year age group is the 51 to 55 year age group (19.2%), followed by the 46 to 50 year age group (16.8%), and that 7.6% (72) of the workforce were aged over 65 years of age. The youngest specialist was 33 and the oldest was 76 with an average age of 51.5 years. The youngest obstetrician was 35 years and the oldest was 77 years with a mean age of 45.4 years. The youngest gynaecologist was 39 years and the oldest was 76 years with a mean age of 47.9 years. Table 6 provides a summary of specialists by major age categories. It shows that for Australia, 47.2% (449) of specialists was aged less than 50 years, and 18.0% (171) were aged over 60 years. The specialist workforce is predominantly (52.8%) over 50 years of age (502). Table 5: Age profile of obstetrics and gynaecology specialists, by State/Territory and gender (RACOG data), 1998 State/Terr.
Sex
31-35
yrs
36-40
yrs
41-45
yrs
46-50
yrs
51-55
yrs
56-60
yrs
61-65
yrs
66-70
yrs
71+ yrs
Total
NSW
M
11
21
37
47
68
45
27
22
1
279
F
4
12
12
7
3
1
3
0
2
44
Victoria M
8
17
27
30
46
35
31
13
1
208
F
5
12
15
7
4
2
1
3
0
49
Queensland M
5
17
13
31
22
29
12
10
4
143
F
2
6
3
3
3
2
0
0
0
19
South Aust. M
3
6
9
11
14
11
10
3
0
67
F
2
4
5
2
1
2
0
1
0
17
West. Aust. M
3
6
4
11
15
12
6
4
4
65
F
1
2
4
4
0
1
2
0
0
14
Tasmania M
0
2
4
3
3
2
5
2
0
21
F
0
1
0
0
0
0
0
0
0
1
North. Terr. M
0
1
0
2
1
2
0
1
0
7
F
0
0
1
0
0
0
0
0
0
1
ACT M
1
1
2
2
2
4
1
0
1
14
F
0
0
0
0
1
0
1
0
0
2
Australia M
31
71
96
137
171
140
92
55
11
804
F
14
37
40
23
12
8
7
4
2
147
Total
45
108
136
160
183
148
99
59
13
951 % Total
4.7
11.4
14.3
16.8
19.2
15.6
10.4
6.2
1.4
100.0 % Female
31.1
34.3
29.4
14.4
6.6
5.4
7.1
6.8
15.4
15.5
Source: RACOG 1998
AMWAC 1998.6 26
Table 6: Age profile of obstetrics and gynaecology specialists, by State/Territory, gender and major age group, 1998
State/Terr.
Sex
NSW
Vic
Qld
SA
WA
Tas
NT
ACT
Aust
under 50 years
M
116
82
66
29
24
9
3
6
335
F
35
39
14
13
11
1
1
0
114
51-60 years
M
113
81
51
25
27
3
3
6
311
F
4
6
5
3
1
0
0
1
20
over 60 years
M
50
45
26
13
14
7
1
2
158
F
5
4
0
1
2
0
0
1
13
Total
323
257
162
84
79
22
8
16
951
Source: RACOG 1998 Gender Profile Women make up 15.1% of the total obstetrics and gynaecology workforce, and this compares to women comprising 14.0% of all specialists. In comparison to other specialties obstetrics and gynaecology appears to be one speciality that is relatively attractive to women. As well as the proportion of women in the specialty being above the national average for specialists, obstetrics and gynaecology has the fifth highest proportion of female specialists of all specialties (AIHW 1997). In addition, 55.3% (156) of the current trainees in obstetric and gynaecology and 43.6% (17) of the sub-specialist trainees are female; and this is one of the highest levels of female participation in a specialist training program (MTRP 1997). The largest proportion of female obstetrics and gynaecology specialists is in the 41 to 45 year age group (29.7%) followed by the 36 to 40 year age group (24.7%) and the 46 to 50 year age group (15.2%). Males represent 84.9% of the total workforce, with the largest proportion of male specialists/sub-specialists in the 51 to 55 year age group (21.3%) followed by the 46 to 50 year age group (18.0%) and the 56 to 60 year age group (16.6%). The upward trend in female participation will need to be monitored as it has implications for the future available workforce. Previous AMWAC studies have shown that female specialists have a lower lifetime workforce participation than male specialists. The AMWAC/AIHW report on female participation in the medical workforce estimated the lifetime workforce participation of female obstetrics and gynaecology specialists at 74% of the male lifetime hours worked (AMWAC/AIHW 1996). However, feedback received from RACOG indicated that there is a possibility that the younger cohort of females entering the profession intend to provide a longer lifetime contribution than their predecessors. Increased levels of female participation are also likely to have an effect
AMWAC 1998.6 27
on patterns of practice. Hours Worked The data used in this section have been derived from the 1997 RACOG/AMWAC survey, comparative data from the 1995 AIHW medical labour force survey are provided in Appendix C. The level of active supply in any medical workforce is affected by the participation rate of practitioners, in terms of hours worked. Accordingly, obstetrics and gynaecology specialists working different hours can be converted to a standard estimate of productivity by the number of hours worked. This approach is an important aspect of the projection analysis used later in this report. Table 7 details the average hours provided by the total workforce. The average hours worked per week is estimated at 62.0; 42.6 hours per week were spent in direct patient care and an additional 19.4 hours were worked on call. It is estimated that specialists worked a total of 2,747,138 hours in 1997; of these hours 1,869,458 hours were in direct patient care. This equates to 37,654 hours per 100,000 female population (>15 years) in total hours worked, with the provision of hours worked per 100,000 population significantly above the average in Victoria and South Australia, and below the average in Western Australia and the Australian Capital Territory.
AMWAC 1998.6 28
Table 7: Specialists and sub-specialists in obstetrics and gynaecology average hours worked per week and annual labour supply hours, by State/Territory, 1998
State/Terr.
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Total hours worked
Ave. hours per week
58.7
70.8
66.2
64.7
49.5
52.2
48.9
57.0
62.6
Annual hours worked >000)a
855.9
846.8
493.3
255.9
188.9
52.2
35.9
18.4
2,747.1
Hours worked per 100,000 female pop.
34,470
45,885
37,715
42,701
27,521
29,314
29,524
29,319
37,654
Direct patient care hours worked
Ave. hours per week
41.9
43.2
44.7
42.1
41.3
35.8
36.4
52.0
42.6
Annual hours worked (>000)a
610.9
516.7
333.1
166.5
157.7
37.9
26.8
16.7
1,869.5
Hours worked per 100,000 female pop.
24,604
27,998
25,467
27,786
22,962
20,104
21,977
26,748
25,624
Hours on call worked
Ave. hours per week
17.6
21.1
21.7
24.7
13.0
18.2
6.6
26.7
19.4
Annual hours worked (>000)a
256.0
252.3
161.7
97.7
49.6
19.3
4.8
8.6
851.3
Hours worked per 100,000 female pop.
10,335
13,674
12,363
16,301
7,228
10,221
3,984
13,734
11,669
Hours on call not worked
Ave. hours per week
63.0
61.3
64.3
66.8
58.9
82.2
45.6
84.0
63.1
Annual hours worked (>000)a
918.7
733.1
479.2
264.3
224.9
86.9
33.6
27.1
2,769.1
Hours worked per 100,000 female pop.
36,995
39,728
36,633
44,087
32,747
46,161
27,532
43,208
37,955
Female pop. > 15 years (>000)
2,483.2
1,845.4
1,308.0
599.4
686.7
188.4
121.9
62.6
7,296.6
Specialists
317
260
162
86
83
23
16
7
954
AMWAC 1998.6 29
Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year . Source: RACOG
AMWAC 1998.6 30
Table 8 details the average hours provided by the total workforce in obstetrics and gynaecology by gender and age. In 1997, specialists worked on average 62.0 hours per week, 64.0 for males and 54.0 for females. For both males and females, those under 55 years of age averaged around 62.5 hours per week; this declined to 54.1 hours for the 55 to 64 years age group and to 45.8 hours for 65 to 74 years age group. The highest average hours worked per week were 71.2 hours by males aged 45 to 54 years and for females 60.7 hours per week in the 35 to 44 age range. Table 8: Specialists in obstetrics and gynaecology average hours and annual hours worked, by gender and age group, 1998 Gender
25-34
yrs
35-44
yrs
45-54
yrs
55-64
yrs
65-74
yrs
75 yrs &
over
Total
Total hours worked
Male
51.9
70.5
71.2
54.9
47.1
10.0
64.0
Female
48.7
60.7
44.8
30.0
10.0
0.0
54.0
Total
51.0
67.1
69.4
54.1
45.8
10.0
62.0
Annual hrs worked (>000)a
70.4
762.4
1,209.9
652.0
69.5
1.4
2,733.9
Direct patient care hours worked
Male
37.9
45.4
47.7
38.2
31.0
10.0
43.1
Female
40.5
40.8
35.1
33.5
nr
0.0
39.0
Total
38.4
43.8
46.7
38.0
31.0
10.0
42.6
Annual hrs worked (>000)a
52.9
497.6
814.2
457.9
47.1
1.4
1,869.5
Hours on call not worked
Male
67.9
59.7
67.1
63.6
51.5
0.0
63.7
Female
50.0
54.1
59.7
102.7
0.0
0.0
58.6
Total
65.9
57.9
66.6
64.8
51.5
0.0
63.1
Annual hrs worked (>000)a
90.9
657.6
1,161.1
780.9
78.2
0.0
2,769.1
Hours on call worked
Male
13.3
21.6
18.7
15.8
26.7
0.0
18.6
Female
5.0
2.5
25.4
1.5
0.0
0.0
21.9
Total
12.3
21.9
19.1
15.6
26.7
0.0
19.4
Annual hrs worked (>000)a
16.9
248.8
332.9
188.0
40.5
0.0
851.4
Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG and RACOG/AMWAC Survey 1997
AMWAC 1998.6 31
There were 10% (50) specialists who worked less than 35 hours per week and 14% (71) who reported working 80 hours per week or more. By way of comparison the AIHW Labour Force survey found that in 1995 specialists worked on average 55.0 hours per week, 55.7 for males and 49.3 for females. Those under 55 years of age averaged around 60 hours per week, and this declined to 49.5 hours for 55 to 64 years age group, 31.7 hours for 65 to 74 years age group and 27.3 hours for those aged 75 years or more. The highest average hours worked per week were 54.0 hours by males aged 45 to 54 years. There were 13.5% (132) specialists who worked less than 35 hours per week and 12.3% (119) who reported working 80 hours per week or more. Table 9 shows the average hours worked by location and reveals several interesting trends: - average hours worked increase with remoteness from a capital city and range
from an estimated 60.4 hours per week for capital city based specialists to 74.5 hours per week for specialists located in remote areas;
- the hours worked on call are higher in rural and remote areas, and this appears as the main reason for the higher average hours per week in these areas;
- the proportion of the workforce on call in small rural and remote areas is higher than in metropolitan and large rural centres;
- specialists in small rural centres and remote areas are, on average, three to five years older than their metropolitan counterparts; and
- there is little difference in hours worked, practitioners on call and average age between metropolitan and large rural centres.
Table 9: Hours worked by specialists in obstetrics and gynaecology, by geographic location, 1997
Hours worked
Major urban centre
Large rural
centre
Small rural
centre
Other rural area
Remote
Total
Total
60.4
60.7
62.3
73.8
74.5
62.6
Direct patient care
41.9
43.8
45.7
45.7
60.0
42.5
Hours on call worked
17.1
20.1
39.1
20.2
27.0
19.4
Hours on call
60.3
59.1
64.9
59.6
66.5
63.1
Per cent practitioners on call (%)
81.7
80.0
93.3
100.0
100.0
80.8
Average age (years)
50
50
53
49
55
51
% of the specialist workforce
82.3
9.6
3.9
2.3
1.9
100.0
Source: RACOG and RACOG/AMWAC Survey 1997
AMWAC 1998.6 32
Similar results were found with the AIHW data (Table C5) which showed that 63.6% reported being on call . The proportion on call and the number of hours on call rose with distance away from a metropolitan area, with remote area specialists reporting working 100% on call hours. The average hours worked varied by region, increasing from 46.1 hours a week in urban areas to to 68.3 hours a week in remote areas. Intentions to Change Hours Worked 55% (263) of respondents of the RACOG/AMWAC survey indicated that they planned to change the hours they work, with 43.1% (207) of respondents anticipating their work hours to decrease, 12.2% (60) expecting their work hours to increase and 44.7% (214) of respondents expected their hours to remain the same (n=476). Table B14 indicates the change in hours worked by State/Territory, with the most significant anticipated change being that of the obstetric and gynaecology workforce in New South Wales, with 50% (75) of practitioners indicating an anticipated a reduction in their work over the next five years. Significant associations were observed between respondents indicating an anticipated reduction in the hours over the next five years and gender, geographic location, rising medical indemnity insurance, lifestyle preferences, family considerations, health considerations and retirement. A significant association was observed between intention to increase hours worked and an expected increase in demand for obstetrics and gynaecology services (p<0.01). Other reasons cited by respondents that would increase the hours worked by specialists over the next five years included: financial incentives and children beginning school. Practice Profiles Of the 501 specialists who responded to the RACOG/AMWAC survey, 63.7% were in a private practice and/or undertaking public hospital work; 15.8% were salaried in a public hospital; 14.2% were in a private practice with no public hospital role; 2.2% were public hospital salaried and in a private practice: 0.6% were salaried in private hospital and in a private practice and/or undertake public hospital role; 0.5% had a university appointment with a public hospital role. The proportion reporting employment in public hospitals was much higher in New South Wales (32.9%) and lower (1.3%) in Tasmania. Private practice employment was highest in the New South Wales (20.0%) and lowest in the Northern Territory (1.4%) (Table B10, Appendix B). The majority (67.1%) of respondents indicated they worked as solo-specialists; 20.8% worked with other obstetricians and gynaecologists and 3.2% worked with a multi-disciplinary group (Table B8 in Appendix B).
AMWAC 1998.6 33
Services Provided Obstetrics and gynaecology services in Australia are provided through Medicare and other insurance arrangements in fee for service practice and through the government funded public hospital system. Detailed service specific data on medical services which attract Medicare benefits is available for twelve years. Public and private hospital casemix activity data is only available for the last few years. It is also important to note that there are data limitations in determining the number of services provided by specialists in obstetrics and gynaecology, this is due in part to the substitution of services by other providers, particularly GPs and midwives (see later discussion on substitution of services); and in this respect there is no definitive national data set available to separate the number of services contributed by each provider. In addition, Medicare data only covers private practice billing activity; with only a minority of the population with private health insurance (approximately 30% in 1998), consequently the Medicare data needs to be interpreted with this shortcoming in mind. One advantage of the Medicare data, however, is that it can be separated into services provided by specialists and those provided by non-specialists. National Hospital Morbidity Data One of the key sources of services data is AIHWs National Hospital Morbidity data. The Working Party analysed obstetrics and gynaecology procedures performed on private and public patients in Australian hospitals for the period 1993-94 to 1995-96. The data is outlined in full in Appendix I but notable trends are: Between 1993-94 and 1995-96 the growth in gynaecological procedures was 7.7%
(Table I9); However, the growth in individual procedures varied widely eg growth in
salpingotomy and salpingostomy procedures was 38.7% (Table I9); The overall growth in obstetrical procedures was 11.8% from 1993-94 to 1995-96.
Procedures with considerably more than the overall growth included medical induction of labour which showed 65.3% growth (Table I10);
Proportions of private versus public patients for given procedures varied widely especially for gynaecological procedures (Tables I1 to I2, I11 to I12). The overall proportion of procedures undertaken on private patients was 51.3%. This
ranged from a high of 91.8% for the incision of vagina and cul-de-sac to a low of 33.8% for other bilateral destruction or occlusion of fallopian tubes (excluding those procedures with low incidence of less than 1,000) (Table I11);
Overall, obstetrics procedures were less likely to be performed on private patients than were gynaecological procedures Β (34.9% of obstetrical procedures compared with 51.3% of gynaecological procedures were performed on private patients, Tables I11 and I12);
The proportions of specific obstetrical procedures performed on private patients varied less than for gynaecological procedures. They ranged from a high of 50.2% for forceps rotation of fetal head to a low of 15.0% for other intrauterine operations
AMWAC 1998.6 34
on fetus and amnion (excluding those with low incidence of less than 1,000) (Table I12);
Analysis of age profile data is limited to 1995-96 data: Gynaecological procedures were more commonly performed on 25 to 34 year olds
than other age groups (30.9% were undertaken on females in this age group, Table I5);
Young aged females (0-24 years) and older aged females (65 years and over) were less likely to undergo gynaecological procedures as private patients. About 39% of procedures on 0 to 24 year olds were performed on private patients Β the proportion is about 45% for over 65 year olds (Table I7). This compared with around 57% of the procedures being undertaken on 25 to 64 year olds as private patients;
On average more patients aged 45 to 54 years underwent gynaecological procedures as private patients than other age groups (Table I7);
Obstetrics age trends were more consistent than gynaecological trends. The age range of patients was relatively narrow and there was less variation between individual procedures. Obstetrics procedures were more commonly performed on 25 to 34 year olds than other age groups (62.4% were undertaken on females of this age bracket, Table I6);
Obstetrics procedures undertaken on private patients tended to be performed on a slightly older age group (Tables I3 and I4). Obstetrical procedures on public patients were more likely to be undertaken on 25 to 34 year old age group and next most likely the younger 15 to 24 years (56.5% and 32.7% of procedures on public patients, respectively). The peak age for procedures on private patients was also 25 to 34 years followed by the older 35 to 44 group (73.4% and 19.3% of procedures on private patients, respectively); and
35 to 44 year olds were on the whole more likely to undergo the procedures as private patients than other age groups (Table I8).
Services Attracting Medicare Benefits Over the ten year period, 1986-87 to 1996-97, all obstetrics and gynaecology Medicare services provided by specialists increased by 27.2%. This represents a growth of 2.7% per annum. For gynaecological items there was an increase of 8.0% in the period 1986-87 and 1996-97 (0.8% growth per annum). During the period 1995-96 and 1996-97, Medicare services provided by obstetrics and gynaecology specialists for obstetric items increased by 42.7% (growth of 21.3% per annum over the two year period). Only the period 1995-96 to 1996-97 was examined because in 1995-96 ante-natal visits were included in the number of services for the first time. Confinement services provided by specialists in obstetrics and gynaecology decreased by 33.0% in the period 1986-87 to 1996-97.
AMWAC 1998.6 35
Table 10: Obstetrics and gynaecology services attracting Medicare benefits provided by specialists, 1986-87 to 1996-97 Derived specialty/item
1986-87
1991-92
1992-93
1993-94
1994-95
1995-96
1996-97
Change 1986-87 1996-97
All obstetrics and gynaecology specialists
Confinement items Providers
775
778
767
720
709
690
681
-12.1%
Confinement items Services
105,334
97,004
91,287
82,400
79,091
73,524
70,537
-33.0%
Obstetrics Providers
787
762
753
706
700
706
725
-7.9%
Obstetrics Services
253,189
174,602
174,507
178,278
173,653
620,074
885,259
42.7%a
Gynaecology Providers
834
893
894
934
849
845
853
2.3%
Gynaecology Services
293,433
368,837
360,012
324,714
375,216
344,549
316,849
8.0%
IVF Providers
-
116
128
80
82
96
102
-12.1%b
IVF Services
-
89,414
90,187
10,673
12,099
12,803
14,326
-83.9b
Total Providers
837
899
902
838
862
859
870
3.9%
Total Services (>000)
2,142.6
2,269.5
2,244.7
1,993.9
2,137.9
2,505.8
2,725.2
27.2%
Notes: a - from 1995-96 ante-natal visits were included in the number of services therefore percentage change has been calculated for the period 1995-96 to 1996-97; b - percentage difference calculated from 1991-92 to 1996-97 Source: AIHW 1998 Training Arrangements The RACOG is the governing body overseeing the obstetrics and gynaecology profession in Australia and was established in 1978. The RACOG administers the training program for new specialists and a programme of continuing education and continuing certification for the Fellows of the College. The training program is currently six years duration with an introductory four year Integrated Program and a two year Elective Program. Specialists are initially conferred the status of Members of the RACOG and subsequently become Fellows with full practising rights. Fellowships are granted on a time limited basis and Fellows are required to document their participation in continuing education and quality assurance activities to retain their Fellowship status (see Appendix E). RACOG also offers certificates in five sub-specialties: gynaecological oncology, maternal fetal medicine, uro-gynaecology and reproductive endocrinology and infertility. The training for which is of three years duration. The certificate in the sub-specialty of obstetrical and gynaecological ultrasound requires two years of training. In March 1998, there were a total of 208 integrated training positions in obstetrics and gynaecology medicine as shown in Table 11.
AMWAC 1998.6 36
Table 11: Accredited obstetrics and gynaecology training positions, by hospital and State/Territory, 1998 State/Territory
Hospital
Accredited positions
New South Wales (61) John Hunter 6
King George V
10
Liverpool
12
Nepean
3
Royal Hospital for Women
11
Royal North Shore
7
St George
5
Westmead
7
ACT (6) Canberra
6
Victoria (53) Ballarat Base 1
Geelong
1
Mercy Hospitals Inc.
7
Mildura Base
1
Monash Medical Centre
14
Peter MacCallum Cancer Institute
1
Northern Hospital
1
Royal Women’s
23
Sunshine
1
West Gippsland
1
Warnambool
1
Western General
1
Queensland (40) Bundaberg Base 1
Caboolture
1
Cairns Base
1
Gold Coast
2
Ipswich
2
Kirwan Hospital for Women
2
Logan
4
Mackay Base
1
Mater Mothers
9
Nambour General
2
Princess Alexandra
1
Queen Elizabeth II
2
Redcliffe
3
Rockhampton Base
1
Royal Women’s
7
Toowoomba Base
1
South Australia (26) Flinders Medical Centre 5
The Lyell McEwin
5
Modbury
2
Mt Gambier
1
Queen Elizabeth
4
Royal Adelaide
3
Women’s and Childrens
6
Western Australia (14) King Edward Memorial 14 Tasmania (5)
Launceston
1
Northwest Regional
1
Queen Victoria
1
Royal Hobart
2
Northern Territory (3) Royal Darwin
3
Total trainees in an ITP (Integrated Training Program)
208 Source: RACOG 1998
AMWAC 1998.6 37
In March 1998 there were 282 advanced trainees in obstetrics and gynaecology, the bulk of whom are in years 1, 2 and 3 of the program (60.1%); reflecting the large increase in annual intake from 1995 onwards (Table 12). Table 13 shows that 22.3% of trainees are part time, with female trainees representing 53.9% of part time trainees. In terms of the State/Territory distribution of trainees, the number in Queensland and Western Australia is noticeably below those States population shares, and conversely South Australia has a noticeably higher proportion of trainees compared to population. The bulk of the trainees are located in New South Wales and Victoria (57.2%/152). These two States share of trainees is roughly in proportion to their respective population shares (Table 14). Female trainees are well represented in each State/Territory with the highest proportions in Queensland (63.8%), the Australian Capital Territory (60.0%) and New South Wales (58.0%). Table 12: RACOG trainees, by year of training, age group and gender, 1998
21-25 yrs
26-30 yrs
31-35 yrs
36-40 yrs
41-45 yrs
>45 yrs
Unknown
Total
Male
Year 1
0
11
2
6
1
2
3
25 Year 2
0
7
4
4
1
1
1
18
Year 3
0
6
15
4
2
0
0
27 Year 4
0
2
12
8
1
0
0
23
Year 5
0
1
15
1
2
0
0
19 Year 6
0
0
3
6
1
1
0
11
Unknown
0
0
1
0
1
1
0
3 Total
0
27
52
29
9
5
4
126
Female Year 1
1
15
10
3
0
1
2
32
Year 2
0
18
5
5
2
0
0
30 Year 3
0
13
9
5
2
1
0
30
Year 4
0
5
13
2
2
0
0
22 Year 5
0
0
20
8
1
1
1
31
Year 6
0
0
5
5
0
0
0
10 Unknown
0
1
0
0
0
0
0
1
Total
1
52
62
28
7
3
3
156 Total
Year 1
1
26
12
9
1
3
5
57 Year 2
0
25
9
9
3
1
1
58
Year 3
0
19
24
9
4
1
0
57 Year 4
0
7
25
10
3
0
0
45
Year 5
0
1
35
9
3
1
1
50 Year 6
0
0
8
11
1
1
0
21
Unknown
0
1
1
0
1
1
0
4 Total
1
79
114
57
16
8
7
282
%Female
100.0
65.8
54.4
49.1
43.8
37.5
42.9
55.3Source: RACOG March 1998
AMWAC 1998.6 38
Table 13: RACOG trainees, by full time and part time status, age group and gender, 1998 Gender
21-25 yrs
26-30 yrs
31-35 yrs
36-40 yrs
41-45 yrs
>45 yrs
Unknown
Total
Full time
Male
0
19
39
23
8
4
4
97 Female
1
45
46
20
6
2
2
122
Total
1
64
85
43
14
6
6
219 % female
100.0
70.3
54.1
46.5
42.9
33.3
33.3
55.7
Part time Male
0
8
13
6
1
1
0
29
Female
0
7
16
8
1
1
1
34 Total
0
15
29
14
2
2
1
63
% female
0.0
46.7
55.2
57.1
50.0
50.0
100.0
54.0 Total
Male
0
27
52
29
9
5
4
126 Female
1
52
62
28
7
3
3
156
Total
1
79
114
57
16
8
7
282 % part time
0.0
19.0
25.4
24.6
12.5
25.0
14.3
22.3
Source: RACOG March 1998 Table 14: Obstetrics and gynaecology trainees, by State/Territory and gender, 1998 Gender
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Not
known
Aust
Male
37
29
17
15
9
3
2
2
12
126
Female
51
35
30
16
11
2
3
2
6
156
Total
88
64
47
31
20
5
5
4
18
282
% trainees
33.3
24.2
17.8
11.7
7.5
2.0
2.0
1.5
-
100.0
% popn.
33.9
24.8
18.3
8.1
9.7
2.4
1.7
1.0
-
100.0
% female
58.0
54.7
63.8
51.6
55.0
40.0
60.0
50.0
33.3
55.3
Source: RACOG March 1998 and ABS The AIHW medical labour force survey figures for 1995 indicate that specialists in training in obstetrics and gynaecology worked, on average, a total of 60.8 hours per week, 61.2 for males and 60.7 hours for females (Tables 15 and 16).
AMWAC 1998.6 39
Table 15: Obstetrics and gynaecology specialists-in-training average hours worked, by gender and age, 1995 Gender
<35 years
35-44 years
45-54 years
Total
Total hours worked
Male
61.3
60.0
60.0
61.2
Female
59.6
61.5
70.5
60.7
Total
60.4
60.6
67.0
60.8
Direct patient care hours worked
Male
52.4
57.2
60.0
54.7
Female
56.9
54.2
60.5
57.0
Total
54.8
55.9
60.3
55.7
Hours on call not worked
Male
26.4
32.6
0.0
30.7
Female
39.5
47.5
48.0
40.4
Total
32.1
37.6
48.0
34.8
Source: AIHW Table 16: Obstetrics and gynaecology specialists in training average hours worked, by State/Territory, 1995 Hours
NSW/ACT
Vic
Qld
WA
SA/NT
Tas
Total
Total worked
67.6
69.0
52.8
52.5
61.0
65.0
60.8
Direct patient care
60.0
55.1
49.5
49.2
53.3
60.0
55.7
On all not worked
43.7
19.1
26.5
39.2
33.4
57.0
34.8
Source: AIHW Table 17 shows there has been a 34.3% increase in the number of trainees during the period 1992 to 1998. Trainee numbers increased dramatically in 1995, with a 35.6% increase on the previous year. Female trainees increased by 85.7% during the period 1993 to 1998.
AMWAC 1998.6 40
Table 17: Obstetrics and gynaecology trainees, by gender, 1992 to 1998 Year
Male
Female
Total
% Female
1992
na
na
185
-
1993
126
84
210
40.0
1994
103
105
208
50.5
1995
139
143
282
50.7
1996
143
150
293
51.2
1997
126
150
276
54.3
1998
126
156
282
55.3
na - not available *This includes all registered trainees in RACOG approved training sites in Australia and overseas training posts; special training sites (eg. Masters Degree at Townsville University, laparoscopic surgery post, research), which are not an accredited training post; and RACOG sub-specialty training posts in Australia, as well as prospectively approved posts overseas. Source: RACOG March 1998 Summary of Main Characteristics of the Specialist Obstetrics and Gynaecology Workforce Obstetrics and gynaecology is one of the larger single specialist workforces, representing 6.4% of all specialists (only anaesthesia and psychiatry have significantly larger workforces). The Working Party estimates there are currently 1,049 practising obstetrics and gynaecology specialists in Australia. This represents 14.4 specialists per 100,000 female population (aged 15 years and over) and an estimated SPR of 1:6,954 (female population aged 15 years and over). Specialist obstetricians and gynaecologists practise mainly in capital cities and metropolitan areas (84.7% of the workforce). 15.3% of specialists are located in rural areas (28.5% of the female population). The workforce is unevenly spread between States/Territories, with Tasmania, Western Australia, Queensland and the Northern Territory all having an SPR below the national average. The average age of the workforce is 51.1 years. The largest five year age groups are the 51 to 55 years (19.4%) and the 46 to 50 years (17.5%). In total, 32.0% (336) of the workforce are aged 55 years and over; but of this number only 7.0% (74) are aged 65 years and over. Most of the specialists aged 55 years and over are located in New South Wales and Victoria (197/58.6%). Women make up 15.1% (158) of the workforce, with this proportion expected to increase given that 55.3% of current trainees are female and only 21 women are aged 55 years and over. The five year age group with the largest number of women specialists is the 41 to 45 years (47/29.6% of female specialists). The Working Party estimated that obstetric and gynaecology specialists work on
AMWAC 1998.6 41
average 62 hours per week. The large majority of the workforce (63.7%) work in private practice and undertake some public hospital work. Most specialists practice both obstetrics and gynaecology, and even some of the 98 subspecialists continue to practice general obstetrics and gynaecology.
AMWAC 1998.6 42
ADEQUACY OF THE CURRENT OBSTETRICS AND GYNAECOLOGY WORKFORCE There are a number of indicators of the adequacy of a medical workforce. No single measure can provide a definitive assessment, however by examining each it is possible to gain an indication of whether a workforce is adequately meeting current demand or if there is a significant shortfall or oversupply. The indicators chosen by the Working Party were: specialist (including sub-specialist):population ratio; public hospital vacancies; consultation waiting times; views of the Divisions of General Practice; and views of Fellows of RACOG.
Obstetrics and Gynaecology Surgeons:Population Ratio When considering SPR the Working Party determined that three female population age groups were important. First, the best general indicator is the population aged 15 years and over (and this indicator was used in calculating the SPRs shown in Table 1). Second, obstetric services were really provided to the population aged 15 to 49 years. Comparisons using the female population aged 25 years and over are also provided. RACOG has indicated that an acceptable SPR for females in urban areas is 1:10,000 and for rural areas 1:15,000 (see Appendix F: Service Provision and Requirements of Obstetrics and Gynaecology). The national ratio would therefore be skewed towards the urban areas as the majority of the female population (64%) is situated in capital cities/metropolitan areas and could be considered to be approximately 1:12,500. Table 18 summarises the SPR by State and Territory for each of the three female population groups. The SPR for females aged 15 to 49 years is estimated at 1:4,439 or 22.5 specialists/sub-specialists per 100,000 female population or 2.8 per 12,500 female population. State provision ranged from 15.2 per 100,000 population in the Northern Territory and 25.2 per 100,000 population in South Australia. Using the national SPR indicator from RACOG 1:12,500 all States/Territories are well endowed with specialists. The SPR for females aged over 15 years is estimated at 1:6,954 or 14.4 specialists/sub-specialists per 100,000 female population or 1.8 per 12,500 female population. Using the national SPR indicator from RACOG 1:12,500, all States/Territories are well endowed with specialists. The SPR for females aged over 25 years is estimated at 1:5,629 or 17.8 specialists/sub-specialists per 100,000 female population or 2.2 per 12,500 female population. Using the national SPR indicator from RACOG 1:12,500, all States/Territories are well endowed with specialists.
AMWAC 1998.6 43
Table 18: Specialists/sub-specialists in obstetrics and gynaecology to female population ratio, by State/Territory, 1998 (number per 100,000 population)
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Specialists
361
284
170
92
92
24
18
8
1,049
Females aged 15 years and greater Population (>000)
2,483.2
1,845.4
1,308.0
599.4
686.7
188.4
121.9
62.6
7,295.7
SPR:1
6,879
6,498
7,694
6,515
7,465
7,852
6,777
7,820
6,954
No./100,000
14.5
15.4
13.0
15.3
13.4
12.7
14.8
12.8
14.4
No. /12,500
1.8
1.9
1.6
1.9
1.7
1.6
1.8
1.6
1.8
Females aged 25 years and greater
Population (>000)
2,010.4
1,458.6
1,099.4
486.6
515.0
150.6
92.9
55.6
5,905.2
SPR:1
5,569
5,136
6,467
5,289
5,598
6,275
5,161
6,950
5,629
No./100,000
18.0
19.5
15.5
18.9
17.9
15.9
19.4
14.4
17.8
No. /12,500
2.2
2.4
1.9
2.4
2.2
2.0
2.4
1.8
2.2
Females aged 15 to 49 years
Population (>000)
1,552.1
1,159.7
865.3
364.9
456.4
117.7
87.5
52.8
4,656.5
SPR:1
4,299
4,083
5,090
3,966
4,961
4,904
4,861
6,600
4,439
No./100,000
23.2
24.5
19.6
25.2
20.2
20.3
20.6
15.2
22.5
No./12,500
2.9
3.1
2.5
3.2
2.5
2.5
2.6
1.9
2.8
Source: RACOG 1998 and ABS 1996 Census: Population by Sex and Age Table 19 examines the SPR by State and Territory and RRMA classification for the three female population age ranges. The capital city/metropolitan SPR for females aged between 15 and 49 years is estimated at 1:3,817 or 26.2 specialists per 100,000 female population or 2.6 per 10,000 female population. Using the urban SPR indicator from RACOG 1:10,000, only the Northern Territory falls below this ratio. The capital city/metropolitan SPR for females aged 15 years and over is estimated at 1:5,796 or 17.3 specialists per 100,000 female population or 1.7 per 10,000 female population. Using the urban SPR indicator from RACOG of 1:10,000, only the Northern Territory falls below this ratio.
AMWAC 1998.6 44
The rural/remote SPR for females aged between 15 and 49 years is estimated at 1:7,894 or 12.7 specialists per 100,000 female population or 1.9 per 15,000 female population. Using the rural SPR indicator from RACOG of 1:15,000 all States/Territories are well endowed with specialists. There are no rural/remote centres in ACT. The rural/remote SPR for females aged 15 years and over is estimated at 1:12,614 or 7.9 specialists per 100,000 female population or 1.2 per 15,000 female population. Using the rural SPR indicator from RACOG of 1:15,000 South Australia and Western Australia fall below this SPR indicator. For the female population aged 25 years and over, Western Australia falls below this rural SPR benchmark. In areas where there are outreach services provided to large remote areas such as Cairns, RACOG has recommended that there should ideally be at least four specialists which will allow appropriate cover for those specialists who are on call and/or are visiting remote areas. The distribution of specialists in rural/remote areas indicates that generally South Australia, Western Australia, Queensland and Tasmania fall below the rural RACOG SPR benchmark for the female population. As indicated earlier RACOG has recommended that there should ideally be at least two to four specialists (depending on the size of the catchment population) resident in any one location which will allow appropriate cover for those specialists who are in large remote areas. The above analysis of rural/remote SPR levels indicates that these States/Territories may not have appropriate cover. The Working Party considered that where population size is below the necessary critical mass to support a resident specialist, or there are no specialists interested in establishing a practice in a community large enough to support a resident obstetrics and gynaecology service, a regular visiting outreach service may become an appropriate form of service delivery.
AMWAC 1998.6 45
Table 19: Specialists/sub-specialists in obstetrics and gynaecology to female population ratio, by State/Territory and geographic location, 1998
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Capital cities and metropolitan areas
Workforce
312
242
130
84
84
16
18
3
889
Females aged 15 to 49 years
Population (>000)
1,195.7
896.8
522.6
275.3
340.7
50.1
24.7
87.5
3,393.4
SPR:1
3,832.
3,706
4,020
3,278
4,056
3,132
1,370
29,164
3,817
No./100,000
26.1
27.0
24.9
30.5
24.7
31.9
73.0
3.4
26.2
No./10,000
2.6
2.7
2.5
3.1
2.5
3.2
7.3
0.3
2.6
Females aged 15 years and greater
Population (>000)
1,837.2
1,350.3
795.8
437.5
504.7
77.0
32.0
118.3
5,152.9
SPR:1
5,889
5,580
6,122
5,208
6,008
4,814
1,780
39,450
5,796
No./100,000
17.0
17.9
16.3
19.2
16.6
20.8
56.2
2.5
17.3
No./10,000
1.7
1.8
1.6
1.9
1.7
2.1
5.6
0.3
1.7
Rural and remote areas
Workforce
49
42
40
8
8
8
0
5
160
Females aged 15 to 49 years
Population (>000)
356.4
262.9
342.7
89.6
115.6
67.6
28.1
85
1,263.1
SPR:1
7,273
6,259
8,568
11,206
14,456
8,449
0
5,624
7,894
No./100,000
13.7
16.0
11.7
8.9
6.9
11.8
0
17.8
12.7
No./15,000
2.1
2.4
1.8
1.3
1.0
1.8
0.0
2.7
1.9
Females aged 15 years and greater Population (>000)
591.1
421.4
545.7
145.0
171.2
105.3
38.2
112
2,018.2
SPR:1
12,064
10,034
13,644
18,126
21,401
13,163
0
7,644
12,614
No./100,000
8.3
10.0
7.3
5.5
4.7
7.6
0
13.1
7.9
No./15,000
1.2
1.5
1.1
0.8
0.7
1.1
0.0
2.0
1.2
Females aged 25 years and greater
Population (>000)
499.2
353.9
455.9
124.4
142.9
87.6
87
30.0
1,694.1
SPR:1
10,187
8,427
11,399
15,546
17,860
10,951
0
6,019
10,587
No./100,000
9.8
11.9
8.8
6.4
5.6
9.1
0
16.6
9.4
No./15,000
1.5
1.8
1.3
1.0
0.8
1.4
0.0
2.5
1.4
Source: RACOG 1998, ABS 1996 Census: Population-Capital city/Metropolitan & Rural/Remote
AMWAC 1998.6 46
Public Hospital Vacancies The 1997 AMWAC survey of public hospital specialist vacancies found there were 17 obstetrics and gynaecology vacancies (13.5 full time equivalents). There were 6 (4.2 FTEs) vacancies in New South Wales, one (1 FTE) in Victoria, 8 (6.3 FTEs) in Queensland, one (1 FTE) in South Australia and one (1 FTE) in Tasmania. There were no vacancies in Western Australia. In addition, nine vacancies were filled by TRDs; seven TRDs in New South Wales and one TRD in both Queensland and Western Australia. Provider Shortages Respondents to the RACOG/AMWAC survey were asked to specify any providers in short supply in their primary practice location. Table B15, Appendix B indicates that according to respondents there is a need for more obstetricians and gynaecologists, midwives, anaesthetists, paediatricians and psychiatrists. The survey data revealed a strong association between perceived need for more obstetricians and gynaecologists and geographic location. In total, 80.2% (219) metropolitan and 17.2% (47) of rural specialists indicated a need for more obstetricians and gynaecologists compared with respondents (n=273). In rural and remote areas respondents indicated a greater need for more midwives, obstetric GPs, anaesthetists, paediatricians, psychologists and psychiatrists than obstetricians and gynaecologists. Consultation Waiting Times For dedicated obstetrics and gynaecology units, respondents to the 1997 RACOG/AMWAC survey were asked to estimate the average waiting time for a standard first consultation and an urgent condition. Table 20 shows that the average waiting time for a standard first consultation with a specialist in obstetrics and gynaecology in his/her private rooms was 16.9 days (standard deviation 18.0) while for public patients the wait, on average, was 31.9 days (standard deviation 48.4). The waiting time in Tasmania for public patients was noticeably above the national average. For an urgent condition, private patients were shown to wait much less time (2.0 days, standard deviation 4.1) than did patients in public outpatient departments (7.1 days, standard deviation 18.5) (p<0.01); with public patients in Queensland and the Northern Territory waiting above average times.
AMWAC 1998.6 47
Table 20: Obstetrics and gynaecology average waiting time (days) for a standard first consultation and an urgent procedure, by private rooms/public outpatients department and State/Territory, 1997 (n=501)
State/Territory
Standard consultation
Urgent condition
Private patients
NSW
16.0
2.4
Victoria
19.1
1.9
Queensland
17.2
2.3
Western Australia
15.4
1.7
South Australia
12.7
1.1
Tasmania
15.9
1.0
Northern Territory
10.5
2.5
ACT
40.8
2.7
Total
16.9
2.0
Public patients
NSW
21.9
4.5
Victoria
23.4
5.4
Queensland
37.6
14.0
Western Australia
47.8
7.7
South Australia
32.1
5.7
Tasmania
141.5
5.8
Northern Territory
38.5
14.0
ACT
16.3
5.3
Total
31.9
7.1
Source: RACOG/AMWAC Survey Survey of Divisions of General Practice To gain a GP perspective on the adequacy of the specialist workforce, AMWAC surveyed the Divisions of General Practice, and the results of the survey are detailed in Appendix G. The survey found that 55.4% of Divisions considered that a shortage of obstetrics and gynaecology specialists existed in their area, with the remaining proportion predominantly of the view that supply was about right. A greater proportion of rural divisions (61.5%) perceived the supply of specialists to be inadequate than did Divisions located in urban areas (50.0%).
AMWAC 1998.6 48
Professional Satisfaction Overall, 69.9% (n=485) of respondents (both specialists and sub-specialists) to the RACOG/AMWAC survey were satisfied with their work. Aspects of their work with which they were most satisfied were sufficient work to maintain competence, physical working conditions, opportunity to use your abilities and the availability of other specialists. Aspects of their work with which they were most dissatisfied (in order of percentage of people expressing dissatisfaction) were industrial relations between management and workers in their health service (26.5%), workload sufficient to maintain income (25.5%), hours of work (22.6%), and amount of work (22.4%) (Table B18, Appendix B). Medical Indemnity Insurance One of the issues confronting the obstetrics and gynaecology profession is the real and potential withdrawal of specialists from obstetrics, in part induced by the fear of being sued and high indemnity insurance premiums. Any trend has to be seen against the backdrop of the traditional career changes of obstetrics and gynaecology specialist away from obstetrics as they get older, and the effect on recruitment of trainees to the profession. Respondents to the RACOG/AMWAC survey indicated that rising medical indemnity insurance premiums will affect the way they practice with 83% (403) indicating that they would either cease practising obstetrics or retire early and 9% indicating that they would pass cost on to patients. Conclusions on the Adequacy of the Current Obstetrics and Gynaecology Workforce Overall, the Working Party concluded that there is some indication of a slight workforce shortage, particularly when public hospital vacancies and consultation waiting times are considered. Waiting times for a standard public patient were found to be noticeably higher for patients in Queensland, Western Australia, Tasmania, South Australia and Northern Territory. However, these regional shortages may relate more to maldistribution of the workforce than any significant shortage in the workforce as a whole, especially as the SPR data indicated that most States/Territories had an SPR above the suggested benchmark. The SPR data also showed that in capital cities/metropolitan areas all States/Territories are currently well supplied with obstetrics and gynaecology specialists, with the exception of the Northern Territory. In rural/remote areas South Australia and Western Australia remain below the national rural/remote SPR. However, despite the conclusion of possible shortages, no short term remedial action is recommended by the Working Party, mainly because RACOG dramatically boosted trainee numbers in 1995 and when these trainees commence making a contribution to the workforce from 2001 onwards it is anticipated that shortages in the workforce should begin to diminish.
AMWAC 1998.6 49
PROJECTIONS OF REQUIREMENTS Female Population In 1997 Australia's female population was estimated to be 9.31 million compared to 8.72 million in 1991. The ABS estimates that the female population will reach 9.631 million by 2001 and 10.11 million by 2006 (ABS 1997) (Table 21). Between now and 2006 there is a projected growth of 0.9% growth per annum in the female population. Between now and 2011 the projected growth per annum of females will be 0.93%. The projected growth of the female population is expected to fall to 0.85% per annum by 2036 and to 0.81% per annum by the year 2041. This slow down in growth is being caused by the ageing of the population and a decline in the fertility rate. Table 21: Australian female population estimates and projections, 1997 to 2006
Females
1993
1995
1997
2001
2006
> 15 years
6,998,724
7,108,294
7,403,647
7,697,000
8,142,200
>25 years
5,657,321
5,858,964
6,097,953
6,412,600
6,813,500
15 to 49 years
4,660,453
4,734,965
4,820,066
4,843,900
4,932,100
> 49 years
2,338,271
2,445,329
2,583,581
2,853,100
3,210,100
Total female population
8,866,241
9,073,430
9,314,231
9,631,900
10,105,300
Source: ABS, Australian Demographic Statistics, 3101.0, June quarter 1997 and ABS, Projections of the Populations of Australia, States and Territories, 1995 - 2051, Series A/B
The projected growth rate of the female population differs across age cohorts. For example the population growth of younger women should be fairly small over the next 20 years (numbers of women under 45 years of age are expected to increase by only 3.4%) whilst growth in numbers of women aged 45 or over should be relatively high (50.3%). Increasing proportions of elderly people and decreasing proportions of births due to a fall in fertility rates will also result in the median age of the total population rising from 34.1 years currently to between an estimated 39.4 and 41.8 years in 2041 (ABS 1994). Overall, the ageing of the female population, combined with the heavy utilisation of medical services by this group, can be expected to lead to an increase in the demand for services by the older female population.
AMWAC 1998.6 50
Fertility Rate The total fertility rate is the number of births that a woman could expect to have, based on current age-specific birth rates. Australia’s total fertility rate has been falling over the last two decades, from 2.9 babies per woman in 1971 to 1.8 in 1996. Since the mid 1970s, the total fertility rate has remained below the natural replacement level of 2.1 babies per woman. The decline in the fertility rate has been accompanied by changes in the age pattern of fertility, with the median age of confinement increasing to 28.7 years. Associated with this trend has been an increase in the proportions of births occurring to older women and a decline in the number of women having three or more births. The age group for peak fertility in 1996 was 25 to 29 years old, followed by 30 to 34 years old (ABS 1997). Most of the decline in the fertility rate over the period 1976 to 1996 occurred among younger women. The fertility of women aged less than 24 years declined by 48%, while that for women aged 25 to 29 years declined by about 20%. On the other hand, the fertility of women aged 30 to 34 years and 35 to 39 years increased during the period (ABS 1997). The total fertility rate in 1996 varied substantially between the States and Territories, from 1.7 births per woman in Victoria to 2.3 in the Northern Territory. Between 1976 and 1996, the total fertility rate declined in all States and Territories. However, between 1986 and 1996, the rate for the Northern Territory increased slightly, while the rate for South Australia and Tasmania remained largely unchanged (Table 22) Table 22: Total fertility rate, by State/Territory, 1976, 1986 and 1996
NSW
Vic
Qld
SA
WA
Tas
NT
ACT
Aust
1976
2.04
2.03
2.18
1.86
2.14
2.09
3.06
2.09
2.06
1986
1.91
1.78
1.91
1.76
1.98
1.93
2.21
1.74
1.87
1996
1.83
1.71
1.84
1.75
1.81
1.92
2.29
1.68
1.80
Source: ABS, Births, September 1997, 3301.0 For all States and Territories, expect the Northern Territory, the largest contribution to the total fertility rate in 1996 was made by women aged 25 to 29 years followed by women 30 to 34 years. In the Northern Territory, the age group of peak fertility was 20 to 24 years, followed by 25 to 29 years. The Northern Territory has a much younger fertility age structure, with women aged less than 25 years comprising 43% of the total fertility rate, compared to contributions of between 18% and 30% for the other States. The age-specific birthrate for 15 to 19 year old women was more than three to four
AMWAC 1998.6 51
times as high in the Northern Territory as it was in other States and the Australian Capital Territory, while the age-specific birth rate for women aged 20 to 24 years in the Northern Territory was one to two times higher than rates for other States and the Australian Capital Territory. Indigenous women have an above average fertility when compared with women in the total Australian female population. For example, in 1996, the total fertility rate of Indigenous women ranged between 2.1 in South Australia to 2.7 in the Northern Territory. Indigenous women having a baby in 1996 were, on average, younger than women in the total Australian population. The median age at confinement among Indigenous women was between 23 and 24 years compared to 29 years among all Australian women. Birth Rate The 253,834 births registered in 1996 represented an 11.3% increase over the number registered in 1976 (228,000) and a 4.3% increase over the number registered in 1986 (243,408). However, despite an increase in the total number of births, the actual birth rate declined between 1976 and 1996. Crude birth rate refers to the number of live registered births during a calender year per 1,000 population. Table 23 shows the Australian birth rate falling from 15.2 births per 1,000 population in 1986 to 13.9 births per 1,000 population in 1996. In addition, the average age of women giving birth to their first child in Australia has increased substantially over the last twenty years, from 25.9 years in 1976 to 29.2 years in 1996 (ABS Births 1997). Table 23: Total births, by State/ Territory, 1996
Birth rates
1986
1991
1992
1993
1994
1995
1996
Total births
243,408
257,247
264,151
260,229
258,051
256,190
253,834
Crude birth rate
15.2
14.9
15.1
14.7
14.5
14.2
13.9
Total fertility rate
1.870
1.855
1.894
1.865
1.846
1.824
1.796
Female net reproduction rate
0.895
0.890
0.909
0.896
0.886
0.876
0.860
Source: ABS, Births, September 1997, 3301.0 New South Wales, Victoria and Queensland accounted for nearly three-quarters of births registered in 1996. Out of the total 254,834 births registered in 1996, 34.1% were registered in New South Wales, 24.1% were registered in Victoria and 18.8% were registered in Queensland (Table 24). These proportions broadly reflect the distribution of
AMWAC 1998.6 52
the female population in the reproductive ages. Table 24: Total births, by State/ Territory, 1996
NSW
Vic
Qld
SA
WA
Tas
NT
ACT
Aust
Births
86,595
61,143
47,769
19,056
24,793
6,457
3,562
4,396
253,834*
% births
34.1
24.1
18.8
7.5
9.8
2.6
1.4
1.7
100.0
Indigenous births
-
-
-
557
1,538
-
1,343
66
3,504
Crude birth rate
14.0
1.5
14.2
12.9
14.1
13.6
20.0
14.3
13.9
Total fertility rate
1.825
1.712
1.840
1.746
1.812
1.916
2.286
1.677
1.796
* includes 63 births recorded in other Territories Source: Births, ABS September 1997, 3301.0 At the national level, while the overall number of births registered grew by 11% between 1976 and 1996, among States and Territories the rate of growth varied. The number of births registered grew faster in Queensland (35.4%), the Northern Territory (32.5%) and Western Australia (19.8%) than in New South Wales (10.6%), the Australian Capital Territory (2.0%), Victoria (1.2%) and South Australia (1.0%). In Tasmania the number of births declined by 4.1%. In 1996, the crude birth rate was 20.0 per 1,000 population for the Northern Territory and between 12.9 and 14.3 for the remaining States and the Australian Capital Territory. South Australia had the lowest crude birth rate (12.9) followed by Victoria (13.5) and Tasmania (13.6). The high crude birth rate in the Northern Territory is attributable to its young age structure and the large proportion of Indigenous people; a population characterised by a comparatively high fertility rate and low life expectancy (ABS/AIHW 1997). There has been a trend towards greater numbers of mothers planning to give birth in a birth centre from 2,405 in 1992 to 4,199 in 1995 (Perinatal Statistics, Australia=s Mothers and Babies 1995). This may also be explained by the availability of birth centres. There has also been a trend towards the implementation and increased utilisation of midwifery focused models of care in antenatal clinics and an expansion of domiciliary midwifery programs, with a move to integrate these services with community based care. Cancer of the Cervix, Ovary and Uterus Cervical cancer is the seventh most common cancer in women. However, the incidence of cervical cancer is declining in Australia, with an average annual rate of decline of 1.3% between 1983 and 1994. The incidence on the whole is expected to decrease
AMWAC 1998.6 53
from 13.73 women per 100,000 population in 1989 to a projected 10.41 women per 100,000 population in 1999, a decrease of 1.5% per annum. However, an age-dependent variation has been noted in trends. Among women aged 50 years and over, the incidence of cancer of the cervix has fallen since 1983, while rates for those under the age of 50 years have increased slightly. The incidence of cervical cancer varies substantially at the State and Territory level. Of the States, Queensland (18.2) and Western Australia (20.9) showed the highest rates, whereas South Australia (15.9) showed the lowest rate among women aged 20 to 74 years for the period 1988-90. Table 25: Incidence of cancer of the cervix among women aged 20 to 74 years, by State/Territory
State/Territory
Average 1983-85
Average 1988-90
% change
NSW
17.5
16.6
-4.7
Victoria
16.8
16.5
-1.8
Queensland
22.7
18.2
-20.1
West. Aust.
22.3
20.9
-6.4
South Aust.
18.3
15.9
-13.2
Tasmania
20.7
20.0
-3.6
ACT
18.0
18.4
2.0
North. Terr.
31.5
30.3
-3.8
Australia
18.7
17.4
-7.3
Source: AIHW, National Health Priority Areas 1996 The incidence rate of ovarian cancer is marginally declining in Australia with the incidence rate 11.10 per 100,000 female population in 1989 to a projected 10.93 per 100,000 female population in 1999, a decrease of 0.1% per annum. The incidence rate of cancer of the uterus is increasing in Australia with the incidence rate at 11.85 per 100,000 female population in 1989 projected to 14.86 per 100,000 female population in 1999, an increase of 0.03% per annum. (Cancer in Australia 1991-1994 (with Projections to 1999), AIHW 1998). Table 26 shows projections for the age standardised incidence rates of cancer of the cervix, ovary and uterus and indicates a fall for both cancer of the cervix and ovarian cancer but an increase in cancer of the uterus.
AMWAC 1998.6 54
Table 26: Age standardised rates for incidence of cancer of the cervix, ovary and uterus, selected years 1983 to 1994, with projections to 1999
Cancer
1983
1989
1994
1995
1996
1997
1998
1999
Cervix
13.73
12.37
11.97
11.17
10.98
10.79
10.60
10.41
Ovary
11.10
11.35
10.75
10.90
10.90
10.91
10.92
10.93
Uterus
11.85
11.84
13.38
13.67
13.97
14.26
14.56
14.86
Source: AIHW, Cancer in Australia 1991-1994 (with Projections to 1999), 1997
Trends in Utilisation Forecasts of future obstetrics and gynaecology procedure usage have been calculated by applying projections of the female population to the hospital age utilisation data for 1995-96. It should be noted that this is a simple approach which assumes that population change is the only factor affecting the demand for obstetrics and gynaecology procedures. The projections ignore, for example, the impacts of new technology and change in medical practice, which are extremely difficult to assess let alone quantify. In general, obstetrics procedures are mainly undertaken on younger females and are therefore forecast to increase by a relatively small amount, while gynaecology procedures, which are distributed more widely across the age spectrum, are expected to increase more rapidly. The utilisation projections suggest that in general the demand for gynaecology procedures over the next 20 years will not increase as quickly as the population. Over this period female population is expected to increase by 19.8%, whereas gynaecology services, based on current rates, are expected to grow by 14.0% or 0.7% per annum. The reason for the lesser growth is that the majority of gynaecological procedures are undertaken on young to middle aged women, and this younger female age group is growing less rapidly than the population aged 45 years and over (in 1995-96, 72.4% of procedures were undertaken on women up to age 44 years, Table I5). Growth in the number of obstetrics procedures over the next 20 years is expected to be considerably less than population growth. Female population growth of 19.8% is anticipated, while the demand for obstetrics procedures is only forecast to rise by 2.2% or 0.1% per annum. This is because proportionally more obstetrics procedures are performed on women in the younger age groups, which as already indicated, are growing less rapidly than older age groups (in 1995-96, 86.3% of procedures were undertaken on women up to age 34 years, Table I6).
AMWAC 1998.6 55
Table 27: Projected increases in utilisation for obstetrical and gynaecological procedures, 1998 to 2018
A. Female population
Age (years) Year
0-14
15−24
25−34
35−44
45−54
55−64
65−74
75+
Total
Actual 1995Β96
1,891,00
4
1,321,347
1,425,973
1,386,449
1,118,065
754,395
679,305
52,346
9,128,884
Forecasts: 1998
1,921,33
0
1,298,799
1,455,691
1,444,970
1,223,172
800,255
677,122
604,266
9,425,605
2018
1,992,80
4
1,409,417
1,456,720
1,466,979
1,530,796
1,427,175
1,117,264
892,450
11,293,605
% increase
3.7
8.5
0.1
1.5
25.1
78.3
65.0
47.7
19.8
B. Gynaecological procedures
Age (years) Year
0−14
15−24
25−34
35−44
45−54
55−64
65−74
75+
Total
Actual: 1995Β96
1,417
71,379
165,873
149,950
84,783
31,983
21,615
9,922
536,922
Forecasts: 1998
1,440
70,161
169,330
156,279
92,753
33,927
21,546
10,855
556,291
2018
1,493
76,137
169,450
158,660
116,080
60,506
35,551
16,031
633,907
% increase 1998-2018
3.7
8.5
0.1
1.5
25.1
78.3
65.0
47.7
14.0
C. Obstetrics procedures
Age (years) Year
0−14
15−24
25−34
35−44
45−54
55−64
65−74
75+
Total
Actual: 1995Β96
193
84,437
221,612
48,556
231
6
0
0
355,037
Forecasts: 1998
196
82,996
226,231
50,606
253
6
0
0
360,287
2018
203
90,065
226,391
51,376
316
11
0
0
368,366
% increase 1998-2018
3.7
8.5
0.1
1.5
25.1
78.3
0.0
0.0
2.2
Sources: ABS population projections, series A and AIHW National Hospital Morbidity Database.
AMWAC 1998.6 56
It should also be noted that the number of obstetrics and gynaecology confinements in the private sector has decreased by 40.5% over the last ten years (AIHW, 1995). The Working Party considers the major driving factor has been the declining levels of people with private health insurance and a corresponding increase in patient co-payments. In 1986-87 there were approximately 105,334 private sector confinements and in 1996-97 there were 70,537 representing a fall of 33%. It is anticipated that confinements in the private sector will continue to fall. In turn, this is likely to have an adverse effect on the participation of obstetricians who are faced with a smaller pool of private patients and an increasing level of medical indemnity insurance making the practice of obstetrics less attractive. Despite this trend, the utilisation projections suggest that the Australian female population will continue to require obstetric and gynaecology specialist services (Table 27) and that the specialist obstetric and gynaecology workforce will be required to meet these demands. The Impact of Changes in Technology From a technological perspective, there is no current trend which will have any radical impact on the general configuration of service delivery. However, telehealth is an emerging technological development which is expected to improve access for rural patients and doctors to consultations with specialists. Such developments will be evolutionary and are currently underway in several Australian States. These developments require evaluation along the way. Conceivably, this might impact on costs of service delivery and training/education support as well as improve care outcomes. The future of ultrasonography in obstetric practice may also need to be closely monitored as it may significantly change current practices. Specialists’ Perceptions on Factors Affecting Workforce Requirements Respondents to the RACOG/AMWAC survey of obstetricians and gynaecologists were asked to indicate whether they believed particular factors would increase workforce requirements, decrease workforce requirements or whether requirements would stay the same (refer to Table B19, Appendix B). Among the important issues that respondents (both specialists and sub-specialists) considered would increase requirements included: the practice of more defensive medicine, patients expectations and knowledge, advances in medical technology, and need for improved geographic distribution of specialists. Factors perceived as most likely to decrease workforce requirements were substitution of specialist services by other providers, requirements for procedural practice, and government cost containment strategies.
AMWAC 1998.6 57
PROJECTIONS OF SUPPLY Additions and Losses to the Obstetrics and Gynaecology Workforce The RACOG/AMWAC Survey asked respondents to provide details of their retirement intentions. The average expected age of retirement from the workforce was 63 years (range 50 to 80 years; standard deviation 4.6). Table B7 Appendix B, indicates that 22.7% (113) of survey respondents intend retiring in the next five years. Examining the age and sex distribution of the specialist workforce shows that the majority (52.7%) of the workforce is aged over 50 years, 32.0% of the workforce is aged 55 years and over and 18.0% are aged over 60 years. Assuming the average retirement age from the RACOG/AMWAC survey of 63 years, it can be estimated that there could be approximately 200 (21%) specialists intending to retire in the next five years. In 1997 there were approximately six losses from the total workforce migrating overseas; however, this was balanced with an equal number of specialists in obstetrics and gynaecology entering Australia. It is probably safe to assume that on balance immigration and emigration will be roughly equal. RACOG expects trainee graduations over the next seven years to be: 45 in 1998, 21 in 1999, 50 in 2000, 47 in 2001, 57 in 2002, 49 in 2003 and 42 in 2004; that is an average of 47 graduates per year. Respondents to the RACOG/AMWAC survey indicated that rising medical insurance indemnity premiums will affect the way they practice with 83% (403) indicating that they would either cease practising obstetrics or retire early. Female Participation in the Workforce It is expected that the proportion of women in the workforce will increase; given the continuing increase in the number of female trainees. Women represent 15.5% the current total workforce, but 55.3% of trainees. In addition, of the 336 specialists aged 55 years and over, only 21 are female. The expected lifetime hours worked by a female obstetrics and gynaecology specialist has been estimated at 74.1% of that of a male (AMWAC/AIHW 1996). In conducting the projection analysis, the expected supply has been adjusted to account for increasing female participation and for the expected lower lifetime workforce contribution.
AMWAC 1998.6 58
Provision of Services in Rural and Remote Areas Provision of specialist services outside capital cities and major urban areas will continue to be of concern, as there appears to be little incentive to practice in rural areas. This was evident in the findings of the RACOG/AMWAC Survey (Appendix B) and RACOGs Women’s Career Survey (Appendix E). Reasons stated included the long hours, professional isolation, career dislocation, lack of relative financial reward, the strain on the family and spouse, lifestyle issues, and the lack of locum cover when on leave. There are obviously some communities where there is insufficient workload to warrant recruitment of consultant obstetrics and gynaecology specialists/sub-specialist. In those locations it will be important to encourage GPs and midwives to obtain, maintain and utilise their skills in obstetrics and gynaecology to provide some of these services. The biggest challenge for RACOG and the government is to make visiting posts and resident rural posts attractive for specialists. Respondents from the RACOG/AMWAC survey (refer to Appendix B) indicated that the basic requirements for providing a sustainable rural outreach obstetrics and gynaecology service and/or a resident rural practice do not exist in many locations or are only partially provided. For example, respondents noted problems with: inadequate local hospital facilities/equipment, such as appropriate consulting
facilities and surgical equipment; limited or absent numbers of allied health professionals and ancillary staff such as
midwives/nursing, physiotherapists and dieticians; limited or absent number specialist services such as anaesthetists, paediatricians,
psychiatrists, psychologists, neonatologists; a lack of interest and support of local GPs; good transport to the area for both patients and specialist; and the absence of local accommodation for patients to attend clinics particularly in the
case of the Northern Territory for the Indigenous population. The Working Party recommends that a rural cadetship be established to attract specialists to rural areas who desire to set up in rural practice. Commonwealth and State/Territory health departments should oversee the funding and establishment of rural cadetships to attract final year trainees to rural areas who desire to set up in rural practice. Contribution of Services by Non-specialist Providers One of the features of obstetrics and gynaecology is the scope for non-specialist providers to provide at least some of the services in obstetrics and minor gynaecological procedures. There are no definitive data sources that enable the level of substitution to be assessed, however Medicare data does provide an indication of the number of services provided by specialists and non specialists
AMWAC 1998.6 59
When private services are alone considered the majority of Medicare obstetrics and gynaecology services are provided by specialist obstetricians and gynaecologists. Table 28 shows that in 1996-97, 86.5% of confinements provided by obstetricians and gynaecologists, 57.2% of obstetric items and 75.3% of gynaecological items. Table 28 also shows there has been a fall of 5.6 percentage points in the number of obstetric services provided by a GP during the period 1995-96 and 1996-97. Similarly, obstetrics services provided by specialists increased by 5.7 percentage points and confinement items provided by specialists increased by 1.5 percentage points. Table 28: Percentage of obstetrics and gynaecology services attracting Medicare benefits, by provider, selected years 1986-87 to 1996-97
Provider
Confinement
items
Obstetrics
Gynaecology
IVF group
Total
Percentage of services provided by provider, 1996-97
O&G specialists
86.5
57.2
75.3
12.1
59.1
Other specialists
0.1
0.2
1.0
1.7
0.4
GPs
13.3
42.6
23.7
86.3
40.6
Percentage of services provided by provider, 1995-96
O&G specialists
85.0
51.5
75.4
11.2
56.0
Other specialists
0.2
0.3
1.1
2.2
0.7
GPs
14.8
48.2
23.5
86.6
43.3
Percentage of services provided by provider, 1991-92
O&G specialists
84.0
36.9
79.2
92.3
73.1
Other (incl. GPs)
16.0
63.1
20.8
7.7
26.9
Percentage of services provided by provider, 1986-87
O&G specialists
76.9
53.1
72.4
-
67.5
Other (incl. GPs)
23.1
46.9
27.6
-
22.5
Source: AIHW 1998 In terms of obstetrics it is clear that there has been a relative decline in the provision of privately provided services by GPs against the backdrop of a falling number of private deliveries overall. In 1986, 23.1% of private deliveries were performed by GPs, in 1996-97, the proportion was down to 13.3%, in other words, a dominant trend has been declining involvement of GPs in private obstetrics. As a consequence the proportion of private deliveries undertaken by obstetrics and gynaecology specialists has risen markedly, to the point that nearly 90% of all private deliveries are undertaken by specialists.
AMWAC 1998.6 60
Table 29 indicates the numbers of services attracting Medicare benefits provided by GPs compared to obstetric and gynaecology specialists by State/Territory. In each of the four groupings shown in Table 29 and overall, Queensland and Western Australia show GP involvement above the national average. In antenatal care South Australia and Northern Territory GP involvement is also above the national average, as is the involvement of GPs in the management of labour in Tasmania and the Northern Territory. States/Territories with GP involvement below the national average are New South Wales, Tasmania and the Australian Capital Territory. These figures indicate that there is a predominant role taken by GPs in providing obstetrics and gynaecology services in some of the less populous States/Territories, much of which is likely to be in provincial and rural/remote areas. Table 29: Obstetrics and gynaecology Medicare services, by provider and State/Territory, 1995-96
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Antenatal care: item numbers 16500 to 16514
O&G spec.
210,194
188,971
88,268
45,019
46,589
17,86
1
14,135
4,691
615,728
GP
151,425
161,719
97,523
47,915
86,611
10,63
9
9,583
5,739
571,154
Sub-total
361,619
350,690
185,791
92,934
133,20
0
28,50
0
23,718
10,430
1,186,88
2 % O&G spec.
58.1
53.9
47.5
48.4
35.0
62.7
59.6
45.0
51.9
% GP
41.9
46.1
52.5
51.6
65.0
37.3
40.4
55.0
48.1
Management of labour and delivery: item numbers 16515 to 16525
O&G spec.
25,565
19,255
13,055
5,808
6,333
1,892
1,360
670
73,938
GP
2,866
2,949
3,227
676
2,093
495
211
180
12,697
Sub-total
28,431
22,024
16,282
6,484
8,426
2,387
1,571
850
86,635
% O&G spec.
89.9
86.7
80.2
89.6
75.2
79.3
86.6
78.8
85.3
% GP
10.1
13.3
19.8
10.4
24.8
20.7
13.4
21.2
14.7
Interventional techniques: item numbers 16600 to 16636
O&G spec.
1,431
625
281
1,191
437
116
130
98
4,309
Other spec.
916
148
37
31
70
0
152
0
1,354
GP
2,616
3,079
1,722
108
983
19
27
0
8,554
Sub-total
4,963
3,852
2,040
1,330
1,490
135
309
98
14,217
AMWAC 1998.6 61
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
% O&G spec.
28.8 16.2 13.8 89.5 29.3 85.9 42.1 100.0 30.3
% oth. spec.
18.5
3.8
1.8
2.3
4.7
-
49.2
-
9.5
% GP
52.7
79.9
84.4
8.1
66.0
14.1
8.7
-
60.2
Gynaecological: item numbers 35500 to 35729
O&G spec.
127,714
87,812
52,179
23,026
36,190
8,237
8,455
1,887
345,500
Other spec.
1,467
1,256
603
280
875
97
95
11
4,684
GP
41,893
24,104
19,814
2,655
15,018
898
2,042
101
106,535
Sub-total
171,074
113,172
72,596
25,971
52,083
9,232
10,592
1,999
456,719
% O&G spec.
74.7
77.6
71.9
88.7
69.5
89.2
79.8
94.4
75.6
% oth. spec.
0.9
1.1
0.8
1.1
1.7
1.1
0.9
0.6
1.0
% GP
24.5
21.3
27.3
10.3
28.8
9.7
19.3
5.1
23.3
All obstetrics and gynaecological : item numbers 13200 to 3579
O&G spec.
367,760
298,980
157,603
75,794
90,832
28,70
2
24,929
7,351
1,051,95
1 Other spec.
3,106
1,533
1,182
923
1,425
418
250
15
8,852
GP
231,365
219,525
143,299
60,650
112,03
2
13,15
7
12,572
6,040
798,640
Sub-total
602,231
520,038
302,084
137,367
204,28
9
42,27
7
37,751
13,406
1,859,44
3 % O&G spec.
61.1
57.5
52.2
55.2
44.5
67.9
66.0
54.8
56.6
% oth. spec.
0.5
0.3
0.4
0.7
0.7
1.0
0.7
0.1
0.5
% GP
38.4
42.2
47.4
44.2
54.8
31.1
33.3
45.1
43.0
Percentage of obstetrics and gynaecological services provided by GPs: items 16500 to 35729*
% GP total
35.1
39.2
44.2
40.5
53.6
29.9
32.8
45.0
40.1
* Items commonly performed by specialists/sub-specialists in obstetrics and gynaecology Source: AIHW 1997 Training of General Practitioners GPs wishing to provide obstetrics and gynaecology services complete an additional training program in obstetrics and gynaecology overseen by the Joint Consultative Committee - RACOG and RACGP. Data provided by RACOG shows that currently there are 2,845 GPs who have completed the training. The majority of these GPs are located in Victoria (35.1%) and New South Wales (25.0%). The 1996 Centre For Rural Health
AMWAC 1998.6 62
Rural General Practitioner survey had 541 respondents who indicated they practised in obstetrics and gynaecology and of these respondents the majority (75.1%) were located in small rural and remote areas. Further data on GPs providing obstetrics and gynaecology services is provided in Appendix H. Medicare data indicates that in 1995-96, 60.1% obstetrics service providers (including GPs) were located in a capital city, 6.7% in another metropolitan area, 9.2% in a large rural centre, 9.4% in a small rural centre, 11.8% in another rural area, and 2.9% in remote areas (Table 30). Comparing this data with the distribution of obstetrics and gynaecology specialists indicates that GPs represent an increasingly higher proportion of obstetrics providers, as a function of remoteness of the locality from a metropolitan area. Table 30: Distribution of obstetrics and gynaecology Medicare service providers, by geographic location, 1995-96
Patient location
Provider location
Capital
city
Other metro
Large rural
centre
Small rural
centre
Other rural
centre
Remote
centre
Other
remote
Total
Capital city
97.8
4.9
1.6
3.9
11.3
5.6
12.4
60.1
Other metropolitan
0.5
92.3
0.4
2.0
2.1
1.0
1.1
6.7
Large rural centre
0.2
0.2
94.7
3.2
11.8
5.6
7.4
9.2
Small rural centre
0.5
0.8
1.4
87.7
7.5
1.0
10.3
9.4
Other rural centre
0.8
1.7
1.6
2.8
66.2
0.8
8.4
11.8
Other rural area
0.1
0.1
0.2
0.1
0.4
82.4
12.4
1.6
Other remote
0.1
0.2
0.2
0.2
0.6
3.6
47.9
1.3
Total
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
Source: DHFS The other key alternative providers are midwives. The AIHW Nursing Labour Force Survey shows that in 1995 there were 13,913 registered midwives and 1,540 nurses employed in obstetrics and gynaecology. These two groupings represented 7.9% of the nursing workforce. There is no trend data available on the number of midwives but information provided by several State/Territory health departments indicated the number was declining. More information is provided on midwife numbers in Appendix J.
AMWAC 1998.6 63
BALANCING SUPPLY AGAINST REQUIREMENTS Requirement Trends The Working Party assessed various indicators of future obstetrics and gynaecology requirements. These included: female population growth; birth rates; crude birth rates; fertility rates; cancer of the cervix, uterus and ovary incidence rates; and trends in obstetrics and gynaecology national hospital morbidity data and Medicare services. Australian female population growth: Over the next ten years, the total Australian female population is expected to increase at an annual rate of 1.1% per annum. During the same period it is expected that the female population aged 15 years and over will increase by 1.1% per annum, those aged 15-49 years will increase by approximately 0.3% per annum, and those aged 25 years and over will increase by approximately 1.0% per annum (ABS 3222.0) Birth rate: There has been a growth in births in Australia from 243,408 live births in 1986 to 253,834 in 1996, this represents a growth of 4.3%, or 0.4% per annum. Future projections indicate that birth rates will remain constant (ABS Births 1996, 3301.0). Fertility rate: The total fertility rate since 1992 (1.894) has steadily declined, with the fertility rate for registered births at 1.796 in 1996, the lowest rate on record. The fertility rate is considered to be more likely to fall or remain stable in the longer term, and the age distribution will continue to change in favour of ages over 30 years (ABS Births 1996, 3301.0). Incidence of cervical, uterine and ovarian cancer (per 100,000): Birth rate and fertility rate can be used to give an indication of likely future obstetrics requirements. Useful indicators of likely future gynaecological requirements are less readily available. The Working Party used the trend in the incidence of cervical, uterine and ovarian cancer as a proxy indicator for gynaecological service trends. The incidence rate of cancer of the uterus is increasing in Australia with the incidence rate at 11.85 in 1989 projected to 14.86 in 1999, an increase of 1.6% per annum. Whereas the incidence rate of ovarian cancer is marginally declining in Australia with the incidence rate 11.10 in 1989 to a projected 10.93 in 1999 (a decrease of 0.1% per annum) as is the incidence rate of cervical cancer which indicated an average annual decline of 1.3% between 1983 and 1994. Medicare and ICD-9-CM data: Medicare obstetrics and gynaecology services provided by obstetricians and gynaecologists have shown a 2.7% per annum growth over the period 1986-87 to 1996-97.
AMWAC 1998.6 64
ICD-9-CM data on obstetrics and gynaecology have indicated that for gynaecological procedures there will be overall growth of 14.0% over the next 20 years (1998-2018) or 0.7% per annum. For obstetrical procedures it is forecasted to rise by only 2.2% or by 0.1% per annum in the same period. In projecting requirements the Working Party chose not to use Medicare data because it only covers private practice billing activity; with only a minority of the population with private health insurance and with that minority declining. Accordingly, with the exception of the Medicare data, all the indicators were projected over the period 1999 to 2009. Table 31 below shows projected requirements for obstetrics and gynaecology, using each of the main indicators. The projections have been converted to hours per week using the average hours worked figure of 60 hours per week. Conversion of the data to hours of service allows comparisons to be made with projected supply data, which is similarly adjusted and converted. It is also recognised that a ten year projection period is a long time frame for assumptions to be remain valid. However, this time frame was chosen because five years was considered to be too short for any impact on training numbers to move through, given that the training program is six years in duration. Table 31: Projected requirements for obstetrics and gynaecology services (in full time equivalent hours per week) for selected indicators , 1999 to 2009a
Year
Cancer
incidence
Fertility
rates
Birth rates
Female
pop. 15-49 yrs
ICD-9-CM
Female
pop. growth >15
years
Female
pop. growth >25
years
Female pop.
growth >49 years
1999
56,686
57,041
57,513
57,522
57,647
57,943
58,097
58,685
2000
56,105
56,811
57,755
57,773
58,025
58,621
58,934
60,133
2002
54,962
56,355
58,241
58,279
58,788
60,002
60,645
63,138
2004
53,842
55,901
58,732
58,789
59,561
61,415
62,405
66,292
2006
52,745
55,452
59,226
59,304
60,344
62,862
64,216
69,604
2008
51,670
55,006
59,725
59,823
61,137
64,343
66,079
73,082
2009
51,141
54,784
59,976
60,084
61,538
65,096
67,031
74,885
Note: a - assumes an average of 60 hours worked per week Source: AMWAC
AMWAC 1998.6 65
The Working Party concluded that the birth rate provided the best indicator of likely future obstetrics and gynaecology services requirements, that is requirements growth of an estimated 0.4% per annum. This projection trend is lower than most of the population trends, but higher than the fertility rate and the incidence of cancer trend. It is actually close to the trend in growth in obstetrics and gynaecology ICD-9-CM national hospital morbidity data. Accordingly, the choice of 0.4% represents roughly the mid point of all the indicators examined, and can be considered a conservative choice. Supply Trends The supply of obstetric and gynaecology specialists was projected by ageing the RACOG specialist numbers through each year of age, subtracting expected retirements and attrition due to deaths and specialists leaving the workforce and adding expected new graduates. Importantly, supply trends over the next ten years will be dominated by the large cohort of specialists aged 55 years and over proceeding through to retirement and to a lesser extent by the influx of a comparatively large number of female graduates. The number of specialists was converted to hours per week by applying the average number of hours worked to headcounts in each major age cohort. In doing so the Working Party assumed that the pattern of workforce participation of the current workforce provides a suitable basis on which to project future workforce requirements. In addition, the increasing female participation and the average lower lifetime workforce contribution of female specialists has been assumed. The supply projections show that supply will increase from the estimated current level of 57,272 FTE hours per week to an estimated 59,260 FTE hours per week in 2009, assuming average retirements; with an upper and lower projection range of 58, 084 FTE hours and 62,025 FTE hours per week respectively (Table 32). Table 32: Projected supply of obstetrics and gynaecology services, high, low and average retirement rates, by FTE hours worked per week, 1999, 2004 and 2009
Year
Low retirement rate
Average retirement rate
High retirement rate
1999
56,968
57,191
57,414
2004
56,309
57,359
58,469
2009
58,084
59,260
62,025
Source: AMWAC Using average retirement rates, current workforce supply, average hours worked per week and graduate output, future supply projections indicate that the workforce will fall slightly below the estimated obstetrics and gynaecology service requirements levels growth of 0.4% per annum, representing an estimated 0.6% shortage in 1999, an
AMWAC 1998.6 66
estimated 2.7% shortage in the year 2000 and an estimated 2.4% in the year 2004 (Table 33). Table 33: Projected obstetrics and gynaecology supply and requirements (FTE hours), 0.4% growth per year, 1998 to 2004a
Year
Projected supply
Projected requirements
% shortage
1998
57,272
57,272
base year
1999
57,191
57,513
0.6
2000
56,220
57,755
2.7
2002
56,603
58,241
2.9
2004
57,359
58,732
2.4
Note: a - based on average retirement rates, a working week of 60 hours and constant intake of trainees per annum Source: AMWAC Projected Balance A balance in supply to match a continued growth rate in the requirement indicators of 0.4% per annum can be achieved by ensuring the same number of graduates currently entering the six year program is maintained; that is a trainee intake of 58 per year. This assumes that the length of the RACOG training program would continue to be six years and that all candidates will complete the program within this time frame. This assumption has been necessary in the absence of data from RACOG on average training program completion times. In part, this reflects the difficulty of knowing what, if any, impact on completion will be caused by the increase in female trainees and the introduction of part time training arrangements. If trainee intakes achieve 58 per year, it is expected that there will be no significant shortfall emerging in the workforce. Table 34 shows the obstetrics and gynaecology trainee output needed, to move projected supply into balance with projected requirements for this workforce. The projected requirement used is based on 0.4% growth per year. Under this scenario notional shortages are expected to peak at 2.9% in 2002 but for requirements and supply to move back towards balance thereafter. It is projected that there will only be 1.6% shortfall in 2008.
AMWAC 1998.6 67
Table 34: Obstetrics and gynaecology graduate output needed to move projected supply into balance with projected requirements, 0.4% growth per year, (in FTE hours), 1998 to 2009
Year
Number of graduates
Projected
supply
Projected
requirements
Balance
(shortage)
% shortage
1998
45
57,272
57,272
base year
0.0
1999**
21
57,191
57,513
322
0.6
2000
50
56,220
57,755
1,534
2.7
2001
47
56,466
57,997
1,531
2.7
2002
57
56,603
58,241
1,638
2.9
2003
49
57,153
58,486
1,333
2.3
2004
42
57,359
58,732
1,372
2.4
2005**
58
57,244
58,978
1,734
3.0
2006
58
57,764
59,226
1,462
2.5
2007
58
58,272
59,475
1,203
2.1
2008
58
58,770
59,725
955
1.6
2009
58
59,260
59,976
717
1.2
*Training period is six years ** Constant trainee intake beginning 1999 and graduating in 2005 Source: AMWAC Table 34 is shown graphically in figures 1 and 2 below. Figure 1 includes all demand indicators: female population growth greater than 15 years of age, female population growth in the 15 to 49 year age group, female population growth greater than 25 years of age, birth rates, crude birth rates, fertility rates, female reproduction rate and cancer cervix index and projected trends in ICD-9-CM, plotted against the workforce supply using graduating trainee figures (Table 32) in FTE demand hours per week to the year 2009. Figure 2 shows the workforce supply versus the demand indicators for birth rates and fertility rates in FTE demand hours per week to the year 2009.
AMWAC 1998.6 68
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
FTE
hour
s pe
r wee
k
Population growthFemale population growth (>15yrs)Female growth in the 15-49 age groupFemale population growth >25Birth rates Fertility ratesICD-9-CMFemale population growth > 49cancer cervix index (20 to 74)W orkforce (FTEs hrs/week)
52,000
53,000
54,000
55,000
56,000
57,000
58,000
59,000
60,000
61,000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Birth rates
Fertility rates
W orkforce (FTEs hrs/week)
AMWAC 1998.6 69
Ideally trainee intake should be around 58 per year so that no significant shortfall emerges in the workforce. However, RACOG has indicated that the initial intake of 58 trainees per year may not be achievable as there are limited potential training positions currently available and an already stretched resource of trainers. Maintenance of trainee intake at this level could also impact on trainees obtaining the necessary accumulated training experience. Accordingly, to accommodate this concern several scenarios based on trainee intake ranging from 50 per year to 58 per year were examined and the results are summarised in Table 35. Notional shortfalls range from a near balanced scenario with a trainee intake of 58 per year to an estimated shortfall of 3.6% with a trainee intake of 50 per year. In recognition of RACOGs concern the Working Party has recommended that an intake of 55 trainees per year, which in fact is similar to the trainee intake over the period 1995 to 1997, is a more practical target to aim for as this should lessen any impact in terms of available trainers and accumulation of clinical experience by trainees. A trainee intake of 55 per year, will produce an estimated workforce shortfall of 2.1% in 2009. The Working Party believes that there will be no emerging shortage of obstetrics and gynaecology specialists if the trainee intake is set at 55 per year. Of course this does not address the issue of maldistribution of the workforce and in this respect it will be necessary for RACOG and State/Territory health departments to make internal adjustments to the distribution of training positions.
AMWAC 1998.6 70
Table 35: Estimated obstetrics and gynaecology graduate output required to move projected supply into balance with projected requirements, 0.4% growth per year, (in FTE hours), by selected graduate outputs, 1998 to 2009
Year 2005
2006
2007
2008
2009
Projected requirements
58,978
59,226
59,475
59,725
59,976 Projected supply for 50 graduates per year, beginning in 1999 and graduating in 2005
57,244
57,428
57,591
57,736
57,870 Balance (shortage)
1,734 (3.0%)
1,798 (3.1%)
1,885 (3.3%)
1,989 (3.4%)
2,106 (3.6%) Projected supply for 52 graduates per year, beginning in 1999 and graduating in 2005
57,244
57,512
57,761
57,995
58,217 Balance (shortage)
1,734 (3.0%)
1,714 (3.0%)
1,714 (3.0%)
1,731 (3.0%)
1,759 (3.0%) Projected supply for 55 graduates per year, beginning in 1999 and graduating in 2005
57,244
57,638
58,016
58,382
58,739 Balance (shortage)
1,734 (3.0%)
1,588 (2.8%)
1,459 (2.5%)
1,343 (2.3%)
1,238 (2.1%) Projected supply for 58 graduates per year, beginning in 1999 and graduating in 2005
57,244
57,764
58,272
58,770
59,260 Balance (shortage)
1,734 (3.0%)
1,462 (2.5%)
1,203 (2.1%)
955 (1.6%)
717(1.2%)
Source: AMWAC The Working Party recommends that training positions should be increased proportionately less in the comparatively well endowed state of South Australia, and to a lesser extent Victoria, although it needs to be remembered that Victoria has a significant proportion of older specialists. This is also the case in New South Wales. In particular, emphasis needs to be given to increasing training positions in New South Wales, Western Australia and Queensland. The Working Party recommends that the training positions up to the year 2002 should be distributed as shown below in Table 36. Table 36 also shows the actual intake level for 1997 and 1998.
AMWAC 1998.6 71
Table 36: Distribution of obstetrics and gynaecology first year advanced trainee positions, by State/Territory, 1999 to 2002
State/Territory
1997
1998
1999
2000
2001
2002
actual intake
required intake
NSW
18
14
20
20
20
20
Victoria
12
10
14
14
13
12
Queensland
9
5
11
11
11
11
South Australia
5
6
4
4
4
4
Western Australia
5
2
4
4
4
4
Tasmania
0
2
1
1
2
2
ACT
0
3
1
1
1
2
Northern Territory
0
0
0
0
0
0
Australia
49
42
55
55
55
55
Source: AMWAC Given the sensitivity of the assumptions in the projection modelling, it will be important that obstetrics and gynaecology requirements and supply projections be monitored regularly so that they can be amended if new trends emerge. The Working Party recommends that a review of the specialist obstetrics and gynaecology workforce be undertaken before the level of trainee intake for 2003 is determined, that is by the end of 2000. In this context, it will also be important for AMWAC to continue to monitor the trend in the numbers of non specialist providers. It should also be noted that whilst RACOG has recently introduced a compulsory six month rural training placement for trainees, in an effort to improve awareness of rural practice, this scheme will need the continued support of State/Territory health departments in terms of funding and support of suitable rural training positions. The Working Party would also like the Commonwealth and State/Territory health departments to consider the establishment of rural cadetships aimed at providing financial assistance to those training in their last year and are interested in remaining and establishing a rural practice. This process coupled with the compulsory experience to rural practice through the training program may help to alleviate some of the geographical maldistribution inherent in the workforce. In the first instance the Commonwealth Department of Health and Family Services and RACOG should jointly examine the feasibility of such a scheme.
AMWAC 1998.6 72
RECOMMENDATIONS The Working Party recommends: 1. There be an increase in the number of funded obstetrics and gynaecology
training positions to maintain trainee intake during the period 1999 to 2002 at 55 per year.
2. That State and Territory health departments undertake negotiations with the
RACOG to ensure intake numbers for first year trainees remain constant at 55 per year to 2002 and distributed as shown below.
Distribution of obstetrics and gynaecology first year advanced trainee positions, by State/Territory, 1999 to 2002
State/Territory
1997
1998
1999
2000
2001
2002
actual intake
required intake
NSW
18
14
20
20
20
20
Victoria
12
10
14
14
13
12
Queensland
9
5
11
11
11
11
South Australia
5
6
4
4
4
4
Western Australia
5
2
4
4
4
4
Tasmania
0
2
1
1
2
2
ACT
0
3
1
1
1
2
Northern Territory
0
0
0
0
0
0
Australia
49
42
55
55
55
55
Source: AMWAC 3. State/Territory based obstetrics and gynaecology services working groups,
comprising RACOG and State/Territory department of health representatives, be organised to oversee the funding and establishment of any new training positions.
4. That obstetrics and gynaecology requirements and supply projections be
monitored regularly so that they can be amended if new trends emerge, and that the specialist obstetrics and gynaecology workforce be reviewed before the level of trainee intake for 2003 is decided, that is at the end of 2000.
AMWAC 1998.6 73
5. That this monitoring be coordinated by RACOG and AMWAC and the results incorporated into the AMWAC annual report to AHMAC. AMWAC will provide all necessary support.
6. AMWAC also to continue to monitor the trend in the numbers of non specialist
obstetric and gynaecology providers (general practitioners and midwives). 7. The RACOG and the Commonwealth Department of Health and Family Services
examine the feasibility of establishing a rural obstetric and gynaecology graduate cadetship scheme to encourage graduates from the obstetrics and gynaecology training program to consider rural practice.
AMWAC 1998.6 74
PART B:
THE OBSTETRICS AND GYNAECOLOGY SUB-SPECIALIST WORKFORCE
AMWAC 1998.6 75
INTRODUCTION As indicated in the Introduction to the main, part A, report, the Working Party decided that the various obstetrics and gynaecology sub specialist workforces should also be examined in some detail. There are five obstetrics and gynaecology sub specialties - maternal fetal medicine, uro-gynaecology, obstetrical and gynaecological ultrasound, gynaecological oncology and reproductive endocrinology and infertility. The main data sources used in preparing this section of the report where the RACOG information on Fellows and trainees and the RACOG/AMWAC survey of Fellows. Where available data from the AIHW Medical Labour Force Survey and Medicare has also been used. It should also be noted that the 98 sub specialists identified by the RACOG and the Working Party are not in addition to the 1,049 obstetrics and gynaecology specialists identified in part A of this report as the total specialist workforce, rather they are part of that total. Sub-specialist Definitions The Working Party defined a gynaecological oncology specialists as:
A Gynaecological Oncologist is a FRACOG who has completed a formal three year training program in gynaecological cancer care and passed the examination for Certified Gynaecological Oncologist. She/he is competent in the comprehensive management of the women with a genital malignancy. The sub-specialist will work in gynaecology with at least 66% of the time in gynaecological oncology. She/he will submit themselves for reaccreditation every five years, and only those actively practising will continue to be accredited.
The aims of sub-specialisation are to: improve the education and skills of those treating women with genital malignancy; improve outcomes for these women; promote research into the management of these diseases; ensure that women receive the highest standards of care; and, to ensure that all women have access to sub-specialist care in the management of gynaecological cancer.
The Working Party defined a sub-specialist in maternal fetal medicine as :
A specialist in obstetrics and gynaecology, possessing the FRACOG, who is trained and assessed as being competent in the comprehensive management in obstetrical, medical and surgical complications of pregnancy and their effect on both the mother and fetus. It requires expertise in the most current approaches to diagnosis and treatment of patients with complicated pregnancies and also requires a setting where requisite technical support is available. Personnel with advanced knowledge of newborn adaptation also are necessary to ensure a continuum of excellence in care from the fetal to newborn periods.
AMWAC 1998.6 76
A sub-specialist in this field should spend the majority of their time in clinical work and have a practice profile that demonstrates in excess of 80% of clinical time is spent in this specialty area. Such a person must have a full time tertiary base which satisfies the definition of a Maternal Fetal Medicine Unit. Activities conducted outside this base may be permitted where the primary purpose is teaching, research or administration in fields related to maternal-fetal medicine. To maintain status as a specialist the practitioner would need to remain affiliated with a hospital providing the facilities of a tertiary referral perinatal centre.
The Working Party defined a sub-specialist in obstetrical and gynaecological ultrasound specialists as:
A Sub-specialist in Obstetrical and Gynaecological Ultrasound is a Fellow in good standing of RACOG who is trained and has been assessed as being competent in all aspects of ultrasound diagnosis relating to obstetrics and gynaecology including ultrasound guided interventional diagnostic and therapeutic techniques. Such an individual would spend of at least 22 hours per week in obstetrical and gynaecological diagnostic ultrasound practice. It is desirable but not mandatory that he/she work part of this time in a tertiary care institution where the ultrasound department provides a comprehensive diagnostic service to general obstetrics and gynaecology and to the sub-specialties.
The Working Party defined a sub-specialist in reproductive endocrinology and infertility as :
A gynaecological sub-specialist in Reproductive Endocrinology and Infertility is a specialist in obstetrics and gynaecology, possessing the FRACOG, who is trained and assessed as being competent in the comprehensive management of patients with reproductive endocrine disorders and infertility. His or her continued medical activity may be in gynaecology and/or obstetrics, but with at least 67% of his or her clinical time being spent in the area of reproductive endocrinology and/or infertility. At least part of this work must be within a professional setting that provides a comprehensive service for patients with infertility or gynaecological endocrine disorders. This may include private units as well as public hospitals.
The Certificate of Reproductive Endocrinology and Infertility (CREI) is recognised by the National Specialist Qualification Advisory Committee as a registrable degree only for individuals who hold the qualification of Fellow of the Royal Australian College of Obstetricians and Gynaecologists (FRACOG). It is not intended that only persons with their CREI should treat infertile couples. It is probable, though, that leaders in this area and directors of assisted conception units will have this qualification.
AMWAC 1998.6 77
The Working Party defined a sub-specialist in uro-gynaecology as: A specialist in obstetrics and gynaecology, possessing the FRACOG, who is trained and assessed as being competent in the comprehensive management of patients with uro-gynaecological disorders. Continued medical activity may be in gynaecology and/or obstetrics, but with at least 50% of their time spent in the area of uro-gynaecology.
All the sub-specialist certificates are recognised by the National Specialist Qualification Advisory Committee as a registrable degree only for individuals who hold the qualification of FRACOG.
AMWAC 1998.6 78
CHARACTERISTICS OF THE OBSTETRICS AND GYNAECOLOGY SUB-SPECIALTY WORKFORCE Number of Practising Sub-specialists in Obstetrics and Gynaecology The current size of the practising obstetrics and gynaecology sub-specialist workforce is estimated to be 98. The number of sub-specialists is relatively small, making up approximately 9.3% per cent of the profession. The estimated numbers within each of the five sub-specialties are 10 maternal fetal medicine specialists, 13 uro-gynaecologists, 23 obstetrical and gynaecological ultrasound specialists, 24 gynaecological oncology specialists and 28 reproductive endocrinology and infertility specialists. Distribution of the Sub-specialist Workforce Table 37 shows the sub-specialties by State/Territory and indicates that 38.8% of all sub-specialties are located in New South Wales with none in the Northern Territory. Table 38 shows the geographic distribution of sub-specialists and indicates that the majority (91.8%) are located in capital cities. Only obstetrics and gynaecology ultrasound is represented in rural centres (1.0%). 7.2% of sub-specialists are located in other metropolitan areas (16.8% of the female population).
AMWAC 1998.6 79
Table 37: Number of obstetrics and gynaecology sub-specialists, by sub-specialty, State/Territory and gender, 1998
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Aust
Gynaecological oncology
Males
8
6
4
1
3
1
0
0
23
Females
0
0
0
1
0
0
0
0
1
Total
8
6
4
2
3
1
0
0
24
Maternal fetal medicine
Males
4
0
0
0
1
0
2
0
7
Females
0
0
1
1
1
0
0
0
3
Total
4
0
1
1
2
0
2
0
10
Obstetrical and gynaecological ultrasound
Males
5
10
2
0
2
0
0
0
19
Females
1
2
0
0
1
0
0
0
4
Total
6
12
2
0
3
0
0
0
23
Reproductive endocrinology and infertility
Males
12
7
1
4
1
1
0
0
26
Females
2
0
0
0
0
0
0
0
2
Total
14
7
1
4
1
1
0
0
28
Uro-gynaecology
Males
5
2
0
1
4
0
0
0
12
Females
1
0
0
0
0
0
0
0
1
Total
6
2
0
1
4
0
0
0
13
All obstetrics and gynaecology sub-specialists
Males
34
25
7
6
11
2
2
0
87
Females
4
2
1
2
2
0
0
0
11
Total
38
27
8
8
13
2
2
0
98
% distribution
38.8
27.6
8.2
8.2
13.2
2.0
2.0
0.0
100.0
% female
10.5
7.4
12.5
25.0
15.4
0.0
0.0
0.0
11.2
Source: RACOG
AMWAC 1998.6 80
Table 38: Distribution of obstetrics and gynaecology sub-specialists; by geographic location, 1998 State/Territory
Total
% of
Australia
% capital city
% other
metro.
% large
rural centre
% small
rural centre
Gynaecology Oncology
24
24.5
100.0
0.0
0.0
0.0
Maternal Fetal Medicine
10
10.2
80.0
20.0
0.0
0.0
Obstetrics and Gynaecology Ultrasound
23
23.5
87.0
8.7
4.3
0.0
Reproductive Endocrinology & Infertility
28
28.6
89.3
10.7
0.0
0.0
Uro-gynaecology
13
13.3
100.0
0.0
0.0
0.0
Australia
98
100.0
91.8
7.2
1.0
0.0
Source: RACOG Age Profile The youngest sub-specialist was aged 35 years and the oldest were aged between 66 and 70 years, with a mean age of 46.5 years. The largest five year age groups were the 46 to 50 year age group (24.5%), and the 41 to 45 year age group (23.5%). Nine individuals (9.2%) are aged over 60 years. In Victoria, 18.5% (5) of the total sub-specialists were aged over 60 years. Queensland had the youngest group (under 50 years of age) of specialists in the workforce representing 87.5% (7) followed by New South Wales at 63.2% (24). For all sub-specialties the majority of individuals were aged under 50 years, that is, 90% (9) of maternal fetal medicine specialists, 61.5% (8) uro-gynaecology specialists, 65.2% (15) obstetrical and gynaecological ultrasound specialists, 62.5% (15) gynaecological oncology specialists and 50% (14) reproductive endocrinology and infertility specialists.
AMWAC 1998.6 81
Table 39: Age profile of obstetrics and gynaecology sub-specialists, by State/Territory and gender, 1998 State/Terr.
Sex
31-35
yrs
36-40
yrs
41-45
yrs
46-50
yrs
51-55
yrs
56-60
yrs
61-65
yrs
66-70
yrs
71+ yrs
Total
NSW
M
1
5
9
5
9
3
2
0
0
34
F
0
1
2
1
0
0
0
0
0
4
Vic M
0
2
3
9
6
0
3
2
0
25
F
0
0
0
2
0
0
0
0
0
2
Qld M
0
0
1
2
3
0
1
0
0
7
F
0
0
0
1
0
0
0
0
0
1
SA M
0
0
0
2
1
2
1
0
0
6
F
0
0
1
0
1
0
0
0
0
2
WA M
0
1
1
4
2
3
0
0
0
11
F
0
1
1
0
0
0
0
0
0
2
Tas M
1
0
0
0
1
0
0
0
0
2
F
0
0
0
0
0
0
0
0
0
0
NT M
0
0
0
0
0
0
0
0
0
0
F
0
0
0
0
0
0
0
0
0
0
ACT M
0
1
1
0
0
0
0
0
0
2
F
0
0
0
0
0
0
0
0
0
0
Australia M
2
10
16
23
19
8
7
2
0
87
F
0
2
7
1
1
0
0
0
0
11
Total
2
12
23
24
20
8
7
2
0
98 % female
0.0
16.7
30.4
4.2
5.0
0.0
0.0
0.0
0.0
11.2
Source: RACOG Table 40 provides a summary of the sub-specialists by major age categories. It shows that for Australia, 62.2% (61) of sub-specialists were aged less than 50 years, and 9.2% (9) were aged over 60 years. The sub-specialist workforce is predominantly under 50 years of age.
AMWAC 1998.6 82
Table 40: Age profile of obstetrics and gynaecology sub-specialists, by State/Territory, gender and major age group, 1998
State/Terr
Sex
NSW
Vic
Qld
SA
WA
Tas
NT
ACT
Aust
under 50 years
M
20
14
6
2
6
1
0
2
51
F
4
2
1
1
2
0
0
0
10
51-60 years
M
12
6
0
3
5
1
0
0
27
F
0
0
0
1
0
0
0
0
1
over 60 years
M
2
5
1
1
0
0
0
0
9
F
0
0
0
0
0
0
0
0
0
Total
38
27
8
8
13
2
0
2
98
Source: RACOG Gender Profile Women represent 11.2% (11) of the sub-specialist workforce (Table 39). The largest proportion of female sub-specialists is in the 41 to 45 year age group (30.4%) followed by the 36 to 40 year age group (16.7%). Hours Worked Table 41 details the average hours provided by obstetrics and gynaecology sub-specialists by State and Territory. The average hours worked per week by sub-specialists was 64.2, 42.3 hours per week were worked in direct patient care and an average of 13.4 hours per week were worked on call.
AMWAC 1998.6 83
Table 41: Sub-specialists in obstetrics and gynaecology average hours worked per week and annual labour supply hours, by State/Territory, 1998 State/Terr.
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Total hours worked
Average
69.5
63.1
54.0
64.8
60.0
70.0
54.0
-
64.2
Annual hours
121,486
78,370
19,872
23,846
35,880
6,440
4,968
-
289,414
hrs worked per 100,000 female pop
4,892
4,247
1,519
3,978
5,225
3,418
4,075
-
3,967
Direct patient care hours worked
Average
40.5
48.4
35.2
36.2
53.3
40.0
20.0
-
42.3
Annual hours
70,794
60,113
12,954
13,322
31,873
3,680
1,840
-
190,688
hrs worked per 100,000 female pop
2,851
3,257
990
2,222
4,642
1,953
1,509
-
2,614
Hours on call worked
Average
19.8
16.7
1.7
2.0
0.0
0.0
4.0
-
13.4
Annual hours
34,610
20,741
626
736
0.0
0.0
368
-
60,407
hrs worked per 100,000 female pop
911
768
78
92
0.0
0.0
184
-
616
Hours on call not worked
Average
63.8
23.0
6.0
58.0
0.0
0.0
24.0
-
38.3
Annual hours
114,457
24,334
2,208
21,344
0.0
0.0
2,208
-
172,656
hrs worked per 100,000 female pop
2,935
1,058
276
2,668
0.0
0.0
1,104
-
1,762
Female pop >15 years (>000)
2,483.2
1,845.4
1,308.0
599.4
686.7
188.4
121.9
62.6
7,296.6
Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG/AMWAC Survey 1997 Table 42 details the average hours provided by sub-specialists by gender and age. In 1997 sub-specialists worked on average 64.2 hours per week, 62.6 for males and 77.6 for females. However, those under 55 years of age averaged around 66.6 hours per week; this declined to 58.4 hours for males in the 55 to 64 years age group, and 51.3 hours for males in the 65 to 70 years age group.
AMWAC 1998.6 84
Table 42: Sub-specialists in obstetrics and gynaecology average hours and annual hours worked, by gender and age group, 1998
Gender
35-44 yrs
45-54 yrs
55-64 yrs
65-70 yrs
Total
Total hours worked
Male
60.5
67.4
58.4
51.3
62.6
Female
77.6
-
-
-
77.6
Total
65.8
67.4
58.4
51.3
64.2
Annual total hours worked
111,922
136,418
40,296
4,720
289,414
Direct patient care hours worked
Male
48.5
42.7
33.3
43.7
42.4
Female
41.6
-
-
-
41.6
Total
46.2
42.7
33.3
43.7
42.3
Annual direct hours worked
78,632
86,425
22,977
4,020
190,688
Hours on call not worked
Male
38.8
41.8
16.8
0.0
33.9
Female
58.4
-
-
-
58.4
Total
48.6
41.8
16.8
0.0
38.3
Annual hours on call not worked
82,717
84,603
11,592
0
172,656
Hours on call worked
Male
31.0
3.3
32.6
0.0
15.2
Female
4.3
-
-
-
4.3
Total
18.9
3.3
32.6
0.0
13.4
Annual hours on call worked
32,168
6,679
22,494
0.0
60,407
No. of sub-specialists
37
44
15
2
98
(a) Calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG/AMWAC Survey The RACOG/AMWAC survey indicated that the average hours worked by sub-specialists varied by region with the average hours in direct patient care in major urban areas at 42.5 hours a week compared to 32.0 hours a week in large rural centres. 64.5% of sub-specialists from major urban centres reported being on call for after hours worked as is shown in Table 43.
AMWAC 1998.6 85
Table 43: Sub-specialists in obstetrics and gynaecology average hours worked per week, by geographic location of main job, 1997
Major urban centre
Provincial/ rural
town
Total
Total hours worked
65.3
32.0
64.2
Direct patient care hours worked
42.5
32.0
42.3
Hours on call worked
13.9
0.0
13.9
Hours on call not worked
39.7
0.0
38.3
Per cent practitioners on call (%)
64.5
0.0
64.5
Average age
50
44
50
Source: RACOG/AMWAC Survey Practice Profiles The majority (58.3%) of sub-specialists worked as solo specialists, 18.6% worked with other obstetricians and gynaecologist and 16.7% worked with a multi-disciplinary group and the remaining 6.4% made no response. Of the 48 sub-specialists from the RACOG/AMWAC Survey, 41.7% were in a private practice and/or undertake public hospital work; 31.3% were salaried in a public hospital; 16.7% were in a private practice with no public hospital role; 4.2% were public hospital salaried and in a private practice and 6.1% made no response. There were 45 sub-specialists respondents who indicated their appointment by State/Territory. The proportion reporting employment in public hospitals was much higher in New South Wales (46.7%) and lower (6.7%) in the Australian Capital Territory. There was no public hospital representation in Western Australia, Tasmania and the Northern Territory (Table B11, Appendix B). Training Arrangements RACOG offers certificates in each of the five sub-specialties. With the exception of obstetrical and gynaecological ultrasound each of the sub-specialty training programs are of three years duration. The ultrasound training is a two year program. Sub-specialty trainees by age group and year of training is shown in Table 44. There are 17 (43.6%) female sub-specialist trainees, the majority (23.5%) of which are aged under 40 years.
AMWAC 1998.6 86
Table 44: Obstetrics and gynaecology sub-specialty trainees, by year of training, gender and major age group, February 1998 Sub-specialty trainees
Sex
31-35 yrs
36-40 yrs
41-45 yrs
46-50 yrs
Total
Gynaecological Oncology
Year 1 M
2
1
-
-
3
F
-
-
-
-
0 Year 2
M
1
-
-
-
1
F
-
-
-
-
0 Year 3
M
-
-
-
-
0
F
-
2
-
-
2 M
0
1
1
-
2
Completed clinical training but not all assessment requirements
F
-
-
-
-
0 Total
3
4
1
0
8
Maternal-Fetal Medicine Year 1
M
-
-
-
1
1
F
-
-
1
-
1 Year 2
M
-
1
-
-
1
F
-
2
-
-
2 Year 3
M
-
-
-
-
0
F
-
-
-
-
0 M
-
0
0
-
0
Completed clinical training but not all assessment requirements
F
-
1
-
-
1 Total
1
4
1
1
7
Obstetrical and Gynaecological Ultrasound (2 year program only) Year 1
M
0
2
-
-
2
F
1
-
-
-
1 M
-
1
1
-
2
Completed clinical training but not all assessment requirements
F
-
2
1
-
3 Total
1
5
2
0
8
Reproductive Endocrinology and Fertility Year 1
M
-
-
-
-
0
F
-
1
-
-
1 Year 2
M
-
-
-
-
-
F
-
1
-
-
1 Year 3
M
1
1
-
-
2
F
1
1
-
1
3 M
-
1
1
0
2
Completed clinical training but not all assessment requirements
F
-
-
-
-
- Total
2
5
1
1
9
AMWAC 1998.6 87
Uro-gynaecology Year 1
M
1
-
-
-
1
F
-
1
-
-
1 Year 2
M
-
1
-
-
1
F
1
-
-
-
1 Year 3
M
1
1
-
-
2
F
-
-
-
-
- M
-
-
-
-
-
Completed clinical training but not all assessment requirements
F
-
-
1
-
1 Total
3
3
1
0
7
Total Sub-specialists
9
22
6
2
39 % Females Sub-specialists
33.3
45.5
50.0
50.0
43.6
Source: RACOG Currently there are no sub-specialty trainees in the Australian Capital Territory, the Northern Territory, Tasmania and Western Australia. Trainees in their last year represent 20.5% of the total trainee numbers. Table 45: Obstetrics and gynaecology sub-specialty trainees, by State/Territory and gender, February 1998 Sex
NSW
ACT
Vic
Qld
SA
WA
NT
TAS
OS
Total
No. in 3rd
year
Clinical training
Gynaecological Oncology
M
3
-
1
1
1
-
-
-
-
6
2 F
-
-
2
-
-
-
-
-
-
2
2
Maternal-Fetal Medicine
M
2
-
-
2
-
-
-
-
3
7
1 F
1
-
1
-
1
-
-
-
-
3
1 Obstetrical and Gynaecological Ultrasound
M
2
-
2
1
-
-
-
-
-
5
2
F
2
-
1
-
1
-
-
-
-
4
1 Reproductive Endocrinology and Infertility
M
2
-
-
1
1
-
-
-
1
5
2
2 F
3
-
1
1
-
-
-
-
-
5
3
Uro-gynaecology
M
2
-
1
-
-
-
-
-
-
3
2 F
2
-
1
-
-
-
-
-
1
4
3 Sub-specialist total
19
0
10
6
4
0
0
0
5
44
9
12 Female sub-specialist total
8
0
6
1
2
0
0
0
1
18
5
5 Female sub-specialist %
42.1
0
60.0
16.7
50.0
0
0
0
20.0
40.9
55.6
41.7* Obstetrical and gynaecological ultrasound is a two year program Source: RACOG
AMWAC 1998.6 88
Obstetrics and Gynaecology Sub-Specialist:Population Ratios Table 46 indicates the five sub-speciality ratios by State and Territory for the female population age ranges. The sub-specialist:population ratio (SSPR) are based upon the 1998 number of sub-specialists in the workforce. The number of sub-specialists per 100,000 population indicates the current level nationally. The RACOG sub-specialist committees have indicated the following sub-specialist:population ratio (SSPR) benchmarks for females. For gynaecological oncologist 0.4 per 100,000; 0.33 per 100,000 for maternal fetal medicine sub-specialists; 0.4 per 100.000 for sub-specialists in ultrasound; 2 per 100,000 for sub-specialists in reproductive endocrinology and infertility and 0.32 per 100,000 for uro-gynaecologists. No national SSPR benchmark has been derived, however, Table x shows that the current national SSPR for females aged greater than 15 years in Australia is estimated at 1:72,955 or 1.4 per 100,000 population. State/Territory provision ranged from 0 per 100,000 population in the Northern Territory to 1.9 per 100,000 population in Western Australia. The gynaecological oncology SSPR for females aged 15 years and greater in Australia is estimated at 1:303,979 or 0.3 per 100,000 population. The RACOG Gynaecological Oncology Committee recommends an acceptable SSPR for the Australian female population as 0.4 per 100,000 population. State/Territory provision ranged from 0 per 100,000 population in the Territories to 0.5 per 100,000 population in Tasmania. Western Australia is also in line with the Committee’s recommended benchmark. The maternal fetal medicine SSPR for females aged 15 to 49 years in Australia is estimated at 1:665,200 or 0.2 per 100,000 population. The RACOG Maternal Fetal Medicine Committee has estimated an acceptable SSPR as 0.33 per 100,000 population. State/Territory provision ranged from 0 per 100,000 population in the Northern Territory, Tasmania South Australia, Queensland and Victoria to 2.2 per 100,000 population in the Australian Capital Territory. The ultrasound SSPR for females aged 15 years and greater in Australia is estimated at 1:383,973 or 0.3 per 100,000 population. The RACOG Ultrasound Committee has estimated an acceptable SSPR as 0.4 per 100,000. State/Territory provision ranged from 0 per 100,000 population in the Northern Territory, Tasmania, and the Australian Capital Territory to 0.5 per 100,000 population in Victoria. The reproductive endocrinology and infertility SSPR for females aged 15 to 49 years in Australia is estimated at 1:179,092 or 0.6 per 100,000 population. The RACOG Reproductive Endocrinology and Infertility Committee has estimated an acceptable SSPR as 2 per 100,000 population. State/Territory provision ranged from 0 per 100,000 population in the Territories to 1.1 per 100,000 population in South Australia. All
AMWAC 1998.6 89
States/Territories fell below the Committee SSPR level. The uro-gynaecology SSPR for females aged 25 years and greater in Australia is estimated at 1:590,510 or 0.2 per 100,000 population. The SSPR for the Australian female population that has been recommended by RACOG as 0.32 per 100,000. State/Territory provision ranged from 0 per 100,000 population in the Australian Capital Territory and the Northern Territory, Tasmania and Queensland to 0.7 per 100,000 population in Western Australia. New South Wales and South Australia are also in line with the RACOG benchmark.
AMWAC 1998.6 90
Table 46: Sub-specialists in obstetrics and gynaecology female population: population ratio, by State/Territory, 1997
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Total number of sub-specialists Number
38
27
8
8
13
2
2
0
98
Pop A (x 1000)
2,483.2
1,845.4
1,308.0
599.4
686.7
188.4
121.9
62.6
7,295.7
SPR:1x1000
65.3
68.3
163.5
74.9
52.8
94.2
60.9
0
72.9
No. per 100,000
1.5
1.5
0.6
1.3
1.9
1.1
1.6
0.0
1.4
Gynaecological Oncology
Number
8
6
4
2
3
1
0
0
24
Pop A (x 1000)
2,483.2
1,845.4
1,308.0
599.4
686.7
188.4
121.9
62.6
7,295.7
SPR:1x1000
310.4
307.6
327.0
299.7
228.9
188.4
0
0
304.0
No. per 100,000
0.3
0.3
0.3
0.3
0.4
0.5
0.0
0.0
0.3
Maternal Fetal Medicine
Number
4
0
0
0
1
0
2
0
7
Pop B (x 1000)
1,552.1
1,159.7
865.3
364.9
456.4
117.7
87.5
52.8
4,656.4
SPR:1x1000
388.0
0
0
0
456.4
0
43.7
0
665.2
No. per 100,000
0.3
0.0
0.0
0.0
0.2
0.0
2.2
0.0
0.2
Obstetrical and Gynaecological Ultrasound
Number
5
10
2
0
2
0
0
0
19
Pop A (x 1000)
2,483.2
1,845.4
1,308.0
599.4
686.7
188.4
121.9
62.6
7,295.7
SPR:1x1000
496.6
184.5
654.0
0
343.4
0
0
0
383.9
No. per 100,000
0.2
0.5
0.2
0.0
0.3
0.0
0.0
0.0
0.3
Reproductive Endocrinology and Infertility
Number
12
7
1
4
1
1
0
0
26
Pop B (x 1000)
1,552.1
1,159.7
865.3
364.9
456.4
117.7
87.5
52.8
4,656.4
SPR:1x1000
129.3
165.7
865.3
91.2
456.4
117.7
0
0
179.1
No. per 100,000
0.8
0.6
0.1
1.1
0.2
0.8
0.0
0.0
0.6
Uro-gynaecology
Number
5
2
0
1
4
0
0
0
12
Pop C (x 1000)
2,048.4
1,458.6
1,099.4
486.6
551.0
150.6
92.9
55.6
5,905.1
SPR:1x1000
402.1
729.3
0.0
486.6
137.8
0
0
0
492.1
No. per 100,000
0.2
0.1
0.0
0.2
0.7
0.0
0.0
0.0
0.2
Notes: Pop A - females aged 15 years and greater; Pop B - females aged 15 to 49 years; Pop C - females aged 25 years and greater. Source: RACOG and ABS 1997
AMWAC 1998.6 91
APPENDIX A: RURAL, REMOTE AND METROPOLITAN AREAS
CLASSIFICATION The Commonwealth Departments of Health and Family Services and Primary Industries and Energy, Rural, Remote and Metropolitan Areas classification, has been used to classify the geographic location of the job of responding medical practitioners in the following seven categories. Metropolitan areas: 1. Capital cities consist of the State and Territory capital cities of Sydney,
Melbourne, Brisbane, Perth, Adelaide, Hobart, Darwin and Canberra. 2. Other metropolitan centres consist of one or more statistical subdivisions which
have an urban centre of population of 100,000 or more in size. These centres are: Newcastle, Wollongong, Queanbeyan (part of Canberra-Queanbeyan), Geelong, Gold Coast-Tweed Heads, Townsville-Thuringowa.
Rural zones: 3. Large rural centres are statistical local areas where most of the population reside
in urban centres of population of 25,000 to 99,999. These centres are: Albury-Wodonga, Dubbo, Lismore, Orange, Port Macquarie, Tamworth, Wagga Wagga (NSW); Ballarat, Bendigo, Shepparton-Mooroopna (Vic); Bundaberg, Cairns, Mackay, Maroochydore-Mooloolaba, Rockhampton, Toowoomba (Qld), Whyalla (SA); Launceston (Tas) and Alice Springs (NT).
4. Small rural centres are statistical local areas in rural zones containing urban
centres of population between 10,000 and 24,999. These centres are: Armidale, Ballina, Bathurst, Broken Hill, Casino, Coffs Harbour, Forster-Tuncurry, Goulburn, Grafton, Griffith, Lithgow, Moree Plains, Muswellbrook, Nowra-Bombaderry, Singleton, Taree (NSW); Bairnsdale, Colac, Echuca-Moama, Horsham, Mildura, Moe-Yallourn, Morwell, Ocean Grove-Barwon Heads, Portland, Sale, Traralgon, Wangaratta, Warrnambool (Vic); Caloundra, Gladstone, Gympie, Hervey Bay, Maryborough, Tewantin-Noosa, Warwick (Qld); Mount Gambier, Murray Bridge, Port Augusta, Port Lincoln, Port Pirie (SA); Albany, Bunbury, Geraldton, Mandurah (WA); Burnie-Somerset, Devonport (Tas).
5. Other rural areas are the remaining statistical areas within the rural zone.
Examples are Cowra Shire, Temora Shire, Guyra Shire (NSW); Ararat Shire, Cobram Shire (Vic); Cardwell Shire, Whitsunday Shire (Qld); Barossa, Pinnaroo (SA); Moora Shire, York Shire (WA); George Town, Ross (Tas); Coomalie, Litchfield (NT).
AMWAC 1998.6 92
Remote zones: These are generally less densely populated than rural statistical local areas and hundreds of kilometres from a major urban centre. 6. Remote centres are statistical local areas in the remote zone containing urban
centres of population of 5,000 or more. These centres are: Blackwater, Bowen, Emerald, Mareeba, Moranbah, Mount Isa, Roma (Qld); Broome, Carnarvon, East Pilbara, Esperance, Kalgoorlie/Boulder, Port Hedland, Karratha (WA); Alice Springs, Katherine (NT).
7. Other remote areas are the remaining areas within the remote zone. Examples
are: Balranald, Bourke, Cobar, Lord Howe Island (NSW); French Island, Orbost, Walpeup (Vic); Aurukun, Longreach, Quilpie (Qld); Coober Pedy, Murat Bay, Roxby Downs (SA); Coolgardie, Exmouth, Laverton, Shark Bay (WA); King Island, Strahan (Tas); Daly, Jabiru, Nhulunbuy (NT).
AMWAC 1998.6 93
APPENDIX B: SURVEY OF FELLOWS OF THE ROYAL AUSTRALIAN COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS
METHODOLOGY To assist with the establishment of a profile of the obstetrics and gynaecology workforce in Australia, a mailed survey of all RACOG fellows was conducted. The survey was administered by AMWAC in consultation with the RACOG. 501 Fellows of the RACOG responded to the questionnaire, which is a response rate of 53%. RESULTS Distribution of Respondents Table B1 shows that the distribution of respondents to the RACOG/AMWAC Survey is similar to the overall State/Territory distribution of RACOG members and the AIHW Medical Labour Force Survey (1995). Victoria was the only State with a low representation of respondents compared to the RACOG membership. Table B1: Distribution of survey respondents compared to RACOG members and AIHW survey, by State/Territory, 1997
State/Territory
NSW/ACT
Vic
Qld
SA
WA
Tas
NT
Aust
RACOG/AMWAC Survey (n=501)
% respondents
35.6
24.2
18.6
9.8
8.8
2.4
0.6
100.0
RACOG members (n=954)
% of members
34.9
27.3
17.0
9.0
8.7
2.4
0.7
100.0
AIHW 1995 Survey (n=974)
%respondents
34.4
26.5
16.9
9.3
9.1
2.5
1.1
100.0
Source: AIHW, RACOG and RACOG/AMWAC survey Table B2 indicates that the geographic distribution of respondents to the RACOG/AMWAC Survey is consistent with the distribution of the workforce as defined by the AIHW 1995 Survey. Table B2: Geographic distribution of RACOG/AMWAC survey respondents compared to AIHW survey, 1997
Major urban centre
Rural area
No response
Aust
RACOG/AMWAC Survey (n=501)
% respondents
81.0
14.6
4.4
100.0
AIHW 1995 Survey (n=896)
% workforce
83.8
16.2
-
100.0
Source: AIHW and RACOG/AMWAC Survey
AMWAC 1998.6 94
Table B3 indicates the RACOG specialists and sub-specialists that responded to the questionnaire. Table B3: Response rate of specialists/sub-specialists, by gender, 1997 Qualifications
Male
Female
Total
RACOG members
Obstetrics and gynaecology
389
64
453
854
Maternal -fetal medicine
2*
1*
3
7
Uro-gynaecology
3*
1*
4
13
Obstetrical and gynaecological ultrasound
12*
2*
14
26
Gynaecology oncology
9
0
9
25
Reproductive endocrinology and infertility
17
1
18
29
Total
432
69
501
954
*not available for confidentiality reasons Source: RACOG/AMWAC survey Age Profile From the RACOG/AMWAC Survey, the age range of respondents was from 33 years to 76 years with an average age of 50.5 years. The largest group of respondents was the 45 to 54 year age group (40.24%), followed by the 35 to 44 year age group (27.3%); 29% of respondents were aged 55 years and over (Table B4). Compared to the AIHW Survey, obstetricians and gynaecologists in the 65 years and over age group are under reported in the RACOG/AMWAC survey. Table B4: Age profile of RACOG/AMWAC survey compared to AIHW survey, 1997
<35 yrs
35-44 yrs
45-54 yrs
55-64 yrs
65-74 yrs
75+yrs
RACOG/AMWAC survey (n=501)
% respondents
3.5
27.3
40.2
24.4
3.4
1.2
AIHW (n=974)
% respondents
1.5
26.3
35.6
26.1
8.4
2.1
Source: AIHW and RACOG/AMWAC survey Gender Profile 13.8% of respondents to the RACOG/AMWAC survey were female obstetricians and gynaecologists compared with the data from RACOG of 13.4%. Overall, the Working Party concluded that a response rate of 53% was reasonable and that the profile of respondents was sufficiently consistent with the profile of the
AMWAC 1998.6 95
workforce to provide representative data. Qualifications As indicated in Table B5, the majority of survey respondents obtained their Fellowship of the RACOG between 1971 and 1990. B5: Year of RACOG qualifications obstetrics and gynaecologists, 1997 (n=501) Year
Number
%
<1960
13
2.8
1961-1970
88
17.6 1971-1980
140
27.9
1981-1990
137
27.3 1991-1997
91
18.2
No response
32
6.4Source: RACOG/AMWAC survey Year of sub-specialty qualifications are outlined in Table B6. Table B6: Year of RACOG qualifications obstetrics and gynaecologists, 1997 (n=501) Year
Number
%
1961-1970
1
0.2
1971-1980
12
2.4 1981-1990
18
3.6
1991-1997
31
6.2 No response
439
87.7
Source: RACOG/AMWAC survey Hours Worked The RACOG/AMWAC survey asked respondents to indicate the hours worked in a typical week. The definitions used were: Total hours worked in a typical week The total hours spent in patient care, including hours on call back worked and time spent on non patient care activities such as administration, continuing medical education, teaching and research. Hours worked excluded time spent on travel between work locations (except travel to calls out) and unpaid professional and/or voluntary activities.
Total hours on call back worked in a typical week Once called to duty, the time spent on duty, including travel time. Total hours on call not worked in a typical week The average hours per week for which the practitioner was on standby for a call to duty
AMWAC 1998.6 96
but were not worked. Once called to duty, the time spent on duty including travel time is counted in total hours worked and should have been indicated in the total hours on call back worked in a typical week. On average, respondents worked a total of 62.6 hours per week (mode 60 hours; median 60 hours; standard deviation 31.6). 22.4% of respondents worked less than 45 hours per week and 55.1% worked 55 hours or more. A significant difference was observed between the total hours worked by males and females, with 36% of women working less than 45 hours per week compared with 23% of men and 53% of women working 55 hours or more per week compared with 70.8% of men. Table B7 details the average hours provided by obstetrics and gynaecology specialists/sub-specialists by State and Territory. The number of The average hours worked per week was 62.0, 42.6 hours per week were worked in direct patient care and an additional 19.4 hours on average per week were worked on call. It is estimated that specialists/sub-specialists worked a total of 2,747,138 hours in 1997; of these hours 1,869,458 hours were in direct patient care. This equates to 37,654 hours per 100,000 female population (>15 years) in total hours worked, with the provision of hours worked per 100,000 population significantly above the average in Victoria and South Australia because of its higher local and regional catchment population and higher workforce provision, and below the average with 27,521 in Western Australia. This compares with the RACOG data shown in Table 1 on obstetricians and gynaecologists population ratio per 100,000 where Victoria and South Australia have higher specialists/sub-specialists per 100,000 and Western Australia which has one of the lower number of specialists/sub-specialists per 100,000 ratio. The average amount of time spent on direct patient care was 42.6 hours per week (range 1-90 hours; median 42.0; mode 40; standard deviation 15.8). 80.8% of respondents indicated they worked on-call hours out of work hours. The average time worked on-call out of hours was 19.4 hours per week (median 8.0; mode 10.0; standard deviation 34.8).
AMWAC 1998.6 97
Table B7: Specialists and sub-specialists in obstetrics and gynaecology average hours worked per week and annual labour supply hours, by State/Territory, 1998
State/Terr.
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Total hours worked
Ave. hours per week
58.7
70.8
66.2
64.7
49.5
52.2
48.9
57.0
62.6
Annual hours worked >000)a
855.9
846.8
493.3
255.9
188.9
52.2
35.9
18.4
2,747.1
Hours worked per 100,000 female pop.
34,470
45,885
37,715
42,701
27,521
29,314
29,524
29,319
37,654
Direct patient care hours worked
Ave. hours per week
41.9
43.2
44.7
42.1
41.3
35.8
36.4
52.0
42.6
Annual hours worked (>000)a
610.9
516.7
333.1
166.5
157.7
37.9
26.8
16.7
1,869.5
Hours worked per 100,000 female pop.
24,604
27,998
25,467
27,786
22,962
20,104
21,977
26,748
25,624
Hours on call worked
Ave. hours per week
17.6
21.1
21.7
24.7
13.0
18.2
6.6
26.7
19.4
Annual hours worked (>000)a
256.0
252.3
161.7
97.7
49.6
19.3
4.8
8.6
851.3
Hours worked per 100,000 female pop.
10,335
13,674
12,363
16,301
7,228
10,221
3,984
13,734
11,669
Hours on call not worked
Ave. hours per week
63.0
61.3
64.3
66.8
58.9
82.2
45.6
84.0
63.1
Annual hours worked (>000)a
918.7
733.1
479.2
264.3
224.9
86.9
33.6
27.1
2,769.1
Hours worked per 100,000 female pop.
36,995
39,728
36,633
44,087
32,747
46,161
27,532
43,208
37,955
Female pop. > 15 years (>000)
2,483.2
1,845.4
1,308.0
599.4
686.7
188.4
121.9
62.6
7,296.6
Specialists
317
260
162
86
83
23
16
7
954
Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG and RACOG/AMWAC survey
AMWAC 1998.6 98
Table B8 details the average hours provided by specialists/sub-specialists in obstetrics and gynaecology by sex and age. In 1997 specialists/sub-specialists worked on average 62.6 hours per week, 64.0 for males and 54.0 for females. For both males and females, those under 55 years of age averaged around 62.5 hours per week; this declined to 54.1 hours for 55 to 64 years age group, 45.8 hours for 65 to 74 years age group and 10.0 hours for those aged 75 years or more. The highest average hours worked per week were 71.2 hours by males aged 45 to 54 years and for females 60.7 hours per week in the 35 to 44 age range. Table B8: Specialists and sub-specialists in obstetrics and gynaecology average hours and annual hours worked, by gender and age group, 1998
Sex
25-34
yrs
35-44
yrs
45-54
yrs
55-64
yrs
65-74
yrs
75 yrs & over
Total
Total hours worked
Male
51.9
70.5
71.2
54.9
47.1
10.0
64.0
Female
48.7
60.7
44.8
30.0
10.0
0.0
54.0
Total
51.0
67.1
69.4
54.1
45.8
10.0
62.0
Annual hrs worked (>000)a
70.4
762.4
1,209.9
652.0
69.5
1.4
2,733.9
Direct patient care hours worked
Male
37.9
45.4
47.7
38.2
31.0
10.0
43.1
Female
40.5
40.8
35.1
33.5
nr
0.0
39.0
Total
38.4
43.8
46.7
38.0
31.0
10.0
42.6
Annual hrs worked (>000)a
52.9
497.6
814.2
457.9
47.1
1.4
1,869.5
Hours on call not worked
Male
67.9
59.7
67.1
63.6
51.5
0.0
63.7
Female
50.0
54.1
59.7
102.7
0.0
0.0
58.6
Total
65.9
57.9
66.6
64.8
51.5
0.0
63.1
Annual hrs worked (>000)a
90.9
657.6
1,161.1
780.9
78.2
0.0
2,769.1
Hours on call worked
Male
13.3
21.6
18.7
15.8
26.7
0.0
18.6
Female
5.0
2.5
25.4
1.5
0.0
0.0
21.9
Total
12.3
21.9
19.1
15.6
26.7
0.0
19.4
Annual hrs worked (>000)a
16.9
248.8
332.9
188.0
40.5
0.0
851.4
Specialists
30
247
379
262
33
3
954
Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG and RACOG/AMWAC survey
AMWAC 1998.6 99
Expected Age of Retirement 99.2% (497) of respondents provided details of their retirement intentions. The average expected age of retirement from the workforce was 63 years (range 50 to 80 years; standard deviation 4.6). Table B9 indicates that 22.7% of survey respondents intend retiring in the next five years. Table B9: Actual year of intended retirement in obstetrics and gynaecology, by State/Territory, 1997 Year
NSW
Vic
Qld
SA
WA
Tas
NT
ACT
Aust
% Aust
to 2002
24
25
18
12
11
2
-
21
113
22.7
2003-4
24
20
14
4
2
2
-
-
66
13.3
2005-7
27
16
22
8
9
1
1
-
84
16.9
2008-9
8
7
2
3
3
-
-
2
25
5.0
2010-11
28
19
14
7
7
2
1
-
78
15.7
2012-14
15
10
6
5
4
4
1
1
46
9.3
2015-17
14
12
10
7
4
1
-
-
48
9.7
2018-21
11
11
3
2
4
-
-
-
31
6.2
2022-26
6
4
7
2
1
-
-
1
6
1.2
Total
152
121
91
49
44
12
3
25
497
100.0
Source: RACOG/AMWAC survey Type of Practice Table B10 indicates the different practice groups of the respondents and Table B9 the percentage of appointments in the public or private sector. Table B10: Obstetrics and gynaecology specialists practice profiles, 1997 (n=501) Solo and group practices
% of respondents
solo specialist
67.1
with other obstetricians and gynaecologist
20.8
No response to type of practice
8.1
multi-disciplinary group
3.2
solo and with other specialists not in obstetrics and gynaecology
0.8
Source: RACOG/AMWAC survey
AMWAC 1998.6 100
Table B11: Appointments (percentage) in the public or private sector, 1997 (n=501) Type of practice
%
respondents in private practice and/or undertake public hospital work
63.7
salaried in a public hospital
15.8
in private practice with no public hospital role
14.2
public hospital salaried and private practice
2.2
salaried in private hospital & in private practice &/or undertake public hospital role
0.6
university appointment with public hospital role
0.5
No response
3.0
Source: RACOG/AMWAC survey The university appointment response rate (0.5%) is low allowing for the number of teaching units in Australia and may be explained by respondents classifying themselves as salaried in a public hospital role. There were 480 respondents who indicated appointment by State/Territory as shown in Table B12. The proportion reporting employment in public hospitals was much higher in New South Wales (32.9%) and lower (1.3%) in Tasmania, Northern Territory and the Australian Capital Territory. Private practice employment was highest in the New South Wales (20.0%) and lowest in the Northern Territory (1.4%). There were 45 sub-specialists respondents who indicated their appointment by State/Territory. The proportion reporting employment in public hospitals was much higher in New South Wales (46.7%) and lower (6.7%) in the Australian Capital Territory and with no representation in Western Australia, Tasmania and the Northern Territory (Table B13).
AMWAC 1998.6 101
Table B12: Obstetrics and gynaecology specialists appointments in the public or private sector (%), by State/Territory, 1997a Main job (% of total)
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
salaried in a public hospital
32.9
14.5
27.6
15.8
5.3
1.3
1.3
1.3
100.0
in private practice and/or undertake public hospital work
33.6
29.2
13.2
8.8
11.0
2.5
1.3
0.3
100.0
in private practice with no public hospital role
20.0
18.6
38.6
8.6
7.1
2.9
2.9
1.4
100.0
public hospital salaried and private practice
45.5
36.4
0.0
18.1
0.0
0.0
0.0
0.0
100.0
salaried in private hospital & in private practice &/or undertake public hospital role
50.0
0.0
0.0
0.0
0.0
50.0
0.0
0.0
100.0
university appointment with public hospital role
0.0
33.3
33.3
33.3
0.0
0.0
0.0
0.0
100.0
Total
31.9
25.2
19.0
10.2
9.2
2.5
1.5
0.6
100.0
Notes: a - n=480 for respondents who indicated main job and State/Territory Source: RACOG/AMWAC survey Table B13: Practice profiles of sub-specialists in obstetrics and gynaecology (%), by State/Territory, 1997(n=45) Main job (% of total)
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Sub-specialists Salaried in a public hospital
46.7
20.0
13.3
13.3
0.0
0.0
6.7
0.0
100.0
in private practice and/or undertake public hospital work
35.0
30.0
5.0
10.0
15.0
5.0
0.0
0.0
100.0
In private practice with public hospital role
12.5
50.0
12.5
0.0
12.5
12.5
0.0
0.0
100.0
public hospital salaried and private practice
50.0
50.0
0.0
0.0
0.0
0.0
0.0
0.0
100.0
Sub-specialists
33.3
29.2
10.4
10.4
8.3
4.2
2.1
0.0
100.0
Source: AMWAC/RACOG survey
AMWAC 1998.6 102
Consultation Waiting Times Table B14 shows that the average waiting time for a standard first consultation with a specialist in obstetrics and gynaecology in his/her private rooms is 16.9 days (standard deviation 18.0) while public patients wait, on average, 31.9 days (standard deviation 48.4). The waiting time in the Australian Capital Territory for a standard first consultation is well above the average for private patients. Tasmania exceeds that national average waiting time (31.9 days) for public patients with a waiting period of 141.5 days for public patients and may be contributed to an undersupply of specialists.These waiting times are not benchmarks but are self reported. Table B14: Obstetrics and gynaecology average waiting time (days) for a standard first consultation and an urgent procedure, by private rooms/public outpatients department and State/Territory 1997
State/Territory
Standard consultation
Urgent condition
Private patients
NSW
16.0
2.4
Victoria
19.1
1.9
Queensland
17.2
2.3
South Australia
12.7
1.1
Western Australia
15.4
1.7
Tasmania
15.9
1.0
Northern Territory
10.5
2.5
ACT
40.8
2.7
Total
16.9
2.0
Public patients
NSW
21.9
4.5
Victoria
23.4
5.4
Queensland
37.6
14.0
South Australia
32.1
5.7
Western Australia
47.8
7.7
Tasmania
141.5
5.8
Northern Territory
38.5
14.0
ACT
16.3
5.3
Total
31.9
7.1
Source: RACOG/AMWAC survey
AMWAC 1998.6 103
For an urgent condition, private patients wait less time (2.0 days, standard deviation 4.1) than do patients in public outpatient departments (7.1 days, standard deviation 18.5) (p<0.01) with public patients in Queensland and Northern Territory waiting above average times for urgent conditions. Table B15 shows that the average waiting times for a standard first consultation with sub-specialists in his/her private rooms ranging from 5.5 to 35 days while public patients wait, on average, from 9.6 to 63 days. The waiting time in Victoria for a standard first consultation is well above the average for both private and public patients (Table B 11). Waiting times for public patients in Western Australia exceed the national average. Table B15: Sub-specialists average waiting time (days) for a standard first consultation and an urgent procedure, by private rooms/public outpatients department and State/Territory 1997 (n=48)
Gynaecological
Oncology
Maternal-fetal
medicine
Ultrasound
Reproductive
Endocrinology and Infertility
Uro-gynaecology
State/ Territory
Standard
Urgent
Standard
Urgent
Standard
Urgent
Standard
Urgent
Standard
Urgent
Private patients
NSW
3.0
2.0
-
-
1.0
.5
24.0
2.3
49.0
4.0
Vic
14.0
2.5
-
-
7.7
0.6
29.8
4.0
-
-
Qld
4.0
4.0
-
1.0
4.5
1.0
7.0
1.0
-
-
WA
2.0
1.0
-
-
4.5
1.0
14.0
2.0
-
-
SA
-
-
-
-
-
-
26.3
4.0
7.0
1.0
Tas
7.0
1.0
-
-
-
-
5.0
0
-
-
NT
-
-
-
-
-
-
-
-
-
-
ACT
-
-
7.0
1.0
-
-
-
-
-
-
Total± (std dev)
6.25 5.1
2.14 1.2
7.0 0
1.0
0
5.5 4.6
0.7 0.5
23.2 18.7
2.8 2.8
35.0 25.2
3.0 2.0
Public patients
NSW
8.3
6.1
-
-
1.0
1.
35.0
2.0
98.0
1.0
Vic
14.0
4.5
-
-
18.8
1.8
46.7
13.3
-
-
Qld
4.0
4.0
14.0
1.0
-
-
45.0
5.0
-
-
WA
14.0
7.0
-
-
5.5
1.0
120.0
-
-
-
SA
-
-
-
-
-
-
35.0
4.3
28.0
7.0
Tas
7.0
1.0
-
-
-
-
-
-
-
-
NT
-
-
-
-
-
-
-
-
-
-
ACT
-
-
7.0
1.0
-
-
-
-
-
-
Total± (std dev)
9.6
6.4
4.6 4.2
10.5 4.9
1.0
0
12.4 11.4
1.5 2.3
43.7 25.2
5.3 7.1
63.0 49.5
4.1 4.2
Source: RACOG/AMWAC survey
AMWAC 1998.6 103
In general for an urgent condition, private patients wait less time (0.7 to 3.0 days) than do patients in public outpatient departments (1.0 to 4.6 days) (p<0.01). Plans to Change Hours Worked 55% (263) of respondents indicated that they planned to change the hours they work with 43.1% (207) of respondents anticipating their work hours to decrease, 12.2% (60) expecting their work hours to increase and 44.7% (214) expecting their hours to remain the same. Table B16 indicates the change in hours worked by State/Territory with 50% (75) of the obstetric and gynaecology workforce from New South Wales anticipating a reduction in hours over the next five years. Table B16: Obstetricians and gynaecologists plans to change the hours they work by State/Territory, 1997 (n=476) State/Territory
Reduce work hours (%)
Increase work hours (%)
Remain the same (%)
NSW
50
10
40
Victoria
48
12
40
Queensland
38
8
54
South Aust.
38
16
46
West. Aust.
29
19
52
Tasmania
33
33
33
North. Terr.
0
0
100
ACT
43
14
43
Total
43.1
12.2
44.7
Source: RACOG/AMWAC survey Significant associations were observed with those respondents indicating an anticipated reduction in the hours over the next five years worked and (p<0.01): - Gender - 46.4% of males indicated that they anticipate to reduce the hours worked
over the next five years compared to 20.3% of females. - Geographic location - 43.3% (172) of the metropolitan workforce and 44.4% (32) of
rural areas will reduce the hours worked over the next five years. Other reasons stated include: rising medical indemnity insurance - 80.7% (167); lifestyle preferences - 93.5% (143); family considerations 86.5% (96); health considerations - 66.7% (62); work place change - 62.8% (59); retirement - 60.0% (63). Respondents also sited the following would decrease the hours worked over the next five years: work is being done by midwives; the risk of burnout due to long hours and
AMWAC 1998.6 104
lack of appropriate support; oversupply of fellow obstetricians and gynaecologists; the fall in private patients and dissatisfaction with the public health sector. A significant association was observed between intention to increase hours worked and an expected increase in demand for obstetrics and gynaecology services (p<0.01). Other reasons sited by respondents that would increase the hours worked over the next five years included: financial incentives and children beginning school. Provider Shortages Respondents were asked to specify any providers in short supply in their primary practice location. Table B17 indicates that there is a need for more obstetricians and gynaecologists in New South Wales/Australian Capital Territory, Victoria and Queensland. Respondents from these three States/Territories also perceived a need for more midwives, anaesthetists, paediatricians, psychiatrists and sub-specialists in obstetrics and gynaecology and a range of other specialists. Among the other specialties identified by respondents were neonatologists, general physicians, psychologists, psychiatrists, dieticians, physiotherapists and genetic counsellors. Table B17: Obstetricians and gynaecologists= estimates of provider shortages in the area of their main job, by State/Territory 1997 State/ Territory
Obstetrician/
Gynaecologists
Sub-
specialist
Anaesthetists
Nurses/
midwives
Other
specialists NSW
8
5
10
20
16
Victoria
6
3
29
9
12
Queensland
5
8
18
12
17
South Aust.
4
1
6
5
5
West. Aust.
3
-
10
3
-
Tasmania
1
1
2
1
2
North. Terr.
3
-
2
2
1
ACT
-
3
2
-
-
Total
30
21
79
52
53
Source: RACOG/AMWAC survey There was a strong association observed between perceived need for more obstetricians and gynaecologists and geographic location. 80.2% (219) metropolitan respondents indicated the need for more obstetricians and gynaecologists compared to 17.2% (47) of rural respondents (n=273). Rural respondents indicated a need for more midwives, anaesthetists, paediatricians, neonatologists, psychologists and psychiatrists
AMWAC 1998.6 105
Metropolitan Specialists Providing Rural Outreach Services 72 out of 501 (14.4%) metropolitan obstetricians and gynaecologists that responded to the survey reported that they provided services to rural areas with the majority being males 94.4% (68). The average time spent by obstetricians and gynaecologists in rural areas was 23 hours per month (mode 4 hours; median 12 hours; standard deviation 34.5). The gynaecologists spending less than half a day and others up to 10 days per month. The majority of metropolitan obstetricians and gynaecologists that indicated they provided services to rural areas were aged between 41 and 55 years (53.4%). Table B18 shows wide variation across States/Territories in the percentage of respondents involved in the provision of rural outreach services. For example, 25.3% of metropolitan based obstetricians and gynaecologists in Victoria and 23.9% in South Australia reported providing rural outreach services while 15.5% of metropolitan providers in New South Wales indicated they provided rural outreach services. Table B18: Metropolitan obstetricians and gynaecologists providing rural outreach services (%), by State/Territory, 1997 (n=72)
NSW
Vic
Qld
SA
WA
Tas
ACT
15.5
25.3
19.7
23.9
11.3
1.4
2.8
Source: RACOG/AMWAC survey Respondents gave the main reasons for providing rural outreach services as: rural lifestyle; rural demand for obstetrics and gynaecology services; committed to providing a rural service; adds variety to my work; maintain skills; opportunity to expand practice; remuneration; and, continue to work in rural areas because there is no replacement. Respondents indicated that the catchment population required to sustain a rural outreach obstetrics and gynaecology service ranged from 20,000 to 100,000 people. The average catchment population was 40,000. It was also noted that an appropriate infrastructure with necessary equipment and the availability of other specialists was necessary (please refer to Appendix B for further information on requirements). Respondents also indicated that ideally there should be a pool of about three specialists available for visiting posts so that issues concerning on call, study leave and holidays can be covered. More importantly this pool of specialists should remain the same so communities are not faced with new individuals at each visit. Women have repeatedly stressed the importance of receiving care during pregnancy and childbirth from the same care giver, or from a small group of caregivers with whom they can become familiar. Evidence from a controlled trial shows that women who had continuity of caregivers were less likely to use pharmacological analgesia or anaesthesia during
AMWAC 1998.6 106
labour and birth, to have labour augmented with oxytocin, to have a labour length of more than six hours. They were also more likely to feel well prepared for labour, perceive the labour staff as caring, feel in control during labour and feel well prepared for labour (Enkin et al, 1996). Table B18 summarises the requirements for providing a sustainable rural outreach obstetrics and gynaecology service, refer to Appendix B for further information on service requirements. Table B18: Basic requirements for providing a rural outreach obstetrics and gynaecology service
Local hospital facilities/equipment
In-patient bed, casualty Small surgical/limited equipment Telelink to consultants Appropriate consulting facilities Good hospital administration
Allied health professionals and ancillary staff
Midwives/nursing Physiotherapists Dieticians
General practitioners
The interest and support of local GPs was considered paramount by numerous respondents
Other specialist services
Anaesthetists Paediatricians Psychiatrists Psychologists Neonatologists
Other
Good transport to the area for both patients and specialist local accommodation for patients
Source: RACOG/AMWAC survey Metropolitan obstetrics and gynaecologists providing rural outreach services were asked to indicate their reasons for preferring to live in a capital city or urban centre the comments in order of frequency of comment are: children=s schooling, family considerations; lifestyle, friends, cultural interests; convenience/availability of professional facilities; always lived in an urban area; academic and research interests; dislike rural isolation; financial considerations; better work in the city. Resident Rural Obstetricians and Gynaecologists 94 respondents (18.8%) out of 501, indicated that they lived and worked outside a major urban centre. The main reasons for living and working in a rural area were given as: rural lifestyle; variety of work; good place to raise children; came from the country. The average number of years that obstetricians and gynaecologists practising in a rural
AMWAC 1998.6 107
area intend remaining in the country was 12 years (minimum 1 years and maximum 40 years, mode 20 years). The majority of rural respondents considered that a catchment population of 40,000-60,000 was required to sustain two specialists in a resident rural practice. Two specialists are required so that a viable obstetric and gynaecology service is offered to the community and covered for 24 hours. Respondents were asked to rank in order of priority the basic requirements for providing a good resident rural obstetrics and gynaecology services. These were: the availability of local hospital facilities and equipment; the availability of skilled nursing staff; the availability of other specialists (ie., specialists other than obstetricians and gynaecologists); the availability of sufficient similar specialists to provide 24 hour cover; the availability of allied health/ancillary staff; attributes/skills of referring GPs and finally the public hospital appointments. Other basic requirements included the need for holiday/study leave cover, access to locum services and good schools for children, spouse satisfaction with lifestyle, income parity with city specialists. Locum Service Requirements 54 of the 94 rural obstetricians and gynaecologists indicated that if a specialty locum scheme were established they would make use of it. The majority of those interested indicated a requirement for 5 weeks of locum support (minimum 2 weeks, maximum 24 weeks, mode 4 weeks). Professional Satisfaction Overall, 69.9% of respondents were satisfied with their work. Aspects of their work with which they were most satisfied were sufficient work to maintain competence, physical working conditions, and the opportunity to use your abilities. Aspects of their work with which they were most dissatisfied (in order of percentage of people expressing dissatisfaction) were industrial relations between management and workers in your health service, workload sufficient to maintain income, hours of work, and amount of work (Table B20). No difference was observed in overall level of satisfaction between urban practitioners and rural practitioners. No differences were observed based on location of primary practice and satisfaction with hours of work and amount of work. There also were no differences observed in level of satisfaction with hours worked and age or gender or with satisfaction with work hours and plans to reduce work hours.
AMWAC 1998.6 108
Table B20: Obstetrics and gynaecologists’ professional satisfaction (percentage), 1997 (n=485) Indicator
Satisfied
Uncommitted
Dissatisfied
No
response Overall satisfaction
69.9
14.6
11.8
3.8
Work environment - physical working conditions
66.9
17.8
11.2
4.2
- industrial relations
39.3
28.9
26.5
5.2
The work itself - opportunity to use your abilities
75.4
11.2
10.2
3.2
- workload sufficient to maintain competence
71.9
16.0
8.6
3.6
Workload - hours of work
43.9
29.9
22.6
3.6
- amount of work
48.7
24.8
22.4
4.2
Level of income - workload sufficient to maintain income
48.9
21.0
25.5
4.6
Support from other providers in your area - availability of similar specialists
69.1
16.2
10.2
4.6
- availability of other specialists
78.2
11.6
5.8
4.4
- support from primary care practitioners
63.7
21.6
10.2
4.6
- availability of skilled nursing staff
63.9
21.6
10.4
4.2
- availability of skilled allied health personnel
60.7
25.0
9.0
5.4
Source: RACOG/AMWAC survey Respondents indicated that rising medical insurance indemnity premiums will affect the way they practice with 83% (403) indicating that they would either cease practising obstetrics or retire early, 9% indicated that they would pass costs on to patients. Other changes indicated were: work solely in public sector; increase workload to cover costs; practice defensive medicine by providing more information to patients; change career; and take more detailed medical records on patient. Perceptions of the Factors Affecting Workforce Requirements Respondents were asked to indicate whether they believed particular factors would
AMWAC 1998.6 109
increase workforce requirements, decrease workforce requirements or whether requirements would stay the same (Table B21). Among the important issues that respondents considered would increase included: more defensive medicine, patients expectations and knowledge, advances in medical technology, and need for improved geographic distribution of specialists. Factors perceived as most likely to decrease workforce requirements were substitution of specialist services by other providers, requirements for procedural practice, and cost containment strategies. Table B21: Obstetrics and gynaecologists= perceptions of the factors that could affect the size of the obstetrics and gynaecology workforce over the next ten years (%), 1997 (n=476)
Factors affecting the size of the workforce
Increase
Decrease
Stay the
same
No
response Population trends Ageing of the population
42.7
8.0
44.1
5.2
Changing disease patterns
23.4
6.8
63.5
6.4
Lifestyle changes that improve population health
17.0
13.8
63.5
5.8
Patients expectations/knowledge
69.3
2.8
23.0
5.0
Clinical practice trends Requirements for safer procedural practice
66.1
26.9
0.8
6.2
Advances in medical technology
68.3
3.6
22.8
5.4
Multi-disciplinary team provision
45.3
6.0
41.3
7.4
More defensive medicine
73.1
1.4
20.2
5.4
Workforce trends Need for improved geographic distribution of specialists
54.5
5.2
33.3
7.0
Increasing doctor specialisation
46.3
9.8
37.7
6.2
Substitution of specialist services by other providers
16.0
31.7
43.9
8.4
Health care system trends Cost containment strategies
34.3
24.4
34.1
7.2
Reforms to increase efficiency
33.5
14.6
44.3
7.6
The introduction of coordinated care processes
25.7
17.2
46.5
10.6
Evidence-based medicine
33.9
6.2
49.7
10.2
Source: RACOG/AMWAC survey
AMWAC 1998.6 110
Medical Indemnity Insurance One of the issues confronting the obstetrics and gynaecology profession is the real and potential withdrawal of specialists from obstetrics, in part induced by the fear of being sued and high indemnity insurance premiums. Any trend has to be seen against the backdrop of the traditional career changes of obstetrics and gynaecology specialist away from obstetrics as they get older, and the effect on recruitment of trainees to the profession. Respondents to the RACOG/AMWAC survey indicated that rising medical indemnity insurance premiums will affect the way they practice with 83% (403) indicating that they would either cease practising obstetrics or retire early and 9% indicating that they would pass cost on to patients. Other comments included: to work solely in public sector; increase workload to cover costs; practice defensive medicine by providing more information to patients; change career; and take more detailed records on patients.
AMWAC 1998.6 111
APPENDIX C: AIHW NATIONAL MEDICAL LABOUR FORCE SURVEY 1995 The Medical Labour Force Survey does not differentiate between specialists and sub-specialists but examines the total workforce. In this report when reference is made to the AIHW survey this data includes both specialists and sub-specialists. Number of Practising Consultants in Obstetrics and Gynaecology The Medical Labour Force Survey, 1995, AIHW, identified 974 obstetrics and gynaecology specialists and sub-specialists indicating their main specialty of practice. The AIHW defined a specialist in obstetrics and gynaecology as a clinician in active practice who reported being a specialist with a qualification in obstetrics and gynaecology. In 1986 there were 833 obstetricians and gynaecologists who were identified as Medicare providers and a total of 968 in 1996, indicating a 16.2% increase in the workforce during this period., with the number per 100,000 population increasing slightly from 5.2 to 5.3. Geographic Distribution The geographic distribution by State/Territory was similar. State provision ranged from 5.1 per 100,000 population in New South Wales and Queensland to 6.2 in South Australia. The two Territories had a higher provision but this would be expected given a younger age structure and relatively more births and more women in the child rearing age groups. The distribution of obstetrics and gynaecology specialists was 83.8% had their primary practice in a major urban centre; 9.0% large rural centre; 4.3% in small rural centre, 2.3% in other rural centre and 0.6% in remote centre. The Medicare data indicate that metropolitan areas and large rural centres are well serviced with specialist obstetrics and gynaecology services, but rural and remote populations elsewhere have a much lower patient and service coverage. Gender Profile There were 115 (11.8%) female obstetrics and gynaecology specialists. Males made up 88.2% (859) of the specialty. Age Profile There were 14 (1.4%) obstetrics and gynaecology specialists aged less than 35 years (20.2% of which were females) and 21 (2.2%) males who were aged over 65 years of age. For females the largest age range was the 35 to 44 year age group representing 60 (52.2%), followed by 22 (19.1%) in the 45 to 54 year age group. There were no females aged 75 and over. For males the largest age range was the 45 to 54 year age group representing 325 (37.8%), followed by 234 (27.2%) in the 55 to 64 year age group. There were 21 (2.4%) male obstetrics and gynaecology specialists aged 75 years and over.
AMWAC 1998.6 112
The largest five year age cohort group was the 45 to 54 year age group with 347 specialists (35.6%), followed closely by the 35 to 44 years age group with 256 (26.3%) and 254 (26.1%) in the 55 to 64 year age group. Table C1: Age profile of obstetrics and gynaecology specialists, by State/Territory and gender, 1995, AIHW
Sex
<35 yrs
35-44 yrs
45-54 yrs
55-64 yrs
65-74 yrs
75+ yrs
Total
Males
11
197
325
234
71
21
859
Females
3
60
22
20
10
0
115
Persons
14
256
347
254
82
21
974
(Per cent)
Males
79.8
76.7
93.7
92.0
87.6
100.0
88.2
Females
20.2
23.3
6.3
8.0
12.4
0.0
11.8
Source: Medical Labour Force Survey, 1997, AIHW The 1995 AIHW data indicated that the average age of the both the specialists and sub-specialists was 51.1 years, with 103 (10.5%) aged 65 and over. Table C2: Age profile of obstetrics and gynaecology specialists and sub/specialists, by State/Territory and age, 1995
Age (years)
NSW
Vic
Qld
WA
SA
Tas
ACT
NT
Total
%
<35
4
2
6
2
0
0
0
0
14
1.5
35-44
84
74
42
20
20
5
12
0
256
26.3
45-54
121
85
62
35
34
6
12
4
347
35.6
55-64
67
68
42
25
30
11
7
4
254
26.1
65-74
26
23
14
5
7
1
2
4
82
8.4
75 +
8
6
0
3
0
2
3
0
21
2.1
Total
309
258
165
89
91
25
26
11
974
100.0
Average age
51.2
51.4
50.0
50.5
51.2
55.2
49.0
56.8
51.1
-
% aged 65 yrs +
10.8
11.2
8.3
8.8
7.2
13.1
18.4
36.5
10.5
-
Source: Medical Labour Force Survey, 1997, AIHW Hours worked AIHW data gave the total average hours per week as 55 hours (Table C3) with male specialist/sub-specialists averaging 55.7 hours and for females 49.3 hours (Table C3). Specialist/sub-specialists worked an average of 46.6 hours per week in the direct care
AMWAC 1998.6 113
of patients, with male specialist/sub-specialists averaging 47.3 hours and for females 41.2 hours. This varied from 68.3 hours in remote areas compared to 46.1 hours in major urban areas. Average Hours Worked - State/Territory It is estimated that specialist/sub-specialists worked a total of 2,457,400 hours in 1995 (of these 2,079,000 were in direct patient care). This equates to 33,678 hours per 100,000 population, with the provision of hours worked per 100,000 population significantly above the average for the Australian Capital Territory and below the average for Tasmania with 10,721. Table C3: Specialists and sub-specialists in obstetrics and gynaecology average hours provided per week, annual labour supply hours (a) and hours worked per 100,000 female population (>15 years) in obstetrics and gynaecology, direct care patient care hours worked, hours on call not worked, by State/Territory, 1995 State/Terr.
NSW
Vic
Qld
SA
WA
Tas
ACT
NT
Total
Total hours worked
Average
55.8
55.7
55.7
49.3
56.2
43.6
56.4
50.2
55.0
(hours >000)
792.3
660.0
423.4
202.0
235.3
50.7
67.1
26.5
2,457.4
Hrs worked per 100,000 female pop
31,906
35,765
32,369
33,700
34,264
26,905
55,003
42,361
33,678
Direct patient care hours worked
Average
47.7
45.1
50.5
44.0
42.4
35.4
49.8
47.7
46.6
(hours >000)
677.3
534.4
383.9
180.3
177.5
41.2
59.3
25.1
2,079.0
Hrs worked per 100,000 female pop
27,275
28,959
29,349
30,080
25,847
21,864
48,610
40,123
28,493
Hours on call not worked
Average
64.6
56.6
61.6
56.7
71.6
87.2
60.1
81.8
63.2
(hours >000)
608.0
367.5
281.8
149.7
232.6
77.6
57.2
28.7
1,803.2
Hrs worked per 100,000 female pop
24,484
19,915
21,544
24,975
33,871
41,180
46,888
45,877
24,712
Female pop > 15 years (>000)
2,483.2
1,845.4
1,308.0
599.4
686.7
188.4
121.9
62.6
7,296.6
Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: Medical Labour Force Survey, 1997, AIHW
AMWAC 1998.6 114
Average Hours Worked - Gender and Age Those under 55 years of age averaged 60 hours per week; this declined to 49.5 hours for 55 to 64 year olds, 31.7 hours for 65 to 74 year olds and 27.3 hours for those aged 75 or more (Table C4). The highest average hours worked per week were 54.0 hours by males aged 45 to 64 years. 132 specialists/sub-specialists (13.5%) worked less than 35 hours per week and 12.3% reported working 80 hours per week or more, more than double the proportion of other specialists. Table C4: Specialists and sub-specialists in obstetrics and gynaecology average hours and annual hours worked*, by sex and age, 1995 Sex.
25-34
yrs
35-44
yrs
45-54
yrs
55-64
yrs
65-74
yrs
75 yrs & over
Total
Total hours worked
Male
57.2
63.5
61.2
50.3
32.8
27.3
55.7
Female
65.0
53.7
49.0
38.9
21.2
0.0
49.3
Total
59.1
61.2
60.5
49.5
31.7
27.3
55.0
Annual hours worked (>000)
38.7
725.0
969.0
580.2
118.2
26.2
2,457.4
Direct patient care hours worked
Male
50.0
53.9
51.1
41.9
29.3
27.8
47.3
Female
0.0
45.1
44.2
31.2
17.8
0.0
41.2
Total
50.0
51.8
50.7
41.0
28.2
27.8
46.6
Annual hours worked (>000)
26.5
617.7
817.2
485.1
105.7
26.9
2,079.0
Hours on call not worked
Male
46.0
60.7
66.0
63.3
60.7
40.0
63.6
Female
70.0
59.4
53.8
87.6
19.5
0.0
59.0
Total
52.0
60.4
65.4
64.4
57.0
40.0
63.2
Annual hours worked (>000)
15.1
468.3
728.7
493.0
91.1
7.0
1,803.2
Total spec/sub-spec
14
256
347
254
82
21
974
* Calculated as average weekly hours multiplied by persons by 46 weeks per year. Source: Medical Labour Force Survey, 1997, AIHW Average Hours Worked - Location The results indicated that 63.6% reported on call hours worked. Hours on call not worked for these averaged 64.3 hours per week. The proportion on call and the number of hours on call rose with distance away from a metropolitan area, with remote area
AMWAC 1998.6 115
specialists/sub-specialists reporting 100% on call, an average of 75 hours per week worked and a further average of 93.7 hours on call not worked as is shown in Table C5. The average hours worked varied by region with the average hours in direct patient care in major urban areas at 46.1 hours a week compared to 68.3 hours a week in remote areas. Table C5: Specialists in obstetrics and gynaecology: average working hours and average age, by geographic location, 1995
Region of main job
Major urban centre
Large rural
Centre
Small rural
centre
Other rural area
Remote
Total
Total obstetrics and gynaecology workforce AIHW (1997) Total hours worked
54.8
58.4
59.0
39.9
75.0
55.0
Direct patient care hours worked
46.1
51.5
53.2
41.5
68.3
46.9
Hours on call not worked
64.3
59.1
66.1
70.5
93.0
64.3
Per cent practitioners on call (%)
62.0
63.9
79.3
81.3
100.0
63.6
Average age
51
50
50
58
48
51
Source: RACOG/AMWAC Survey 1997 and AIHW Practice Profiles In 1995, 84.7% of obstetricians and gynaecologists reported their main job or secondary job was located in private rooms, 49.5% in an acute care public hospital, 9.7% in acute care private hospital, and 16.1% in other settings. The proportion reporting employment in public hospitals was much higher in the Australian Capital Territory (79.8%) and lower (31.1%) in Western Australia. Private hospital employment was highest in the Australian Capital Territory (19.8%), New South Wales (17.2%) and Tasmania (11.9%).
AMWAC 1998.6 116
APPENDIX D: SERVICE PROVISION AND REQUIREMENTS OF OBSTETRICS AND GYNAECOLOGY
In compiling this report, the Working Party agreed that the Australian community should have available an adequate number of trained obstetric and gynaecology specialists appropriately distributed to provide the obstetrics and gynaecology services it requires. All Australian residents must have access to a good standard of obstetric and gynaecology services as well as sub-specialty services, irrespective of geography and economic status. The community is therefore best served when obstetric and gynaecology specialists and sub-specialists have high standards of qualification and work with a high level of ongoing experience. A RACOG specialists/sub-specialist in obstetric and gynaecology therefore should be able to provide the following services: deliver expert advice and treatment to maximise the safety and well-being of the
patient in a caring professional manner appropriate management of pregnancy; appropriate management of gynaecological diseases; appropriate service proficiency across all female age groups; appropriate level of information and explanation to patients; appropriate tests and treatment to patients; to arrange a further opinion if requested and practicable; to offer referral to another obstetrician/gynaecologist if unable to care for any reason; to provide appropriate professional cover for periods off duty or on leave; and to be available within 15 minutes travelling time from the nearest serviced hospital;
this also holds for rural and remote areas. Population Catchment The population catchment required for a capital city/major urban area has been identified as 1 per 20,000 total Australian population. In rural and remote areas it is recommended area there be two specialists covering a total Australian population catchment of 40,000-60,000. Two specialists are required so that a viable obstetric and gynaecology service is offered to the community and covered for 24 hours. Two specialists will be able to support emergencies, provide cover during travelling time of colleague, and provide on call hours support, relief during holidays, study and sick leave. In areas where there is outreach services provided to large remote areas such as Cairns, RACOG has recommended that there should ideally be at least four specialists which will allow appropriate cover for those specialists who are on call and/or are visiting remote areas. Other Specialist Services Required in Close Proximity
AMWAC 1998.6 117
In capital cities/major urban areas the following specialists are considered necessary in providing a good standard of obstetric and gynaecology service: anaesthetists
dieticians
midwives
physiotherapists
neonatal trained nurses
genetic counselling services
paediatricians
access to community mental health
psychiatrists neonatologists
ultrasound provided by individual with medical training
psychologists
availability of specialist physicians and specialist surgeons
for cross referral and consultation
In rural and remote areas the following specialists are considered necessary in providing a good standard of obstetric and gynaecology service: anaesthetists psychiatrists
availability of specialist physicians and specialist surgeons
for cross referral and consultation midwives genetic counselling services
the ability to transfer to other hospital to services such as
ICU paediatricians
visiting specialists such as urologists
radiology pathology
general practitioners and surgeons with training in
obstetrics psychologists
ultrasound provided by individual with medical training
Surgical Facilities Surgical facilities that are required to provide obstetrics and gynaecology services include: gynaecological equipment; sterilisation equipment. Colposcopy; ultrasound; office hysteroscopes need to be provided wherever the outreach specialist is consulting. Infrastructure The following infrastructure are required in capital cities /major urban areas to provide obstetrics and gynaecology services: a fully equipped theatre, intensive care unit, maternal fetal unit, ultrasound and radiology unit as well as appropriate medical and surgical backup. In rural and remote areas a level 2 nursery is necessary. Access to the following are also required: ante-natal care services, intensive care unit, maternal fetal unit, ultrasound and radiology unit, telelink to consultants and access to medical and surgical
AMWAC 1998.6 118
backup. The provision of accommodation for both obstetrics and gynaecology patients is also important as well as access to good transport to and from hospital for both patients and specialists. Requirements for the Indigenous Community The most important requirement in providing appropriate services to Indigenous communities is the education of doctors and staff in birthing facilities in appropriate attitudes and ethnic understanding. It is also essential that there is an increase in the number of Indigenous people working in the areas of women=s health care, nursing, midwifery and medicine. The provision of accommodation for both obstetrics and gynaecology patients and the extended family is considered necessary when dealing with the Indigenous communities and their culture. By the same token it is vital that services be provided by the same specialist rather than new specialists so that trust and communication is established with Indigenous patients. Basic Requirements for Providing a Rural Outreach Service In a rural outreach service it is important that there is an appropriate consulting facility with a dedicated nurse or health worker who monitors the practice and sets up appointment times and provides ante-natal care. There is also a need for the availability of appropriate hospital infrastructures for operative procedures; small surgical/limited equipment; access to allied health professionals and ancillary staff; access to other specialist services; and a telelink to other consultants. The interest and support of local GPs is also paramount in the success of maintaining a rural outreach service. Another incentive is the availability of good transport to the area for specialists.
AMWAC 1998.6 119
APPENDIX E: RACOG OBSTETRICS AND GYNAECOLOGY TRAINING PROGRAM
The following information on the obstetrics and gynaecology training program was provided by RACOG Eligibility Prospective trainees must hold medical registration approved by a relevant certifying authority. All trainees commencing the RACOG Training Program will be required to complete the requirements of the new FRACOG Training Program which includes a four year Integrated Training Program and a two year Elective Training Program. The Integrated Program consists of defined clinical and educational experience in training hospitals. This includes the MRACOG Distance Education Program and in-training assessment in the form of the In-Hospital Clinical Assessment modules. The terminal or exit assessment for the Integrated Program will be the MRACOG examination, which is designed to test core knowledge and skill. This examination will continue to consist of the MRACOG written (MCQ) examination and the MRACOG oral (OSCE) examination. Because it will be the terminal assessment for the Integrated Program, trainees are only able to attempt the MRACOG examination for the first time during Year 4 of the (the final year) of the Integrated Program. The Elective Program is completed in the remaining two years of the MRACOG/ FRACOG Training Program. This program is designed to offer Trainees an opportunity to pursue a special interest in a planned way. Trainees are required to submit a plan for a two-year program which is designed to meet their own educational needs. This plan must be prospectively approved. Some obvious options include further training in operative obstetrics and gynaecology, training in provincial posts, research leading to a postgraduate degree (eg. MD or MPH) and the commencement of sub-specialty training. The requirements for being granted the FRACOG will be satisfactory completion of both the Integrated Program (including passing the MRACOG examination) and the Elective Program. Integrated Program Essentials The following are Essentials for an Integrated Program. In other words, for a program to be accredited by the College, it must be able to offer the following: a planned rotation over a four year period which includes at least 12 months
experience in hospitals other than the home hospital and at least 12 months in a tertiary hospital;
a Program Coordinator with responsibility for coordinating that Integrated Program
AMWAC 1998.6 120
a tutorial program specifically designed for MRACOG trainees; and levels of clinical experience such that each Trainee can obtain the following
minimum levels of experience over the four years of the program. Figures for procedures refer to the number of procedures available to be performed, not assisted, by the Trainee. All figures refer to the minimum levels of experience which hospitals must agree to arrange for each Trainee over the four year period of the Integrated Program. However, they do not define absolute requirements that must be met by each Trainee. 100 normal deliveries (supervision and management) 100 Caesarean sections 100 operative vaginal deliveries (including multiple pregnancy, ventouse, breeches,
forceps) 100 major abdominal surgical procedures 50 major vaginal surgical procedures 200 laparoscopic examinations or procedures 100 hysteroscopic examinations or procedures 100 colposcopic examinations 50 hours of ultrasound 300 hours in gynaecology clinics (inc. specialist clinics in uro-gynaecology and
reproductive medicine) 300 hours in obstetrics clinics 3 months in an approved gynaecologic oncology unit (at least 50% of this time must
be spent in clinical work in gynaecologic oncology) In addition to these essentials, each Integrated Program is required to meet the standards already in place for approval of training posts as defined in the document Standards for the Accreditation of MRACOG/FRACOG Training Posts. However, it is not necessary for each of the training posts in the Integrated Program rotation to meet all of these standards (e.g. library requirements) as accreditation is based on the four year program rather than on any individual training post. All trainees who entered the Training Program after 1 January 1997 are required to spend at least six months in a provincial post at some stage of the MRACOG/FRACOG Training Program (i.e. as a component of either an Integrated Program or an Elective Program). Trainees are advised by the Program Coordinator/Training Supervisor of their planned rotation for the four year program, at the commencement of Year 1. Approval for training at a provincial training post will be based on the particular merits of that training post. Flexibility regarding the model for training supervision will be considered.
AMWAC 1998.6 121
Program Coordinators Each Integrated Program is coordinated by a Program Coordinator, appointed by the College for a minimum two year period. The Program Coordinator is responsible for planning the local Integrated Program and coordinating the progress of Trainees through the program. As such, the Program Coordinators role is similar to the Chairman of a State Training and Accreditation Committee in those states which already offer a statewide program or similar to the Senior Training Supervisor in major teaching hospitals which already offer a program involving rotation to other hospitals. The role of the Training Supervisor in the individual hospitals will continue with little change. Hospital-Based and State-Based Integrated Programs Because each Integrated Program is four years in duration and because it must involve at least two hospitals, each program must be offered cooperatively by at least two hospitals. This is, however, the only institutional requirement. An Integrated Program could thus be offered by: a tertiary hospital and a single peripheral hospital; a tertiary hospital and a number of peripheral hospitals; two or more tertiary hospitals; all of the teaching hospitals within an Australian state; two or more hospitals, at least one of which is a tertiary hospital, in different
Australian states; two or more hospitals, at least one of which is a tertiary hospital, in different
countries A program which included all of the teaching hospitals within a state (a state-based program) might, in effect, have no base hospital but instead be coordinated from the State Training and Accreditation Committee. However, it is expected that most programs are hospital-based in the sense that Trainees receive most of their training at a single base or home hospital and rotate out to other hospitals intermittently. Elective Programs While Integrated Programs are designed to standardise the clinical and educational experience available to Trainees in the core areas of obstetrics and gynaecology, Elective Programs may be individualised to meet the needs and interests of the Trainee. Each trainee is required to submit a learning plan for prospective approval by the State Training and Accreditation Committee. The Trainees Elective Program may focus on: extending expertise in general obstetrics and gynaecology; extending expertise in gynaecological surgery; developing expertise in provincial practice; developing research expertise; developing expertise in an area of special interest; commencing sub-specialty training or developing expertise in practice in the third world. The Elective Program is designed to be individualised and its aims will therefore vary from trainee to trainee. However, there are some aims which should be common to most Elective Programs, especially those pursued in the last two years of training.
AMWAC 1998.6 122
These include the development of confidence and competence in surgery; confidence and competence in patient management; career directions; leadership skills; teaching skills; financial management skills; and people management skills. While there is no intention to make any of these mandatory, it is expected that most individualised Elective Programs will focus on at least some of these areas. Resources Required for the Training of Specialists in Obstetrics and Gynaecology Whether a program receives accreditation is determined by the nature and content of the program in regard to its adequacy in: clinical exposure and >in-service= training; teaching sessions and seminars; instruction in pathology; instruction in medicine and surgery relevant to obstetrics and gynaecology; and library facilities which include obstetrics and gynaecology textbooks listed in the College recommended reading list, together with an adequate selection of general medical texts and journals as well as E-mail and Internet access. There also needs to be time for reading and study during normal working hours and arrangements to allow trainees to attend lectures and seminars within the hospital itself and at other institutions. For accreditation a program should have the following content: clinical obstetrics and gynaecology, it is expected that the majority of training will be
spent in clinical work with the trainee responsible, under supervision, for the care of patients in both the outpatients department and the wards;
pathology; medicine and surgery relevant to obstetrics and gynaecology. library with E-mail and Internet access and general reading (journals, preparation for
seminars and case presentations); regular teaching sessions/seminars and group discussions.
AMWAC 1998.6 123
APPENDIX F: GENERAL PRACTITIONERS PROVIDING OBSTETRICS AND GYNAECOLOGY SERVICES
One of the features of the obstetrics and gynaecology workforce is the scope for alternative providers to provide some of the services. The pattern of health care provision in obstetrics and gynaecology varies markedly by region, with specialist involvement much more likely in the capital cities and much less likely in regional areas. In rural and remote areas, GP and midwifery provision is predominant. These patterns have clear implications for specialist requirements and the need for provision of services. GENERAL PRACTITIONERS RACOG Diploma and Certificate Programs in Women=s Health Generally, GPs wishing to provide obstetrics and gynaecology services complete an additional training program in obstetrics and gynaecology. The training is overseen by the Joint Consultative Committee - RACOG and RACGP. GPs can qualify with either the Diploma of RACOG (DRACOG) and the Certificate of Satisfactory Completion of Training in Women’s Reproductive Health (CSCT). The aim of the DRACOG is to provide training to GP obstetricians who wish to be able to: perform normal deliveries, assisted deliveries and to a limited extent, breech
deliveries; perform basic gynaecological procedures; undertake shared ante and postnatal care with specialists obstetricians or a
specialist hospital; manage of the antenatal care of low to moderate risk to patients; and, provide family planning advice
The DRACOG is a time limited qualification and requires re-certification every three years. The aim of the CSCT is to provide training to GP obstetricians who wish to provide: shared ante and postnatal care with specialists obstetricians, GP obstetrician or a
specialist hospital; management of the antenatal care of low to moderate risk to patients; office gynaecology; and, family planning.
CSCT holders do not undergo re-certification, instead they are asked to declare their commitment to maintenance of standards by involvement in the RACGP quality assurance and continuing medical education program.
AMWAC 1998.6 124
The duration of training for the DRACOG is for a minimum period of six months and the CSCT is for a minimum period of three months. Currently there are 2,845 GPs who have the (DRACOG). Table F1 shows that Victoria has the highest number (35.1%) of qualified GPs in obstetrics and gynaecology. There are a further 161 DRACOG candidates who at the end of 1997 have applied to sit the written and oral examinations. Table F1: General practitioners qualified to practice in obstetrics and gynaecology and general practitioners candidates for the DRACOG, by gender and State/Territory 1997
Gender
NSW
Vic
Qld
WA
SA
Tas
ACT
NT
Total
Qualified DRACOG
Males
447
548
223
186
189
35
21
31
1,680
Females
263
451
123
101
135
31
25
36
1,165
Total %
710
25.0
999
35.1
346
12.2
287
10.1
324
11.4
66
2.3
46
1.6
67
2.3
2,845
100.0
DRACOG candidates
Males
21
28
17
10
9
1
0
5
91
Females
19
25
6
8
6
2
1
3
70
Total
40
53
23
18
15
3
1
8
161
Source: RACOG 1997 There are currently 27 GPs who have the CSCT qualification in Australia. There are a further 93 CSCT candidates who at the end of 1997 have applied to sit the written and oral examinations.
AMWAC 1998.6 125
Table F2: General practitioners qualified with the Certificate Satisfactory Completion of Training in women’s health and candidates, by gender and State/Territory 1997
Gender
NSW
Vic
Qld
WA
SA
Tas
ACT
NT
Total
Qualified CSCT
Males
0
4
2
0
1
0
0
0
7
Females
5
7
2
0
4
0
1
1
20
Total
5
11
4
0
5
0
1
1
27
CSCT candidates
Males
6
12
1
3
3
0
1
3
29
Females
12
29
5
5
12
0
1
0
64
Total
18
41
6
8
15
0
2
3
93
Source: RACOG 1997 Rural and Remote General Practitioners who Practice in Obstetrics and Gynaecology The Centre for Rural Health conducted a National Rural General Practitioner Survey in 1996. The survey collected information in regards to rural general practitioners working in obstetrics and gynaecology and this information is shown below in Table F3. Of the survey respondents, 541 indicated that they practice in obstetrics and gynaecology. All of these respondents were qualified in either DRACOG or CSCT. Table F3: Rural and remote general practitioners who practice in obstetrics and gynaecology, by State/Territory, 1997
NSW/ACT
Vic
Qld
WA
SA
Tas
NT
Total
GPs practising in obstetrics & gynaecology
138
123
96
105
61
10
8
541
%
25.5
22.7
17.7
19.4
11.3
1.9
1.5
100.0
Source: Centre for Rural Health, 1997 Female GPs represented 15.5% of the GPs who indicated they practice in obstetrics and gynaecology. Age Profile 50% of respondents who indicated that they were GPs who practice in obstetrics and gynaecology were aged 35 to 44 years, and 41.2% were aged over 45 years.
AMWAC 1998.6 126
Table F4: Age profile of rural and remote general practitioners who practice in obstetrics and gynaecology, by sex and age, 1997
Age (years)
Males
Females
Total
%
less than 35
30
18
48
8.9
35-44
220
50
270
50.0
45-54
138
17
155
28.7
55-64
45
4
49
9.1
65-74
16
1
17
3.1
75+
2
0
2
6.1
Total
451
90
541
100.0
%
83.4
16.6
100.0
100.0
Source: Centre for Rural Health, 1997 Geographic Location The majority of respondents providing obstetrics and gynaecology services were located in other rural areas (28.5% of the total female population) (59.9%); 15.2% of respondents were located in remote areas. Table F5 below shows the age and geographic distribution of GPs who practice in obstetrics and gynaecology in rural and remote areas of Australia. The highest age range is in the 36 to 40 year olds at 26.4% with the majority of this age group (62.9%) working in other rural areas. The highest proportion (30.9%) in remote areas are represented by the 41 to 45 year olds. Table F5: Age profile of rural and remote general practitioners who practice in obstetrics and gynaecology by geographic location, 1997
Age (years)
Small rural area
Other rural area
Remote centre
Remote other
<31
1
6
1
1
31-35
12
36
5
3
36-40
33
90
8
12
41-45
36
79
12
13
46-50
25
55
5
3
51-55
15
19
3
5
56-60
6
17
3
3
61-65
4
8
1
1
66-70
1
10
1
1
Total
133
320
39
42
%
24.9
59.9
7.3
7.9
Source: Centre for Rural Health, 1997
AMWAC 1998.6 127
Hours Worked The average hours worked by GPs who are practising in obstetrics and gynaecology in rural/remote areas of Australia is 1.06 hours (std. deviation ∀ 0.1) in obstetrics. Those aged 35 to 44 years of age indicated the highest average hours per week at 1.36 hours. Current Issues Regarding the Decline in GP Obstetricians Comprehensive national data is not available on the number of services provided by GP obstetricians and therefore the trend in service provision. This is a serious data deficiency when attempting to determine which practitioners are providing obstetrics and gynaecology services. Nevertheless, it is generally considered that there is a decline in the number of GPs providing birthing services. For example, the number of GPs who performed more than five private patient confinements (including Caesareans) annually declined by 37.2% in the period from 1988 to 1992 (AIHW). This does not give the complete picture as it is likely that GPs continue to provide at least the non-procedural components of birthing services quite extensively. Anecdotal evidence suggests that the likelihood that birthing services to public patients in public hospitals are provided by GPs more often in rural and remote areas and less often in provincial/urban areas. However, with the general decline in numbers of rural and remote birthing practitioners and the availability of local birthing services this may have an adverse effect upon patient safety. For example, women in rural areas prefer to give birth close to home which can lead them to choose to stay at home until it becomes too late to go anywhere except the local hospital. This can be because of personal preference, but more often, it can be because of financial necessity or the need for close family support. This is particularly the case for Aboriginal and Torres Strait Islander women. Alternatively, where a woman has a short labour, the same result can occur as an automatic consequence of labour. The delay in attending hospital, the possible lack of facilities and expert back-up close at hand, and the consequent emergency nature of the birth can compromise the safety of the birthing services. As the number of GPs providing procedural birthing services declines, the effect on the availability of local birthing services in rural and remote areas is likely to be more adverse because the majority of services in these areas have traditionally been provided by GPs rather than specialists. Various studies have been undertaken to examine the reasons GP obstetricians are discontinuing practice and these are summarised below. Lifestyle and Family Considerations A study of why GPs are ceasing obstetrics in Victoria was conducted by Dr Kathy Innes in 1996. The findings of this study confirm the hypothesis that reasons other than those related to Medical indemnity insurance premium increases and fear of litigation are
AMWAC 1998.6 128
important in a GPs decision to cease intrapartum obstetric practice. The study found that the other reasons are primarily to do with lifestyle and family. Medicolegal threat was chosen by a significant number of doctors as a secondary reason for ceasing obstetrics. The qualitative information gained from this study indicates that ceasing to provide obstetric care is a difficult decision for many family physicians and that a socially acceptable reason related to cost benefit or fear of litigation is easier to justify to oneself and ones community than the real reason which may be related to home and family. This is particularly true in small to medium size communities where loss of even one service provider is crucial and the family doctor is more likely to be held responsible for the loss of such a service. Analysis of the GPs most important reason for ceasing obstetrics shows that 36% (18) chose personal, family or interference with lifestyle as their number one reason for ceasing. 16% (8) chose rising insurance premiums. Concern regarding the management of unexpected emergencies and lack of remuneration were chosen by 10% (5) and 8% (4) respectively. Other reasons for ceasing obstetrics included: closure of local hospital; not doing enough deliveries to maintain skills and the stress of being constantly on call and the exhaustion of working night and day. Comparison between the reasons from rural GPs and urban or provincial GPs suggested that both groups consider personal, family and lifestyle issues as the most important 29% versus 40%. Urban/provincial GPs, however site lack of remuneration (12%) and interference with other clinical responsibilities (8%) as important. Rural GPs indicated that rising insurance premiums (25%) and concern regarding the management of unexpected emergencies (13%) were also very important to them. In an analysis of the doctors’ suggestions to keep GP’s practising obstetrics, 45% (24) of the GP respondent doctors felt that the most useful suggestion for retaining doctors in obstetrics involved increasing the fees. Comments were made that it takes 10 deliveries just to pay the medical defence premiums. Suggestions included: altering the on-call or after hours arrangements 19% (10) and altering the medical defence arrangements 11% (6). Medical Indemnity Another indicator for the decline in the number of GPs providing obstetric services is the increasing cost of medical indemnity. Indemnity insurance increases pose a problem for GP obstetricians who provide services in rural and remote areas where they need
AMWAC 1998.6 129
to undertake at least 20 deliveries a year under the sessional payment system to cover the extra medical indemnity required to do obstetrics. Specialists have been able in part to compensate the medical indemnity situation by an increase in incomes, as their patient caseload increased as an outcome of the trend for more women to seek specialist care irrespective of the complexity or risk to their birth. While this move to specialist care for all births including low risk births is an option in urban Australia, the same cannot be said for rural areas. It is difficult for specialists to gain what is perceived as adequate remuneration in small rural centres, simply because of the relatively small potential patient base upon which it is possible to draw and this is where the need for rural and remote GP obstetricians emerges. Studies have been undertaken to show that the medical insurance situation is a key reason for the declining numbers of GPs practising in obstetrics. One such study by Watts et al in 1997, found that South Australian GPs are leaving obstetrics at an alarming rate and that the most important reason for ceasing obstetrics was indemnity insurance (56.8%) followed by lifestyle issues (54.5%) and poor remuneration (34.1%), litigation fear (29.5%), declining deliveries (29.5%) and wanning skills (22.7%). The study also reported that the recent rise in obstetric (procedural) indemnity insurance has made rural obstetric practice financially nonviable and threatened the whole service. Most GPs felt that a full subsidy tied to accreditation, but not to the number of activities, is the best way to solve the crisis. GPs also favoured independent legal tribunals as a method to handle malpractice claims. Similarly a New South Wales survey conducted by Dr Mark Henschke in 1997 found that the continuation of GP obstetrics in major rural hospitals (sessional payment) is unlikely unless there is medical insurance intervention to assist GP obstetricians in small rural centres. The survey obtained a 90% (80) response rate and found that almost one in four had stopped providing obstetric services in the previous two years. 54% indicated that they were planning to stop in the next two years, and 17% indicated that they would be continuing with GP obstetrics beyond 1999. Of those GP obstetricians who had stopped in the previous three years, 70% cited the cost of medical indemnity insurance as the major factor and a further 20% indicated the stress associated with the obstetrics and the pressure of constantly being on call. When asked what would entice them back to GP obstetrics, 60% indicated that financial support, such as an Obstetrics Incentive Allowance, would make them reconsider their decision to abandon obstetrics. Other recommendations that would help were specialist support and a roster for Medicare patients.
AMWAC 1998.6 130
Other Reasons Why Rural Doctors Leave Their Communities General social, cultural and professional issues are acknowledged all of which are well documented. A summary of these reasons is presented below. Access to health care in much of rural Australia remains poor by urban standards. There are many rural and remote communities that have traditionally had difficulty in attracting and keeping doctors. While the interest in a rural career among medical students and recent graduates appears to be increasing, there is little evidence that recruitment and retention of rural doctors is dramatically improving. Studies have also been undertaken to examine why rural doctors leave their communities. One such study undertaken by Hays et al in 1997 examined rural and remote Queensland doctors during 1995 and found there were are series of issues such as: family, education and support, cultural deprivation, limited social amenities, lack of privacy, limited education and employment opportunities for family members and financial considerations that are raised. The study found that the initial sense of responsibility to the rural communities, enjoyment of the clinical variety, autonomy and family lifestyle, and appreciation of assimilation into the community were powerful influences to stay. However, enthusiasm waned in response to pressures to return to a larger centre. Overwork, awareness that family and friends were distant and appreciation of the educational and career limitations of staying too long contributed incrementally to a situation where there was no longer any perceived reason to stay. Another very basic factor such as the identification with the community also brought disadvantages. Rural medical families have little, if any, anonymity, contributing to the feeling that it is difficult not to be at work. The close and special relationship with the community can interfere with clinical work. Being an important part of a close community also tests other relationships. Personality clashes can develop with significant community leaders, such as senior nursing staff, other doctors, health managers and local government leaders. Small communities are difficult to live in when there are uncomfortable relationships with powerful but unavoidable individuals. In response to questions about measures that could entice a longer commitment the following suggestions were offered: improving housing quality; quality and access to locums for longer holidays, particularly for longer services; short term CME relief; the provision of more flexible delivery CME through the use of information technology; the provision of management training to be offered during vocational training; the development of educational packages for families, such that children are being supported locally. The study found that many urban background doctors will not stay more than three to five years in certain smaller communities. In the longer term, increased selection of
AMWAC 1998.6 131
students from a rural background should provide a higher proportion of graduates who will remain comfortable with rural community life. In Australia, and particularly rural Australia, where obstetric services are largely dependent upon GPs as service providers, access to obstetric care is threatened if the issues mentioned above are not addressed. Once a doctor has ceased obstetrics, the evidence would suggest that they do not resume and will not consider resuming except under the most urgent of clinical circumstances.
AMWAC 1998.6 132
APPENDIX G: AMWAC SURVEY OF DIVISIONS OF GENERAL PRACTICE METHODOLOGY To obtain information about the adequacy of the supply of specialist obstetric and gynaecology services throughout Australia, AMWAC administered a mailed survey of all Divisions of General Practice. Of a possible 122 Divisions, 77 responded (63.1%). RESULTS Distribution of Respondents Table G1 shows the distribution of responding Divisions to the AMWAC survey by State/Territory and by location. 37.6% of Divisions were from New South Wales, 26% from Victoria, 11.7% from Queensland, 10.4% from Western Australia and 7.8% from South Australia. With respect to location, 35.1% were located in a capital city, 13% in an other metropolitan area and 51.9% in a rural area. Table G1: Distribution of responding Divisions of General Practice, by State/Territory and geographic location, 1997
% DGP* by location
State/Terr.
Total
number of DGP*
% DGP*
by State/Terr.
Capital City
Other
metropolitan
Rural
Total
NSW
29
37.6
24.1
27.6
48.3
100.0
Victoria
20
26.0
40.0
0.0
60.0
100.0
Qld
9
11.7
33.3
22.2
44.4
100.0
South Aust.
6
7.8
16.6
0.0
83.3
100.0
West. Aust.
8
10.4
62.5
0.0
37.5
100.0
Tasmania
2
2.6
50.0
0.0
50.0
100.0
North. Terr.
2
2.6
50.0
0.0
50.0
100.0
ACT
1
1.3
100.0
0.0
0.0
100.0
Australia
77
100.0
35.1
13.0
51.9
100.0
*Number of Divisions of General Practice Source: AMWAC survey of Divisions of General Practice When the data from (Table G1) are compared with the distribution of all Divisions of General Practice (Table G2) it can be seen that among respondents to the AMWAC survey, New South Wales Divisions are over-represented, Queensland Divisions are under-represented and rural Divisions are over-represented.
AMWAC 1998.6 133
Table G2: Distribution of all Divisions of General Practice in Australia, by State/Territory and geographic location, 1997
% DGP* by location
State/Terr.
Total
number of DGP*
% DGP* by State/Terr.
Capital city
Other
metropolitan
Rural
Total
NSW/ACT
36
29.5
44.4
27.7
27.7
100.0
Victoria
32
26.2
53.1
12.5
34.4
100.0
Qld
20
16.4
40.0
35.0
25.0
100.0
South Aust.
14
11.5
35.7
7.1
57.1
100.0
West. Aust.
13
10.7
69.2
0.0
30.8
100.0
Tasmania
3
2.5
33.3
33.3
33.3
100.0
North. Terr.
4
3.4
25.0
0.0
75.0
100.0
Australia
122
100.0
46.7
18.9
34.4
100.0
*Number of Divisions of General Practice Source: AMWAC survey of Divisions of General Practice Triggers for General Practitioner Referral to a Specialist Obstetrician Gynaecologist Divisions of General Practice were asked to indicate the importance of eight Αtriggers≅ for referral to an obstetrician and gynaecologist and to identify any further important triggers. Table G3 indicates that the two most important triggers for a referral are condition unresponsive to treatment and severity of the condition followed by lack of experience within the practice regarding the condition and/or its treatment, the availability of appropriate back-up, rarity of the diagnosis and request of patient to be referred. The least important triggers for referral to an obstetrician and gynaecologist were the age and social circumstances of the patient. No differences were observed among responses to this question based on location (ie., metropolitan or rural).
AMWAC 1998.6 134
Table G3: Importance of eight triggers for general practitioner referral to an obstetrician and gynaecologist, 1997
Trigger
Not important
Very important
1
2
3
4
5
Condition unresponsive to treatment
0.0
1.8
12.5
41.1
44.6
Severity of the condition
0.1
1.2
15.6
57.1
26.0
Lack of experience
0.0
8.8
24.6
43.9
22.8
Availability of appropriate back-up
0.0
10.7
23.2
37.5
28.6
Rarity of the diagnosis
5.4
12.5
17.9
37.5
26.8
Request of patient to be referred
5.3
10.5
24.6
43.9
15.8
Age of patient
22.8
28.1
28.1
15.8
5.3
Social circumstances of the patient
36.8
33.3
19.6
10.5
0.0
Source: AMWAC survey of Divisions of General Practice Supply of Resident and Visiting Obstetricians and Gynaecologists Table G4 indicates that 22.2% (n=14) of Divisions of General Practice reported that there were no resident obstetrics and gynaecology specialists providing services in the area covered by their Division. Of these Divisions, 7 (50%) were from New South Wales, and all but one were from rural locations. Further analysis revealed that of the Divisions with no resident obstetrics and gynaecology specialists all but two had specialists visiting their area. Table G4: Percentage of Divisions with resident obstetricians and gynaecologists providing services in area, by State/Territory, 1997
Number of resident obstetricians and gynaecologists
State/ Terr.
None
One
Two
Three
Four
Five-Ten
11 or more
Total
NSW
28.0
20.0
4.0
20.0
8.0
8.0
12.0
100.0
Vic
15.4
7.7
15.4
46.2
0.0
15.4
0.0
100.0
Qld
28.6
0.0
0.0
14.3
14.3
42.9
0.0
100.0
SA
33.3
50.0
16.6
0.0
0.0
0.0
0.0
100.0
WA
12.5
37.5
0.0
12.5
0.0
25.0
12.5
100.0
Tas
0.0
0.0
0.0
0.0
50.0
50.0
0.0
100.0
NT
0.0
0.0
100.0
0.0
0.0
0.0
0.0
100.0
Aust
22.2
19.0
7.9
20.6
6.3
17.5
6.3
100.0
Source: AMWAC survey of Divisions of General Practice
AMWAC 1998.6 135
Adequacy of the Supply of Obstetricians and Gynaecologists 55.4% (n=43) of Divisions of General Practice considered that a shortage of obstetrics and gynaecology specialists existed in their area with the remaining predominantly of the opinion that supply was about right (Table G5). One Division in South Australia considered there was an oversupply. States/Territories with the greatest shortage of obstetrics and gynaecology specialists were New South Wales, Victoria and the Northern Territory. Significantly (p<0.05), a greater percentage of rural Divisions (61.5%) perceived the supply of obstetrics and gynaecology specialists to be inadequate than did Divisions located in capital cities (50%) or other urban areas (50%). Comments on the adequacy of services reflected the distribution of obstetrics and gynaecology specialists. For example, Divisions in well supplied areas commented that access is good, a specialist is always available and we have excellent access through the flying O&G service in Queensland. Divisions in poorly supplied areas commented that access is excellent in the town but poor in remote areas. Aboriginal women have to travel to town for ultrasounds, waiting time for specialists is three months, waiting times for public patients is too long, adequacy during weekends and nights is poor. Impending shortages were also commented on. For example Divisions indicated that some GPs are giving up obstetric practice because of the costs of indemnity insurance and that in some cases this is placing a heavy burden on other GPs. Suggestions for improving the supply of obstetrics and gynaecology services included training more specialists, specialists doing more visits to regional centres, allowing GPs and midwives to do antenatal care, opening the rural hospital, improved transport, training for small hospital GP antenatal services to Aboriginal women, shared care and improved financial incentives for GP confinements in rural areas with phone link with specialists. Table G5: Adequacy of the supply of specialist obstetricians and gynaecologists by State/Territory, 1997 State/Terr.
Shortage
About Right
Over supplied
Total
NSW
70.0
30.0
0.0
100.0
Victoria
66.7
33.3
0.0
100.0
Queensland
42.9
57.1
0.0
100.0
South Aust.
0.0
83.3
16.7
100.0
West. Aust.
42.9
57.1
0.0
100.0
Tasmania
50.0
50.0
0.0
100.0
NT
100.0
0.0
0.0
100.0
Australia
55.4
42.9
1.7
100.0
Source: AMWAC survey of Divisions of General Practice
AMWAC 1998.6 136
Requirement for Additional Resident and Visiting Obstetricians and Gynaecologists In response to the question ΑIf a shortage for obstetrics and gynaecology specialists exists in your area, please indicate the number of resident and visiting specialists required≅, Divisions with shortages indicated a need for 82 resident specialists and 26 visiting specialists. Resident specialists are required in New South Wales (26), Victoria (22), Queensland (6), Western Australia (5), the Northern Territory (9) and Tasmania (4). Capital city located Divisions perceived a requirement for 44 resident obstetrics and gynaecology specialists while rural Divisions required 31 and other metropolitan Divisions required 7. Visiting specialists are required in Victoria (13), New South Wales (8), Queensland (3), Western Australia (1) and the Northern Territory (1). Capital city located Divisions perceived a requirement for 17 visiting specialists and rural Divisions required nine. Availability of General Practitioners with Qualifications in Obstetrics and Gynaecology Over 72.7% (n=56) of Divisions responded to the question about the number of resident general practitioners providing services in their area with qualifications in obstetrics and gynaecology. Of these, all but three Divisions indicated that there was one or more resident general practitioner providing services in their area with qualifications in obstetrics and gynaecology. Significantly, over 80% of rural Divisions indicated that they had one or more resident qualified general practitioners in their area while the comparative figures for other metropolitan areas and capital city areas were 70% and 48.1% respectively (Table G6). Only five Divisions reported having general practitioners visiting their area with qualifications in obstetrics and gynaecology and all were located in capital cities. Table G6: Number of Divisions with resident general practitioners with qualifications in obstetrics and gynaecology providing services in area, by State/Territory, 1997
Number of resident GPs with qualifications in obstetrics and gynaecology
Location of DGP*
None
One
Two
Three
Four
Five-Ten
11 or more
Total
Capital City
2
2
1
0
0
2
8
15
Other Urban
0
0
0
3
1
1
2
7
Rural
1
3
3
3
0
11
13
34
Total
3
5
4
6
1
14
23
56
* DGP - Divisions of General Practice Source: AMWAC survey of Divisions of General Practice Satisfaction with the Diploma of Obstetrics offered by RACOG
AMWAC 1998.6 137
Divisions indicated strong support for the Diploma of Obstetrics offered by the Royal Australian College of Obstetrics and Gynaecology. Ninety three percent of Divisions answered in the affirmative to the question ΑDo you consider the Diploma of Obstetrics offered by RACOG the preferred qualification by general practitioners in Australia?≅ Comments as to how the program could be improved included a need to develop more hands-on skills to equip rural GPs and the need for a definite rural component. Summary The findings arising from this survey of Divisions of General Practice indicate an overall shortage of obstetrics and gynaecology specialists. However, this shortage is greater in some State/Territories than others and is particularly pronounced in some rural and remote areas. Divisions of General Practice have indicated a need for an additional 82 resident obstetrics and gynaecology specialists and 26 visiting specialists. There is strong support among Divisions for the RACOG Diploma of Obstetrics and at least 43% of Divisions of General Practice throughout Australia have general practitioners with qualifications in obstetrics and gynaecology providing services to patients in their area.
AMWAC 1998.6 138
APPENDIX H: DATA ON MIDWIVES Definition ΑA midwife is a person who, having been regularly admitted to a midwifery educational program, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. She must be able to give the necessary supervision, care and advice to women during pregnancy labour and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant. This care includes preventative measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help. She has an important task in health counselling and education, not only for the women, but also within the family and the community. The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynaecology, family planning and child care. She may practice in hospitals, clinics, health units, domiciliary conditions or in any other service. (Jointly developed by the International Confederation of Midwives and the International Federation of Gynaecology and Obstetrics. Adopted by the International Confederation of Midwives Council 1972. Adopted by the International Federation of Gynaecology and Obstetrics 1973. Later adopted by the World Health Organization. Amended by the International Confederation of Midwives Council, Kobe October 1990. Amendment ratified by the International Federation of Gynaecology and Obstetrics 1991 and the World Health Organisation 1992.) Main Characteristics of the Midwifery Workforce Number of Nurses Employed as Clinicians in Midwifery, Obstetrics and Gynaecology The AIHW Nursing Labour Force Survey indicated that, in 1995, there were 13,913 registered and enrolled nurses employed in midwifery and 1,540 employed in obstetrics and gynaecology. Table H1 below shows that New South Wales has 31.1% of midwives where the Northern Territory has 1.4% of the total workforce. Table H1: Registered and enrolled nurses in midwifery, obstetrics and gynaecology, by State/Territory, 1995
Type of nurse clinician
NSW
Vic
Qld
WA
SA
Tas
ACT
NT
Total
Midwifery
4,325
3,803
2,323
1,152
1,366
399
344
201
13,913
Obstetrics and gynaecology
505
351
284
212
109
39
32
8
1,540
Total
4,830
4,154
2,607
1,364
1,475
438
376
209
15,453
% midwives
31.3
26.9
16.9
8.8
9.5
2.8
2.4
1.4
100.0
% female population
34.0
25.3
17.9
9.4
8.2
2.6
1.7
0.9
100.0
Source: Nursing Labour Force, AIHW 1997 and ABS
AMWAC 1998.6 139
In 1995, there were 195,692 nurses, nurses in midwifery and obstetrics and gynaecology represented 7.9% of the nursing workforce. In 1993 there were 13,759 registered and enrolled nurses in midwifery, obstetrics and gynaecology, a 12.3% increase in the period 1993 to 1995. In 1995 there were 85.6 registered nurses per 100,000 population in midwifery, obstetrics. This consisted of 82.2 registered nurses per 100,000 population and 3.4 enrolled nurses per 100,000 population. Gender Profile In 1995, 99.0% of the midwifery workforce were females. Age Distribution Table H2 shows the age distribution of midwives in Australia in 1995 and indicates that the majority of midwives are aged 35 to 39 years (25.0%) and that 65.5% of midwives are aged over 35 years. 69.2% of nurses employed as clinicians in obstetrics and gynaecology are aged over 35 years. Table H2: Nurses employed as clinicians in midwifery and obstetrics and gynaecology, by age group, 1995
Age (years)
Midwives
% Midwives
Obstetrics & gynaecology
% Obstetrics &
gynaecology Less than 25
133
1.0
58
3.8
25-29
1,494
1.7
145
9.4
30-34
3,176
22.8
271
17.6
35-39
3,482
25.0
293
19.0
40-44
2,547
18.3
294
19.1
45-49
1,569
11.3
229
14.9
50-54
898
6.5
151
9.8
55-59
463
3.3
76
4.9
60-64
132
0.9
19
1.2
65 and over
18
0.1
5
0.3
Total
13,913
100.0
1,540
100.0
Source: Nursing Labour Force, AIHW 1997
AMWAC 1998.6 140
Geographic Location The geographic location of nurses employed as clinicians in midwifery, obstetrics and gynaecology in 1995 indicated that the majority (74.1%) were based in capital cities/metropolitan centres, 23.9% were located in rural areas and 1.9% were in remote areas (Table H3).
Table H3: Nurses employed as clinicians in midwifery and obstetrics and gynaecology, by geographic location, 1995
Geographic location
%
Capital city
66.2
Other metropolitan centre
7.9
large rural centre
11.3
Small rural centre
6.9
Other rural area
5.7
Remote centre
1.2
Other remote area
0.9
Source: Nursing Labour Force, AIHW 1997 Hours Worked The average hours worked by nurses employed as clinicians in midwifery, obstetrics and gynaecology in 1995 was 32.3 hours. Those working part time (<35 hours) represented 53.0% and those working full time (35 hours+) was 47.0%. Work Setting Table H4 shows that 76.2% of nurses employed as clinicians in midwifery, obstetrics and gynaecology worked in the public sector and 23.8% worked in the private sector. Table H4: Nurses employed as clinicians in midwifery and obstetrics and gynaecology, by work setting of main job, 1995 Work setting
Hospital
Community
Agency
Other
Total
Public
72.3
0.8
0.9
2.2
76.2
Private
21.0
1.0*
0.6
1.3
23.8
* Medical (doctors rooms) Source: Nursing Labour Force, AIHW 1997 Current Supply of Midwives Each State/Territory health department was requested to provide recent data on nurses employed as clinicians in midwifery and information on known shortages or oversupply of midwives. There was an overall difficulty experienced by all State/Territories in
AMWAC 1998.6 141
providing baseline data on midwifery staff. It was not possible for Victoria, Queensland and South Australia to provide a response. Of those States/Territories that were able to provide information, all indicated there was an undersupply of midwives. New South Wales The Nurses Registration Board of New South Wales indicated that as of 30 December 1997, there were approximately 10,400 qualified nurses in midwifery/mothercraft of which 3,044 were currently working in midwifery. This leaves a potential pool of recruits of over 7,000 recruits. Of the 3,044 currently working midwives the largest age group is the 35 to 39 year olds at 26.2%. 63.7% of practising midwives were located in capital city/metropolitan areas, 20.7% were located in provincial city/rural areas and 0.2% were located in remote areas, 15.4% gave no response. A 1996 report conducted by the New South Wales Health Department, Workforce Planning Study for Maternity Service Nurses, Adult Critical & Intensive Care and Operating Room Nurses estimated that there is a shortage of maternity service nurses in New South Wales. This conclusion was based on an examination of various trends including demographic, utilisation patterns of hospital maternity services and trends in service delivery patterns in maternity services. It also found that; there has been a trend towards greater numbers of mothers planning to give birth in
a birthing centre from 723 in 1990 to 3,404 in 1994; there are significant differences between rural and metropolitan maternity services
with the segmentation of midwifery practice into large maternity units and a general under utilisation of midwifery skills in smaller hospitals, particularly in rural hospitals; and,
there is a need to enhance parenting education services and maternity services for women with special needs.
The report recommended that to address the gap between requirements of midwives and supply of services there is a need to: increase the number of nurses in the maternity services workforce; reduce the current wastage rate; maintain the current midwifery student numbers (320 per year); and ensure full employment of midwifery students.
Western Australia The Labour Force Survey Western Australia 1997 report which contributes to the AIHW National Labour Force collections indicated that there were 2,814 registered midwives, 2350 actually working and 931 working in midwifery. Midwives represented 16% of the nursing population.
AMWAC 1998.6 142
In Western Australia, the average age of midwife respondents have risen every year for which records are available, from 37.8 years in 1989 to 42.7 years in 1997. A greater proportion of midwives than would be expected of the total nursing population reported that their main job was in rural Western Australia (32% compared to 27% nationally) and fewer midwife respondents worked in the private sector for their main job than was observed for nurses as a whole (27% compared to 30% nationally). Total entrants to the nursing workforce are also decreasing, so it could be expected that fewer nurses will be available to go into midwifery in the future. Western Australia’s projected needs for midwives based on the 1995 Nurse Workforce Planning Project are for 70 new midwives Αproduced in Western Australia≅ to join the workforce per year. Currently, Western Australia does not reach this figure as many students switch from full time to part time, and others do midwifery so they can go on to child health. In December 1996, for example, there were 26 metropolitan and 40 rural midwifery vacancies. The number of agency staff used to temporarily cover midwifery positions was 369 in the metropolitan area and 20 in the rural area, all at considerable expense, and sometimes for considerable durations. 23% of surveyed sites predicted midwifery shortages during 1997 (Nursing Vacancies Survey Report Western Australia: June to December 1996). Western Australia indicated that there is an ongoing shortage of skilled midwives available to practice in rural and remote areas. Some towns had ceased obstetric services because midwives could not be provided. A pilot Rural Midwifery Course between King Edward Memorial Hospital and the rural Health Service Units is underway, with the first cohort of four students commencing the course in October 1997 with a second group of six expected to commence in March 1998. The students are required to give a commitment to return to a rural area as a midwife on completion of the course. South Australia A report produced for the South Australian Health Commission on the South Australian Midwifery Training Requirements 1997-2002 indicated that between May 1994 to September 1996 South Australian midwifery requirements declined from 1,288.4 to 1,112.7 FTEs. However, midwifery requirements are unlikely to decline further, particularly as the birth rate in South Australia is likely to remain steady at a little below 20,000 over the period 1997-2001. It was suggested that at least 109 midwives should be trained each year. Training numbers in South Australia have been historically low, for example, about 60 midwives in total were trained in the three years up to and including 1996. These low training numbers already appear to have had significant impact on the age profile of the
AMWAC 1998.6 143
midwifery workforce. The current age distribution shows less than 7% of working midwives are under the age of 30 years, while 45% are aged between 35 and 45 years. The current age distribution, which indicates 53% of the midwife workforce is aged over 40, lends considerable weight to the argument that training numbers should considerably exceed the levels of the past three years if the midwifery workforce size remains anywhere near its current level. The recommendations by the report were: that universities be notified of the future requirements; midwifery training numbers should be at least 109 per annum over the period 1997 to 2001; and a review be done in 1998-99. Tasmania Tasmania has 1,863 licensed midwives. 50.7% (942) of midwives are aged over 45 years. A 1996 survey by the Nursing Board of Tasmania found that 31.4% (604) of respondents practised midwifery or used their skills in a practice setting which is not exclusively midwifery (ie. family child health nurse, family planning nurse). Those working directly in midwifery totalled 357 (18.5%). Of nurses working directly in midwifery 165 worked in the Southern Region, 116 in the Northern Region and 76 worked the Northwest Region. The survey also found that 554 (47.8%) of licensed midwives had not utilised their skills for in excess of five years. With the implementation of the Board=s new Competence to Practice Policy on 1 July 1998, it is hypothesised that the number of licensed midwives will drop by anywhere between 50% and 70%, giving approximate numbers of licensed midwives from 1 September 1998 to between 930 and 560. The number of graduates in midwifery during 1992 to 1997 was 158 graduates. With hospital based training in Tasmania ceased in 1997 the future training of midwives has raised concerns for the future midwifery workforce. It has been estimated that Tasmania will require at least 20 midwife graduates per year. Arrangements have begun to be formulated with Flinders University in South Australia to provide the necessary training to those students who wish to take up midwifery and practice in Tasmania. Northern Territory Table H5 represents the actual and establishment requirement for midwives in the Northern Territory and indicates there is a definite shortage of community midwives in the Northern Territory. A major problem with attracting and maintaining midwives in the Northern Territory is the professional and personal isolation experienced by the midwives. Another factor that may contribute to the high turnover rates is that a majority of midwives are from interstate and are working their way across Australia.
AMWAC 1998.6 144
The Northern Territory Health Services also holds a 14 day cultural experience rotation for community nurses which tries to address cultural issues that are relevant to the large Aboriginal population in the Northern Territory. Table H5: Midwives in the Northern Territory, by type of employment category (FTE), December 1997 Area of employment
Actual (FTE)
Requirement(FTE)
Public hospital - Darwin
44
44
Public hospital - rural and remote
77
74
Community urban
8
15
Community remote
15
48
Flight nurses (with double certificate)
15
15
Specialised women=s health service
4
4
Educators
4
4
Source: Northern Territory Health Services Issues Anecdotally, midwives are reluctant to participate in the workforce in a midwifery capacity for several reasons, including legal and ethical issues, remuneration, recognition of qualifications, opportunities to apply and maintain specialist skills, the impact of the staffing arrangements offered in terms of compatibility with family responsibilities and financial security offered by limited shift patterns. The modes of health care delivery also have not encouraged team work and mutual recognition of skills between medical and midwifery staff, with an atmosphere of demarcation existing in some instances. It is anticipated that a move toward models in which continuity of care and a team approach is used may improve this situation, as well as the overall quality of care for the patient. While the figures show that a only a low percentage of those registered as midwives are actually practising in midwifery, there are a number of related nursing fields in which a midwifery qualification is of great utility, such as neo-natal intensive care, child health, and community nursing, as well as geographic factors which, while precluding the formal practice of midwifery in small and remote locations, continues to render the possession of midwifery qualifications desirable in at least one staff member, in case of emergency. Midwifery qualifications and registration may also have been a valuable part of achieving a management or administrative position, but return to midwifery practice is unlikely.
AMWAC 1998.6 145
Analysis is yet to be undertaken to determine to what level these factors would raise the proportion of midwifery registrants who use their midwifery qualifications or perceive them to be necessary to their current employment. In short, the proportion of midwifery registrants who are actively employed in midwifery does not comprehensively depict the application of midwifery skills in Australia, nor does it mean that those midwives not currently employed in midwifery are or would be available to move into that field. There is also a range of education issues that are currently under discussion which are outside the concerns of this review but may affect the future midwifery workforce. This includes: The transfer of midwifery education to the higher education sector has been
accepted as a positive way forward by the midwifery profession in Australia and the need for universities to be more flexible with practice based courses as well as the need for close collaboration between service providers and universities to achieve success of midwifery education programs.
Midwifery is currently considered under legislation as a specialty of nursing in all
States, however, there is currently a debate as to whether potential candidates for midwifery can enroll directly into a midwifery degree without having to first undertake a general nursing training degree and therefore not prolong the training period, and making the midwifery qualification subject to HECS rather than a full fee paying status. While this decision is being disputed, the current situation is considered to pose a threat to enrollment, as does the lack of recognition for the additional skills and qualifications gained.
Furthermore, a prospective midwifery student can choose to remain in a nursing
position and be rewarded for years of experience with no further requirement for formal study other than professional updating. Midwifery does not result in any special allowance despite the nature of the increased responsibility and accountability that is expected of the practitioner.
With the move towards the evolving models of care the role of a midwife is expected
to change. This will require new skills/education, increased responsibility and therefore increased autonomy by midwives. It is anticipated that industrial and other implications may arise with the new roles associated with new service models.
AMWAC 1998.6 145
APPENDIX I: AIHW NATIONAL HOSPITAL MORBIDITY DATA Obstetrics and Gynaecology National Hospital Morbidity Data Source Data relating to obstetrics and gynaecology procedures were extracted from the AIHW National Hospital Morbidity Database. The National Hospital Morbidity Database is a compilation of electronic summary records collected in public and private hospitals. Almost all hospitals in Australia are included. The exceptions are public hospitals not within the jurisdiction of a State or Territory health authority or the Department of Veterans= Affairs (that is, hospitals operated by the Department of Defence, for example, and hospitals located in off-shore Territories). In addition, data were not able to be supplied for the one private hospital in the Northern Territory, the private free-standing day hospital facilities in the Australian Capital Territory, the public psychiatric hospitals in Queensland and some private Victorian separations in 1993-94 and 1994-95. For 1995-96, a further expansion of the scope has occurred, with morbidity data for public psychiatric hospitals included for all but Queensland. Definitions Procedures Procedures are reported according to the ICD-9-CM codes (at the 3-digit level). The ICD-9-CM classification encompasses the National Health Data Dictionary definition whereby a procedure is one that is surgical in nature, carries a procedural risk, carries an anaesthetic risk, requires specialised training, or requires special facilities or equipment only available in an acute setting. The ICD-9-CM classification also includes non-surgical investigative and therapeutic procedures such as x-rays and chemotherapy. Obstetrical procedures Obstetrical procedures are defined as in the ICD-9-CM chapter of the same name. Gynaecological procedures Gynaecological procedures are defined as in the ICD-9-CM chapter Operations on the female genital organs. Private patient Either a patient who is eligible for Medicare who elects to be a private patient or a patient who is not eligible for Medicare. Public patient A patient who is eligible for Medicare who does receives treatment free of charge ie charges are paid through the Medicare Agreements, by the Department of Veterans’ Affairs or, less commonly, by other arrangements such as compensation, Defence Force entitlements or common law arrangements.
AMWAC 1998.6 146
Limitations of the Data Although the National Health Data Dictionary definitions form the basis of the definitions of the database, the actual definitions used may have varied among the data providers and from one year to another. In addition, fine details of the scope of the data collections may vary from one jurisdiction to another. Comparisons between years and sectors should therefore be made with caution. Comparison between years in this exercise has been limited by incomplete reporting of the private or public status of patients in 1993-94 and 1994-95.
AMWAC 1998.6 147
Table I1: Gynaecological procedures (ICD-9-CM groupings) undertaken on public and private patients (a), Australia, 1995−96
Unknown
Public
Private
patient
Procedure
patient
patient
status
Total
650
Oophorotomy
589
306
0
895
651
Diagnostic procedures on ovaries
429
536
0
965
652
Local excision or destruction of ovarian lesion or tissue
4,054
4,740
2
8,796
653
Unilateral oophorectomy
1,378
1,176
0
2,554
654
Unilateral salpingo-oophorectomy
2,522
2,384
1
4,907
655
Bilateral oophorectomy
507
500
0
1,007
656
Bilateral salpingo-oophorectomy
4,915
4,857
1
9,773
657
Repair of ovary
181
110
0
291
658
Lysis of adhesions of ovary and fallopian tube
2,285
2,546
1
4,832
659
Other operations on ovary
3,322
14,142
0
17,464
660
Salpingotomy and salpingostomy
1,095
574
0
1,669
661
Diagnostic procedures on fallopian tubes
77
437
0
514
662
Bilateral endoscopic destruction or occlusion of fallopian tubes
12,691
7,289
0
19,980
663
Other bilateral destruction or occlusion of fallopian tubes
3,384
1,728
0
5,112
664
Total unilateral salpingectomy
470
431
0
901
665
Total bilateral salpingectomy
446
303
0
749
666
Other salpingectomy
2,118
1,214
2
3,334
667
Repair of fallopian tube
1,008
672
0
1,680
668
Insufflation of fallopian tube
5,002
7,289
0
12,291
669
Other operations on fallopian tubes
509
5,331
0
5,840
670
Dilation of cervical canal
554
731
0
1,285
671
Diagnostic procedures on cervix
6,558
3,836
1
10,395
672
Conization of cervix
2,850
1,830
0
4,680
673
Other excision or destruction of lesion or tissue of cervix
17,767
15,267
5
33,039
674
Amputation of cervix
159
178
0
337
675
Repair of internal cervical os
431
437
0
868
676
Other repair of cervix
204
104
0
308
680
Hysterotomy
47
18
0
65
681
Diagnostic procedures on uterus and supporting structures
29,723
37,024
12
66,759
682
Excision or destruction of lesion or tissue of uterus
4,741
7,310
2
12,053
683
Subtotal abdominal hysterectomy
249
185
0
434
684
Total abdominal hysterectomy
9,935
9,433
3
19,371
685
Vaginal hysterectomy
7,076
7,494
2
14,572
686
Radical abdominal hysterectomy
307
309
0
616
687
Radical vaginal hysterectomy
17
13
0
30
688
Pelvic evisceration
42
26
0
68
689
Other and unspecified hysterectomy
248
257
0
505
690
Dilation and curettage of uterus
70,465
61,121
19
131,605
691
Excision or destruction of lesion or tissue of uterus and supporting structures
1,883
2,366
0
4,249
692
Repair of uterus supporting structures
708
594
1
1,303
693
Paracervical uterine denervation
59
169
0
228
694
Uterine repair
63
44
0
107
695
Aspiration curettage of uterus
25,895
26,530
6
52,431
696
Menstrual extraction or regulation
2
2
0
4
697
Insertion of intrauterine contraceptive device
1,108
842
1
1,951
699
Other operations on uterus, cervix, and supporting structures
588
4,369
0
4,957
700
Culdocentesis
248
524
0
772
701
Incision of vagina and cul-de-sac
970
10,876
0
11,846
AMWAC 1998.6 148
702 Diagnostic procedures on vagina and cul-de-sac 11,149 6,105 3 17,257 703
Local excision or destruction of vagina and cul-de-sac
2,263
2,950
0
5,213
704
Obliteration and total excision of vagina
40
45
0
85
705
Repair of cystocele and rectocele
8,300
9,062
0
17,362
706
Vaginal construction and reconstruction
15
63
0
78
707
Other repair of vagina
1,897
2,142
0
4,039
708
Obliteration of vaginal vault
134
145
0
279
709
Other operations on vagina and cul-de-sac
798
1,023
1
1,822
710
Incision of vulva and perineum
710
589
0
1,299
711
Diagnostic procedures on vulva
815
605
0
1,420
712
Operations on Bartholin's gland
1,796
1,235
1
3,032
713
Other local excision or destruction of vulva and perineum
2,677
2,417
3
5,097
714
Operations on clitoris
25
17
0
42
715
Radical vulvectomy
62
31
0
93
716
Other vulvectomy
120
100
0
220
717
Repair of vulva and perineum
495
433
0
928
718
Other operations on vulva
62
63
0
125
719
Other operations on female genital organs
103
64
0
167
Total
261,340
275,543
67
536,950
Source: AIHW National Hospital Morbidity Database (a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and 'eligible other patients'. Table I2: Obstetrical procedures (ICD-9-CM groupings) undertaken on public and private patients(a), Australia, 1995−96
Unknown
Public
Private
patient
Procedure
patient
patient
status
Total
720
Low forceps operation
534
538
2
1,074
721
Low forceps operation with episiotomy
2,888
2,272
2
5,162
722
Mid forceps operation
5,920
5,729
0
11,649
723
High forceps operation
140
146
0
286
724
Forceps rotation of fetal head
1,686
1,702
1
3,389
725
Breech extraction
1,042
406
1
1,449
726
Forceps application to aftercoming head
62
30
0
92
727
Vacuum extraction
6,023
4,004
1
10,028
728
Other specified instrumental delivery
13
18
0
31
729
Unspecified instrumental delivery
46
31
0
77
730
Artificial rupture of membranes
50,146
25,413
5
75,564
731
Other surgical induction of labour
226
121
0
347
732
Internal and combined version and extraction
76
33
0
109
733
Failed forceps
477
298
0
775
734
Medical induction of labour
29,705
17,835
4
47,544
735
Manually assisted labour
10,814
3,884
1
14,699
736
Episiotomy
16,052
10,152
0
26,204
738
Operations on fetus to facilitate delivery
76
69
0
145
739
Other operations assisting delivery
353
62
0
415
740
Classical caesarian section
210
142
0
352
741
Low cervical caesarian section
27,643
19,476
4
47,123
742
Extraperitoneal caesarian section
3
3
0
6
743
Removal of extratubal ectopic pregnancy
51
31
0
82
744
Caesarian section of other specified type
11
5
0
16
749
Caesarian section of unspecified type
30
22
0
52
AMWAC 1998.6 149
750 Intra-amniotic injection for abortion 35 19 0 54 751
Diagnostic amniocentesis
380
81
2
463
752
Intrauterine transfusion
82
20
0
102
753
Other intrauterine operations on fetus and amnion
22,695
4,015
13
26,723
754
Manual removal of retained placenta
3,783
1,607
3
5,393
755
Repair of current obstetric laceration of uterus
225
66
0
291
756
Repair of other current obstetric laceration
49,173
25,568
8
74,749
757
Manual exploration of uterine cavity, postpartum
195
69
0
264
758
Obstetric tamponade of uterus or vagina
26
13
0
39
759
Other obstetric operations
174
117
0
291
Total
230,995
123,997
47
355,039
Source: AIHW National Hospital Morbidity Database
(a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and eligible other patients'. Table I3: Percentages of obstetrical procedures (ICD-9-CM groupings) undertaken on public patients (a,b) in given age categories, Australia, 1995−96 in given age
(per cent)
Age (years)
Procedures
0−14
15−24
25−34
35−44
45−54
55−64
Total
720
Low forceps operation
0.0
31.5
56.2
12.2
0.2
0.0
100.0
721
Low forceps operation with episiotomy
0.1
33.2
57.6
9.0
0.1
0.0
100.0
722
Mid forceps operation
0.1
32.0
58.5
9.4
0.1
0.0
100.0
723
High forceps operation
0.0
31.4
60.0
8.6
0.0
0.0
100.0
724
Forceps rotation of fetal head
0.1
31.7
57.8
10.1
0.3
0.0
100.0
725
Breech extraction
0.0
25.0
58.7
16.0
0.2
0.0
100.0
726
Forceps application to aftercoming head
0.0
22.6
67.7
9.7
0.0
0.0
100.0
727
Vacuum extraction
0.2
32.0
58.2
9.6
0.1
0.0
100.0
728
Other specified instrumental delivery
0.0
23.1
69.2
7.7
0.0
0.0
100.0
729
Unspecified instrumental delivery
0.0
32.6
56.5
10.9
0.0
0.0
100.0
730
Artificial rupture of membranes
0.1
35.8
55.0
9.1
0.0
0.0
100.0
731
Other surgical induction of labour
0.0
37.6
52.7
9.7
0.0
0.0
100.0
732
Internal and combined version and extraction
0.0
31.6
52.6
14.5
1.3
0.0
100.0
733
Failed forceps
0.2
31.2
58.9
9.6
0.0
0.0
100.0
734
Medical induction of labour
0.1
33.7
56.1
10.1
0.1
0.0
100.0
735
Manually assisted labour
0.0
34.9
54.9
10.2
0.0
0.0
100.0
736
Episiotomy
0.1
34.2
56.3
9.4
0.0
0.0
100.0
738
Operations on fetus to facilitate delivery
0.0
28.9
51.3
19.7
0.0
0.0
100.0
739
Other operations assisting delivery
0.0
24.9
61.8
13.3
0.0
0.0
100.0
740
Classical caesarian section
0.5
21.0
57.6
20.5
0.5
0.0
100.0
741
Low cervical caesarian section
0.1
24.5
60.1
15.2
0.1
0.0
100.0
742
Extraperitoneal caesarian section
0.0
33.3
66.7
0.0
0.0
0.0
100.0
743
Removal of extratubal ectopic pregnancy
0.0
29.4
52.9
17.6
0.0
0.0
100.0
744
Caesarian section of other specified type
0.0
27.3
63.6
9.1
0.0
0.0
100.0
749
Caesarian section of unspecified type
0.0
16.7
70.0
13.3
0.0
0.0
100.0
750
Intra-amniotic injection for abortion
0.0
42.9
42.9
14.3
0.0
0.0
100.0
751
Diagnostic amniocentesis
0.0
17.9
44.7
36.8
0.5
0.0
100.0
752
Intrauterine transfusion
1.2
14.6
58.5
25.6
0.0
0.0
100.0
753
Other intrauterine operations on fetus and amnion
0.1
37.6
52.2
10.0
0.1
0.0
100.0
754
Manual removal of retained placenta
0.1
28.4
57.4
13.9
0.1
0.0
100.0
755
Repair of current obstetric laceration of uterus
0.0
30.2
48.9
20.9
0.0
0.0
100.0
AMWAC 1998.6 150
756 Repair of other current obstetric laceration 0.1 31.1 58.3 10.5 0.0 0.0 100.0 757
Manual exploration of uterine cavity, postpartum
0.5
32.3
52.3
14.9
0.0
0.0
100.0
758
Obstetric tamponade of uterus or vagina
0.0
34.6
46.2
19.2
0.0
0.0
100.0
759
Other obstetric operations
1.1
28.7
52.9
14.9
1.7
0.6
100.0
Total
0.1
32.7
56.5
10.7
0.1
0.0
100.0
Source: AIHW National Hospital Morbidity Database
(a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and 'eligible other patients'. (b) 47 patients were of unknown accommodation status - these are included in the total tables (Tables 17 and 18) but not in this public patient table nor in the private patient table.
AMWAC 1998.6 151
Table I4: Percentages of obstetrical procedures (ICD-9-CM groupings) undertaken on private patients (a,b) in given age categories, Australia, 1995−96
(per cent) Age (years)
Procedure
0−14 15−24
25−34
35−44
45−54
55−64
75+
Unkn.
Total
720
Low forceps operation
0.0
7.4
72.1
20.4
0.0
0.0
0.0
0.0
100.0
721
Low forceps operation with episiotomy
0.0
7.7
75.7
16.5
0.0
0.0
0.0
0.0
100.0
722
Mid forceps operation
0.0
8.5
75.3
16.2
0.0
0.0
0.0
0.0
100.0
723
High forceps operation
0.0
6.8
77.4
15.8
0.0
0.0
0.0
0.0
100.0
724
Forceps rotation of fetal head
0.0
7.2
75.1
17.6
0.1
0.0
0.0
0.0
100.0
725
Breech extraction
0.2
3.2
75.1
21.4
0.0
0.0
0.0
0.0
100.0
726
Forceps application to aftercoming head
0.0
0.0
76.7
23.3
0.0
0.0
0.0
0.0
100.0
727
Vacuum extraction
0.0
7.5
74.6
17.9
0.1
0.0
0.0
0.0
100.0
728
Other specified instrumental delivery
0.0
5.6
77.8
16.7
0.0
0.0
0.0
0.0
100.0
729
Unspecified instrumental delivery
0.0
6.5
83.9
9.7
0.0
0.0
0.0
0.0
100.0
730
Artificial rupture of membranes
0.0
8.2
74.3
17.4
0.1
0.0
0.0
0.0
100.0
731
Other surgical induction of labour
0.0
10.7
65.3
23.1
0.0
0.8
0.0
0.0
100.0
732
Internal and combined version and extraction
3.0
3.0
60.6
33.3
0.0
0.0
0.0
0.0
100.0
733
Failed forceps
0.0
9.7
74.2
16.1
0.0
0.0
0.0
0.0
100.0
734
Medical induction of labour
0.0
8.0
73.6
18.3
0.1
0.0
0.0
0.0
100.0
735
Manually assisted labour
0.0
6.9
73.1
19.8
0.2
0.0
0.0
0.0
100.0
736
Episiotomy
0.0
7.5
75.5
16.9
0.0
0.0
0.0
0.0
100.0
738
Operations on fetus to facilitate delivery
1.4
37.7
37.7
21.7
1.4
0.0
0.0
0.0
100.0
739
Other operations assisting delivery
0.0
1.6
72.6
25.8
0.0
0.0
0.0
0.0
100.0
740
Classical caesarian section
0.0
4.2
59.9
35.9
0.0
0.0
0.0
0.0
100.0
741
Low cervical caesarian section
0.0
5.3
70.1
24.4
0.2
0.0
0.0
0.0
100.0
742
Extraperitoneal caesarian section
0.0
0.0
100.0
0.0
0.0
0.0
0.0
0.0
100.0
743
Removal of extratubal ectopic pregnancy
0.0
9.7
74.2
16.1
0.0
0.0
0.0
0.0
100.0
744
Ceasarian section of other specified type
0.0
0.0
100.0
0.0
0.0
0.0
0.0
0.0
100.0
749
Caesarian section of unspecified type
0.0
0.0
63.6
31.8
4.5
0.0
0.0
0.0
100.0
750
Intra-amniotic injection for abortion
0.0
21.1
57.9
21.1
0.0
0.0
0.0
0.0
100.0
751
Diagnostic amniocentesis
0.0
2.5
35.8
61.7
0.0
0.0
0.0
0.0
100.0
752
Intrauterine transfusion
0.0
0.0
50.0
50.0
0.0
0.0
0.0
0.0
100.0
753
Other intrauterine operations on fetus and amnion
0.0
8.2
70.2
21.5
0.1
0.0
0.0
0.0
100.0
754
Manual removal of retained placenta
0.0
4.8
70.9
24.0
0.2
0.0
0.0
0.0
100.0
755
Repair of current obstetric laceration of uterus
0.0
6.1
72.7
21.2
0.0
0.0
0.0
0.0
100.0
756
Repair of other current obstetric laceration
0.0
6.8
74.1
19.0
0.0
0.0
0.0
0.0
100.0
757
Manual exploration of uterine cavity, postpartum
0.0
1.4
78.3
20.3
0.0
0.0
0.0
0.0
100.0
758
Obstetric tamponade of uterus or vagina
0.0
30.8
53.8
15.4
0.0
0.0
0.0
0.0
100.0
759
Other obstetric operations
0.0
7.7
72.6
17.1
0.9
0.9
0.9
0.0
100.0
Total
0.0
7.3
73.4
19.3
0.1
0.0
0.0
0.0
100.0
Source: AIHW National Hospital Morbidity Database
(a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and 'eligible other patients'. (b) 47 patients were of unknown accommodation status - these are included in the total tables (Tables 17 and 18) but not in this private patient table nor in the public patient table.
AMWAC 1998.6 152
Table I5: Percentages of gynaecological procedures (ICD-9-CM groupings) undertaken on patients (both public and private) in given age categories, Australia, 1995−96
Age (years)
Procedure
0−14
15−24
25−34
35−44
45−54
55−64
65−74
75+
Unkn
.
Total
650
Oophorotomy
0.4
18.7
36.3
32.1
10.5
1.0
0.4
0.6
0.0
100.0
651
Diagnostic procedures on ovaries
1.5
15.9
31.2
26.7
15.1
4.0
3.0
2.6
0.0
100.0
652
Local excision or destruction of ovarian lesion or tissue
1.1
19.0
38.7
27.9
9.7
1.5
1.4
0.8
0.0
100.0
653
Unilateral oophorectomy
0.6
5.0
18.8
34.7
22.4
7.6
6.1
4.9
0.0
100.0
654
Unilateral salpingo-oophorectomy
0.5
3.8
16.4
41.8
26.9
4.6
4.3
1.7
0.0
100.0
655
Bilateral oophorectomy
0.3
0.5
8.5
23.7
35.4
14.8
10.3
6.5
0.0
100.0
656
Bilateral salpingo-oophorectomy
0.1
0.2
3.7
18.1
43.1
17.1
11.7
6.0
0.0
100.0
657
Repair of ovary
2.4
17.9
39.5
33.0
5.8
0.7
0.3
0.3
0.0
100.0
658
Lysis of adhesions of ovary and fallopian tube
0.2
11.4
41.3
33.0
11.1
2.2
0.5
0.3
0.0
100.0
659
Other operations on ovary
0.3
9.4
46.4
38.5
4.5
0.5
0.3
0.1
0.0
100.0
660
Salpingotomy and salpingostomy
0.1
18.7
58.7
20.3
1.7
0.2
0.1
0.1
0.0
100.0
661
Diagnostic procedures on fallopian tubes
0.6
7.0
58.8
30.0
2.1
0.6
0.4
0.6
0.0
100.0
662
Bilateral endoscopic destruction or occlusion of fallopian tubes
0.0
3.5
45.6
47.8
3.2
0.0
0.0
0.0
0.0
100.0
663
Other bilateral destruction or occlusion of fallopian tubes
0.0
4.7
55.1
38.7
1.4
0.0
0.0
0.0
0.0
100.0
664
Total unilateral salpingectomy
0.3
5.8
25.7
42.6
18.9
2.9
2.9
0.9
0.0
100.0
665
Total bilateral salpingectomy
0.0
2.0
24.6
42.5
20.2
6.0
3.6
1.2
0.0
100.0
666
Other salpingectomy
0.6
16.6
48.8
26.8
5.6
1.2
0.4
0.2
0.0
100.0
667
Repair of fallopian tube
0.0
4.2
52.8
41.5
1.4
0.1
0.0
0.0
0.0
100.0
668
Insufflation of fallopian tube
0.0
13.8
59.8
25.5
0.8
0.0
0.0
0.0
0.0
100.0
669
Other operations on fallopian tubes
0.1
6.2
53.9
37.6
1.9
0.2
0.0
0.0
0.0
100.0
670
Dilation of cervical canal
0.7
17.7
31.1
26.2
13.5
5.7
3.5
1.6
0.0
100.0
671
Diagnostic procedures on cervix
0.1
21.6
30.9
22.4
13.9
5.7
3.5
1.9
0.0
100.0
672
Conization of cervix
0.0
10.8
28.3
29.7
17.1
8.3
4.6
1.2
0.0
100.0
673
Other excision or destruction of lesion or tissue of cervix
0.0
20.2
31.7
24.2
15.6
5.5
2.3
0.6
0.0
100.0
674
Amputation of cervix
0.3
1.2
6.5
19.9
19.6
19.0
19.0
14.5
0.0
100.0
675
Repair of internal cervical os
0.0
12.3
59.1
27.6
0.6
0.2
0.1
0.0
0.0
100.0
676
Other repair of cervix
0.0
15.9
37.0
29.2
12.7
2.3
2.6
0.3
0.0
100.0
680
Hysterotomy
1.5
15.4
26.2
16.9
16.9
6.2
7.7
9.2
0.0
100.0
681
Diagnostic procedures on uterus and supporting structures
0.1
6.8
22.0
28.2
26.6
9.8
4.8
1.8
0.0
100.0
682
Excision or destruction of lesion or tissue of uterus
0.0
5.6
20.3
35.1
25.7
8.2
3.8
1.3
0.0
100.0
683
Subtotal abdominal hysterectomy
0.0
1.6
9.4
39.2
35.3
6.2
5.8
2.5
0.0
100.0
684
Total abdominal hysterectomy
0.0
0.3
9.5
37.2
37.1
8.0
5.2
2.6
0.0
100.0
685
Vaginal hysterectomy
0.0
0.3
9.1
31.9
27.0
11.7
13.1
7.1
0.0
100.0
686
Radical abdominal hysterectomy
0.0
0.3
9.9
24.4
19.8
18.3
17.2
10.1
0.0
100.0
687
Radical vaginal hysterectomy
0.0
0.0
6.7
30.0
23.3
20.0
16.7
3.3
0.0
100.0
688
Pelvic evisceration
0.0
0.0
14.7
11.8
14.7
22.1
20.6
16.2
0.0
100.0
689
Other and unspecified hysterectomy
0.0
1.0
11.5
36.8
32.9
9.1
4.4
4.4
0.0
100.0
690
Dilation and curettage of uterus
0.1
13.3
31.3
27.3
17.5
6.2
3.1
1.2
0.0
100.0
691
Excision or destruction of lesion or tissue of uterus and supporting structures
0.3
23.7
40.5
26.6
7.3
0.8
0.6
0.2
0.0
100.0
692
Repair of uterus supporting structures
0.0
9.5
28.1
19.5
11.8
10.9
13.4
6.8
0.0
100.0
693
Paracervical uterine denervation
0.9
33.3
38.2
23.7
3.9
0.0
0.0
0.0
0.0
100.0
694
Uterine repair
0.0
19.6
43.9
22.4
5.6
2.8
3.7
1.9
0.0
100.0
695
Aspiration curettage of uterus
0.3
37.2
43.1
18.7
0.7
0.1
0.0
0.0
0.0
100.0
AMWAC 1998.6 153
696
Menstrual extraction or regulation
0.0
75.0
0.0
25.0
0.0
0.0
0.0
0.0
0.0
100.0
697
Insertion of intrauterine contraceptive device
0.1
14.0
41.0
35.8
9.1
0.1
0.0
0.0
0.0
100.0
699
Other operations on uterus, cervix, and supporting structures
0.1
3.3
49.3
42.3
2.5
1.0
1.1
0.5
0.0
100.0
700
Culdocentesis
1.2
27.8
36.4
24.5
7.3
1.7
0.8
0.4
0.0
100.0
701
Incision of vagina and cul-de-sac
0.4
4.6
48.6
41.6
2.6
0.9
0.7
0.5
0.0
100.0
702
Diagnostic procedures on vagina and cul-de-sac
1.2
22.9
31.4
21.6
11.9
5.2
3.6
2.1
0.0
100.0
703
Local excision or destruction of vagina and cul-de-sac
1.2
25.9
31.1
21.3
10.6
5.2
3.1
1.5
0.0
100.0
704
Obliteration and total excision of vagina
3.5
0.0
5.9
14.1
20.0
16.5
28.2
11.8
0.0
100.0
705
Repair of cystocele and rectocele
0.0
0.2
4.2
15.6
23.7
21.0
23.7
11.5
0.0
100.0
706
Vaginal construction and reconstruction
6.4
14.1
17.9
21.8
15.4
7.7
11.5
5.1
0.0
100.0
707
Other repair of vagina
1.7
3.4
7.9
17.1
24.5
19.1
18.6
7.6
0.0
100.0
708
Obliteration of vaginal vault
0.0
0.0
3.6
9.0
16.1
20.4
27.6
23.3
0.0
100.0
709
Other operations on vagina and cul-de-sac
0.3
1.0
4.6
11.6
21.7
19.2
26.6
15.0
0.0
100.0
710
Incision of vulva and perineum
10.6
19.6
30.6
15.6
10.3
6.7
4.1
2.5
0.0
100.0
711
Diagnostic procedures on vulva
1.5
8.8
13.9
17.2
16.1
13.8
17.2
11.5
0.0
100.0
712
Operations on Bartholin's gland
0.2
17.4
32.2
28.9
15.9
3.4
1.6
0.5
0.0
100.0
713
Other local excision or destruction of vulva and perineum
1.3
32.1
24.1
16.8
11.9
5.8
4.9
3.1
0.0
100.0
714
Operations on clitoris
45.2
7.1
11.9
9.5
4.8
4.8
4.8
11.9
0.0
100.0
715
Radical vulvectomy
1.1
0.0
2.2
5.4
14.0
15.1
26.9
35.5
0.0
100.0
716
Other vulvectomy
2.3
7.3
10.5
14.5
15.5
14.5
20.5
15.0
0.0
100.0
717
Repair of vulva and perineum
14.0
14.1
26.3
14.4
11.0
8.2
7.0
4.8
0.1
100.0
718
Other operations on vulva
10.4
32.0
22.4
19.2
7.2
4.8
2.4
1.6
0.0
100.0
719
Other operations on female genital organs
2.4
25.1
35.9
22.8
8.4
1.8
0.6
3.0
0.0
100.0
Total
0.3
13.3
30.9
27.9
15.8
6.0
4.0
1.8
0.0
100.0
Source: AIHW National Hospital Morbidity Database
Table I6: Percentages of obstetrical procedures (ICD-9-CM groupings) undertaken on patients (both public and private) in given age categories, Australia, 1995−96
Age (years) Per cent Procedure
0−14
15−24
25−34
35−44
45−54
55−64
75+
Unkn.
Total
720
Low forceps operation
0.0
19.4
64.1
16.5
0.1
0.0
0.0
0.0
100.0
721
Low forceps operation with episiotomy
0.1
22.0
65.6
12.3
0.1
0.0
0.0
0.0
100.0
722
Mid forceps operation
0.0
20.4
66.8
12.7
0.1
0.0
0.0
0.0
100.0
723
High forceps operation
0.0
18.9
68.9
12.2
0.0
0.0
0.0
0.0
100.0
724
Forceps rotation of fetal head
0.0
19.4
66.5
13.9
0.2
0.0
0.0
0.0
100.0
725
Breech extraction
0.1
18.9
63.4
17.5
0.1
0.0
0.0
0.0
100.0
726
Forceps application to aftercoming head
0.0
15.2
70.7
14.1
0.0
0.0
0.0
0.0
100.0
727
Vacuum extraction
0.1
22.2
64.8
12.9
0.1
0.0
0.0
0.0
100.0
728
Other specified instrumental delivery
0.0
12.9
74.2
12.9
0.0
0.0
0.0
0.0
100.0
729
Unspecified instrumental delivery
0.0
22.1
67.5
10.4
0.0
0.0
0.0
0.0
100.0
730
Artificial rupture of membranes
0.1
26.5
61.5
11.9
0.0
0.0
0.0
0.0
100.0
731
Other surgical induction of labour
0.0
28.2
57.1
14.4
0.0
0.3
0.0
0.0
100.0
732
Internal and combined version and extraction
0.9
22.9
55.0
20.2
0.9
0.0
0.0
0.0
100.0
733
Failed forceps
0.1
23.0
64.8
12.1
0.0
0.0
0.0
0.0
100.0
734
Medical induction of labour
0.0
24.1
62.6
13.2
0.1
0.0
0.0
0.0
100.0
735
Manually assisted labour
0.0
27.5
59.7
12.7
0.1
0.0
0.0
0.0
100.0
736
Episiotomy
0.1
23.8
63.7
12.3
0.0
0.0
0.0
0.0
100.0
738
Operations on fetus to facilitate delivery
0.7
33.1
44.8
20.7
0.7
0.0
0.0
0.0
100.0
AMWAC 1998.6 154
739 Other operations assisting delivery 0.0 21.4 63.4 15.2 0.0 0.0 0.0 0.0 100.0 740
Classical caesarian section
0.3
14.2
58.5
26.7
0.3
0.0
0.0
0.0
100.0
741
Low cervical caesarian section
0.0
16.6
64.2
19.0
0.1
0.0
0.0
0.0
100.0
742
Extraperitoneal caesarian section
0.0
16.7
83.3
0.0
0.0
0.0
0.0
0.0
100.0
743
Removal of extratubal ectopic pregnancy
0.0
22.0
61.0
17.1
0.0
0.0
0.0
0.0
100.0
744
Caesarian section of other specified type
0.0
18.8
75.0
6.3
0.0
0.0
0.0
0.0
100.0
749
Caesarian section of unspecified type
0.0
9.6
67.3
21.2
1.9
0.0
0.0
0.0
100.0
750
Intra-amniotic injection for abortion
0.0
35.2
48.1
16.7
0.0
0.0
0.0
0.0
100.0
751
Diagnostic amniocentesis
0.0
15.6
43.0
41.0
0.4
0.0
0.0
0.0
100.0
752
Intrauterine transfusion
1.0
11.8
56.9
30.4
0.0
0.0
0.0
0.0
100.0
753
Other intrauterine operations on fetus and amnion
0.1
33.2
54.9
11.8
0.1
0.0
0.0
0.0
100.0
754
Manual removal of retained placenta
0.1
21.4
61.5
16.9
0.1
0.0
0.0
0.0
100.0
755
Repair of current obstetric laceration of uterus
0.0
24.7
54.3
21.0
0.0
0.0
0.0
0.0
100.0
756
Repair of other current obstetric laceration
0.0
22.8
63.7
13.4
0.0
0.0
0.0
0.0
100.0
757
Manual exploration of uterine cavity, postpartum
0.4
24.2
59.1
16.3
0.0
0.0
0.0
0.0
100.0
758
Obstetric tamponade of uterus or vagina
0.0
33.3
48.7
17.9
0.0
0.0
0.0
0.0
100.0
759
Other obstetric operations
0.7
20.3
60.8
15.8
1.4
0.7
0.3
0.0
100.0
Total
0.1
23.8
62.4
13.7
0.1
0.0
0.0
0.0
100.0
Source: AIHW National Hospital Morbidity Database
Table I7: Gynaecological procedures (ICD-9-CM groupings) undertaken on private patients as a percentage of total gynaecological procedures undertaken in given age categories, Australia, 1995−96
Age (years) Per cent
Procedure
0−14 15−24
25−34
35−44
45−54
55−64
65−74
75+
Unkn.
Total
650 Oophorotomy
0.0
22.2
33.2
42.5
34.0
55.6
25.0
20.0
n.a.
34.2
651
Diagnostic procedures on ovaries
57.1
43.8
60.1
58.1
64.4
46.2
37.9
28.0
n.a.
55.5
652
Local excision or destruction of ovarian lesion or tissue
54.1
41.2
53.9
58.8
61.8
68.4
56.3
52.9
n.a.
53.9
653
Unilateral oophorectomy
12.5
34.6
38.4
45.7
56.6
51.0
47.4
36.3
n.a.
46.0
654
Unilateral salpingo-oophorectomy
26.9
28.5
35.2
49.0
58.7
54.2
46.2
48.8
n.a.
48.6
655
Bilateral oophorectomy
66.7
60.0
31.4
40.6
57.0
59.7
45.2
49.2
n.a.
49.7
656
Bilateral salpingo-oophorectomy
40.0
33.3
39.1
45.7
53.5
54.0
44.1
39.9
n.a.
49.7
657
Repair of ovary
14.3
26.9
32.2
44.8
76.5
100.0
0.0
0.0
n.a.
37.8
658
Lysis of adhesions of ovary and fallopian tube
25.0
42.2
50.6
57.2
56.6
60.7
46.2
57.1
n.a.
52.7
659
Other operations on ovary
38.5
53.5
84.0
86.9
64.1
64.4
43.6
58.3
n.a.
81.0
660
Salpingotomy and salpingostomy
0.0
13.8
35.1
50.7
44.8
25.0
100.0
0.0
n.a.
34.4
661
Diagnostic procedures on fallopian tubes
33.3
63.9
88.1
89.6
72.7
33.3
0.0
0.0
n.a.
85.0
662
Bilateral endoscopic destruction or occlusion of fallopian tubes
n.a.
11.3
27.9
45.1
57.9
100.0
n.a.
n.a.
n.a.
36.5
663
Other bilateral destruction or occlusion of fallopian tubes
50.0
12.0
27.9
43.5
70.0
100.0
n.a.
n.a.
n.a.
33.8
664
Total unilateral salpingectomy
33.3
23.1
35.8
48.7
65.3
65.4
61.5
50.0
n.a.
47.8
665
Total bilateral salpingectomy
n.a.
20.0
32.6
42.8
47.7
40.0
48.1
11.1
n.a.
40.5
666
Other salpingectomy
52.6
22.8
33.5
44.3
59.1
57.5
33.3
16.7
n.a.
36.4
667
Repair of fallopian tube
n.a.
24.3
33.1
49.6
62.5
0.0
n.a.
n.a.
n.a.
40.0
668
Insufflation of fallopian tube
100.0
41.1
60.5
66.0
67.3
0.0
50.0
100.0
n.a.
59.3
669
Other operations on fallopian tubes
75.0
86.5
92.0
92.1
76.1
44.4
100.0
0.0
n.a.
91.3
670
Dilation of cervical canal
33.3
42.1
55.3
66.2
69.4
53.4
46.7
40.0
n.a.
56.9
671
Diagnostic procedures on cervix
16.7
27.2
34.0
42.9
49.7
39.9
31.7
31.0
n.a.
36.9
672
Conization of cervix
0.0
25.4
33.7
42.1
50.1
45.6
32.9
37.9
100.0
39.1
AMWAC 1998.6 155
673 Other excision or destruction of lesion or tissue of cervix 28.6 34.1 42.4 52.5 57.2 55.1 45.9 39.4 n.a. 46.2 674
Amputation of cervix
0.0
50.0
40.9
59.7
56.1
50.0
46.9
57.1
n.a.
52.8
675
Repair of internal cervical os
n.a.
15.0
51.7
63.3
60.0
0.0
100.0
n.a.
n.a.
50.3
676
Other repair of cervix
n.a.
20.4
28.1
46.7
41.0
28.6
25.0
0.0
n.a.
33.8
680
Hysterotomy
0.0
20.0
11.8
45.5
27.3
50.0
20.0
50.0
n.a.
27.7
681
Diagnostic procedures on uterus and supporting structures
59.2
44.6
56.7
56.7
58.1
55.9
47.8
41.0
100.0
55.5
682
Excision or destruction of lesion or tissue of uterus
100.0
52.5
60.1
62.1
64.3
59.3
48.8
35.0
n.a.
60.6
683
Subtotal abdominal hysterectomy
n.a.
57.1
34.1
41.8
51.0
25.9
32.0
27.3
n.a.
42.6
684
Total abdominal hysterectomy
50.0
23.4
32.3
47.7
55.2
51.3
42.8
37.6
n.a.
48.7
685
Vaginal hysterectomy
n.a.
29.3
36.4
50.2
60.0
54.6
47.3
47.0
n.a.
51.4
686
Radical abdominal hysterectomy
n.a.
0.0
26.2
38.0
57.4
59.3
57.5
61.3
n.a.
50.2
687
Radical vaginal hysterectomy
n.a.
n.a.
50.0
11.1
57.1
66.7
60.0
0.0
n.a.
43.3
688
Pelvic evisceration
n.a.
n.a.
40.0
62.5
40.0
53.3
28.6
9.1
n.a.
38.2
689
Other and unspecified hysterectomy
n.a.
60.0
39.7
50.0
54.2
67.4
36.4
40.9
n.a.
50.9
690
Dilation and curettage of uterus
35.8
30.5
43.5
50.5
55.2
54.1
46.4
41.0
100.0
46.4
691
Excision or destruction of lesion or tissue of uterus and supporting structures
30.8
44.0
57.3
62.3
64.4
36.4
51.9
25.0
100.0
55.7
692
Repair of uterus supporting structures
n.a.
22.6
39.9
52.8
49.4
54.2
51.1
49.4
n.a.
45.6
693
Paracervical uterine denervation
50.0
73.7
70.1
77.8
100.0
n.a.
n.a.
n.a.
n.a.
74.1
694
Uterine repair
n.a.
14.3
40.4
58.3
66.7
66.7
25.0
50.0
n.a.
41.1
695
Aspiration curettage of uterus
52.2
49.3
50.1
54.5
48.6
25.0
28.6
10.0
58.3
50.6
696
Menstrual extraction or regulation
n.a.
66.7
n.a.
0.0
n.a.
n.a.
n.a.
n.a.
n.a.
50.0
697
Insertion of intrauterine contraceptive device
0.0
26.3
37.9
50.1
65.0
100.0
n.a.
n.a.
n.a.
43.2
699
Other operations on uterus, cervix, and supporting structures
25.0
56.2
89.1
92.9
81.0
36.5
35.8
56.5
n.a.
88.1
700
Culdocentesis
44.4
53.0
72.2
79.9
66.1
84.6
50.0
33.3
n.a.
67.9
701
Incision of vagina and cul-de-sac
32.0
80.7
93.7
94.1
74.0
61.0
55.7
67.2
n.a.
91.8
702
Diagnostic procedures on vagina and cul-de-sac
31.6
26.5
33.8
40.5
45.6
40.9
33.4
36.8
100.0
35.4
703
Local excision or destruction of vagina and cul-de-sac
47.5
45.6
58.8
62.1
63.8
63.7
60.1
46.2
100.0
56.6
704
Obliteration and total excision of vagina
66.7
n.a.
40.0
33.3
58.8
57.1
58.3
50.0
n.a.
52.9
705
Repair of cystocele and rectocele
100.0
27.5
38.8
53.4
58.8
54.2
48.1
47.0
n.a.
52.2
706
Vaginal construction and reconstruction
40.0
63.6
85.7
94.1
83.3
100.0
88.9
50.0
n.a.
80.8
707
Other repair of vagina
26.5
34.8
43.7
53.0
58.1
57.6
52.5
50.3
n.a.
53.0
708
Obliteration of vaginal vault
n.a.
n.a.
40.0
36.0
75.6
61.4
44.2
44.6
n.a.
52.0
709
Other operations on vagina and cul-de-sac
66.7
52.6
60.2
55.0
65.2
58.2
52.5
46.7
n.a.
56.1
710
Incision of vulva and perineum
37.7
34.6
47.2
47.3
58.2
51.7
52.8
43.8
n.a.
45.3
711
Diagnostic procedures on vulva
22.7
45.6
45.2
50.0
49.8
42.9
34.0
31.3
n.a.
42.6
712
Operations on Bartholin's gland
16.7
26.6
37.5
44.8
54.6
47.6
38.3
40.0
n.a.
40.7
713
Other local excision or destruction of vulva and perineum
40.9
40.8
47.7
50.4
58.6
54.6
45.2
47.2
n.a.
47.4
714
Operations on clitoris
31.6
0.0
60.0
25.0
100.0
50.0
0.0
80.0
n.a.
40.5
715
Radical vulvectomy
0.0
n.a.
0.0
0.0
30.8
35.7
40.0
36.4
n.a.
33.3
716
Other vulvectomy
20.0
50.0
39.1
71.9
41.2
46.9
42.2
33.3
n.a.
45.5
717
Repair of vulva and perineum
26.9
28.2
49.6
56.7
65.7
61.8
44.6
44.4
100.0
46.7
718
Other operations on vulva
30.8
35.0
67.9
66.7
66.7
66.7
0.0
0.0
n.a.
50.4
719
Other operations on female genital organs
0.0
40.5
38.3
42.1
35.7
66.7
0.0
20.0
n.a.
38.3
Total
38.2
39.0
50.4
55.9
56.8
54.0
46.4
43.0
82.1
51.3
Source: AIHW National Hospital Morbidity Database
AMWAC 1998.6 156
Table I8: Obstetrical procedures (ICD-9-CM groupings) undertaken on private patients as a percentage of total Obstetrical procedures undertaken in given age categories, Australia, 1995−96
Age (years) Per cent
Procedure
0−14
15−24
25−34
35−44
45−54
55−64
75+
Unkn.
Total
720
Low forceps operation
n.a.
19.2
56.4
62.1
0.0
n.a.
n.a.
n.a.
50.1
721
Low forceps operation with episiotomy
0.0
15.5
50.8
59.0
25.0
n.a.
n.a.
n.a.
44.0
722
Mid forceps operation
0.0
20.5
55.5
62.6
33.3
n.a.
n.a.
n.a.
49.2
723
High forceps operation
n.a.
18.5
57.4
65.7
n.a.
n.a.
n.a.
n.a.
51.0
724
Forceps rotation of fetal head
0.0
18.7
56.7
63.7
16.7
n.a.
n.a.
n.a.
50.2
725
Breech extraction
100.0
4.7
33.2
34.3
0.0
n.a.
n.a.
n.a.
28.0
726
Forceps application to aftercoming head
n.a.
0.0
35.4
53.8
n.a.
n.a.
n.a.
n.a.
32.6
727
Vacuum extraction
0.0
13.4
46.0
55.3
42.9
n.a.
n.a.
n.a.
39.9
728
Other specified instrumental delivery
n.a.
25.0
60.9
75.0
n.a.
n.a.
n.a.
n.a.
58.1
729
Unspecified instrumental delivery
n.a.
11.8
50.0
37.5
n.a.
n.a.
n.a.
n.a.
40.3
730
Artificial rupture of membranes
7.0
10.4
40.6
49.2
46.7
0.0
n.a.
n.a.
33.6
731
Other surgical induction of labour
n.a.
13.3
39.9
56.0
n.a.
100.0
n.a.
n.a.
34.9
732
Internal and combined version and extraction
100.0
4.0
33.3
50.0
0.0
n.a.
n.a.
n.a.
30.3
733
Failed forceps
0.0
16.3
44.0
51.1
n.a.
n.a.
n.a.
n.a.
38.5
734
Medical induction of labour
9.1
12.5
44.1
52.2
50.0
n.a.
n.a.
n.a.
37.5
735
Manually assisted labour
0.0
6.6
32.4
41.2
66.7
n.a.
n.a.
n.a.
26.4
736
Episiotomy
0.0
12.2
45.9
53.2
62.5
100.0
n.a.
n.a.
38.7
738
Operations on fetus to facilitate delivery
100.0
54.2
40.0
50.0
100.0
n.a.
n.a.
n.a.
47.6
739
Other operations assisting delivery
n.a.
1.1
17.1
25.4
n.a.
n.a.
n.a.
n.a.
14.9
740
Classical caesarian section
0.0
12.0
41.3
54.3
0.0
n.a.
n.a.
n.a.
40.3
741
Low cervical caesarian section
9.1
13.3
45.1
53.0
49.2
0.0
n.a.
n.a.
41.3
742
Extraperitoneal caesarian section
n.a.
0.0
60.0
n.a.
n.a.
n.a.
n.a.
n.a.
50.0
743
Removal of extratubal ectopic pregnancy
n.a.
16.7
46.0
35.7
n.a.
n.a.
n.a.
n.a.
37.8
744
Caesarian section of other specified type
n.a.
0.0
41.7
0.0
n.a.
n.a.
n.a.
n.a.
31.3
749
Caesarian section of unspecified type
n.a.
0.0
40.0
63.6
100.0
n.a.
n.a.
n.a.
42.3
750
Intra-amniotic injection for abortion
n.a.
21.1
42.3
44.4
n.a.
n.a.
n.a.
n.a.
35.2
751
Diagnostic amniocentesis
n.a.
2.8
14.6
26.3
0.0
n.a.
n.a.
n.a.
17.5
752
Intrauterine transfusion
0.0
0.0
17.2
32.3
n.a.
n.a.
n.a.
n.a.
19.6
753
Other intrauterine operations on fetus and amnion
0.0
3.7
19.2
27.5
13.6
n.a.
n.a.
n.a.
15.0
754
Manual removal of retained placenta
0.0
6.7
34.4
42.3
57.1
n.a.
n.a.
n.a.
29.8
755
Repair of current obstetric laceration of uterus
n.a.
5.6
30.4
23.0
n.a.
n.a.
n.a.
n.a.
22.7
756
Repair of other current obstetric laceration
2.8
10.2
39.8
48.5
30.8
n.a.
100.0
100.0
34.2
757
Manual exploration of uterine cavity, postpartum
0.0
1.6
34.6
32.6
n.a.
n.a.
n.a.
n.a.
26.1
758
Obstetric tamponade of uterus or vagina
n.a.
30.8
36.8
28.6
n.a.
n.a.
n.a.
n.a.
33.3
759
Other obstetric operations
0.0
15.3
48.0
43.5
25.0
50.0
100.0
n.a.
40.2
Total
5.7
10.6
41.1
49.2
41.6
50.0
100.0
100.0
34.9
Source: AIHW National Hospital Morbidity Database
AMWAC 1998.6 157
Table I9: Relative growth in gynaecological procedures (ICD-9-CM groupings), Australia, 1993−94 to 1995−96
Procedure
1993−94
%
1994−95
%
1995−96
%
% increase 1993−94 to
1995−96 709
Other operations on vagina and cul-de-sac
136
180
1,822
1239.7
689
Other and unspecified hysterectomy
179
314
505
182.1
696
Menstrual extraction or regulation
2
2
4
100.0
661
Diagnostic procedures on fallopian tubes
281
373
514
82.9
706
Vaginal construction and reconstruction
46
68
78
69.6
693
Paracervical uterine denervation
139
201
228
64.0
660
Salpingotomy and salpingostomy
1,203
1,577
1,669
38.7
687
Radical vaginal hysterectomy
22
19
30
36.4
691
Excision or destruction of lesion or tissue of uterus and supporting structures
3,297
3,716
4,249
28.9
702
Diagnostic procedures on vagina and cul-de-sac
13,420
17,754
17,257
28.6
717
Repair of vulva and perineum
730
849
928
27.1
681
Diagnostic procedures on uterus and supporting structures
52,663
66,317
66,759
26.8
671
Diagnostic procedures on cervix
8,341
11,444
10,395
24.6
669
Other operations on fallopian tubes
4,713
5,261
5,840
23.9
703
Local excision or destruction of vagina and cul-de-sac
4,212
4,712
5,213
23.8
707
Other repair of vagina
3,339
3,657
4,039
21.0
673
Other excision or destruction of lesion or tissue of cervix
27,722
35,941
33,039
19.2
650
Oophorotomy
757
932
895
18.2
714
Operations on clitoris
36
60
42
16.7
670
Dilation of cervical canal
1,106
1,672
1,285
16.2
699
Other operations on uterus, cervix, and supporting structures
4,280
4,641
4,957
15.8
659
Other operations on ovary
15,149
16,398
17,464
15.3
710
Incision of vulva and perineum
1,135
1,170
1,299
14.4
701
Incision of vagina and cul-de-sac
10,386
11,366
11,846
14.1
685
Vaginal hysterectomy
12,814
14,235
14,572
13.7
652
Local excision or destruction of ovarian lesion or tissue
7,760
8,564
8,796
13.4
676
Other repair of cervix
272
341
308
13.2
695
Aspiration curettage of uterus
46,620
50,981
52,431
12.5
657
Repair of ovary
260
289
291
11.9
716
Other vulvectomy
199
271
220
10.6
658
Lysis of adhesions of ovary and fallopian tube
4,392
4,598
4,832
10.0
656
Bilateral salpingo-oophorectomy
8,900
9,959
9,773
9.8
705
Repair of cystocele and rectocele
15,925
16,990
17,362
9.0
664
Total unilateral salpingectomy
829
850
901
8.7
682
Excision or destruction of lesion or tissue of uterus
11,109
11,781
12,053
8.5
Total
498,590
548,047
536,950
7.7
718 Other operations on vulva
117
135
125
6.8
680
Hysterotomy
61
50
65
6.6
654
Unilateral salpingo-oophorectomy
4,648
4,978
4,907
5.6
668
Insufflation of fallopian tube
11,757
11,935
12,291
4.5
655
Bilateral oophorectomy
964
1,043
1,007
4.5
666
Other salpingectomy
3,211
3,298
3,334
3.8
712
Operations on Bartholin's gland
2,928
3,143
3,032
3.6
713
Other local excision or destruction of vulva and perineum
4,968
5,006
5,097
2.6
683
Subtotal abdominal hysterectomy
424
463
434
2.4
653
Unilateral oophorectomy
2,520
2,575
2,554
1.3
AMWAC 1998.6 158
715 Radical vulvectomy 92 96 93 1.1 711
Diagnostic procedures on vulva
1,420
1,555
1,420
0.0
651
Diagnostic procedures on ovaries
981
1,199
965
-1.6
663
Other bilateral destruction or occlusion of fallopian tubes
5,217
5,262
5,112
-2.0
688
Pelvic evisceration
70
75
68
-2.9
665
Total bilateral salpingectomy
772
767
749
-3.0
662
Bilateral endoscopic destruction or occlusion of fallopian tubes
20,896
19,919
19,980
-4.4
694
Uterine repair
112
103
107
-4.5
690
Dilation and curettage of uterus
138,511
141,859
131,605
-5.0
686
Radical abdominal hysterectomy
653
686
616
-5.7
684
Total abdominal hysterectomy
20,910
21,028
19,371
-7.4
675
Repair of internal cervical os
948
876
868
-8.4
672
Conization of cervix
5,113
5,937
4,680
-8.5
697
Insertion of intrauterine contraceptive device
2,148
1,923
1,951
-9.2
692
Repair of uterus supporting structures
1,485
1,463
1,303
-12.3
674
Amputation of cervix
387
402
337
-12.9
667
Repair of fallopian tube
1,973
1,745
1,680
-14.9
700
Culdocentesis
1,083
953
772
-28.7
719
Other operations on female genital organs
256
240
167
-34.8
704
Obliteration and total excision of vagina
142
158
85
-40.1
708
Obliteration of vaginal vault
1,449
1,692
279
-80.7
Source: AIHW National Hospital Morbidity Database
Table I10: Relative growth in obstetrical procedures (ICD-9-CM groupings) , Australia, 1993−94 to 1995−96
Procedure
1993−94
%
1994−95
%
1995−96
%
% increase 1993−94 to
1995−96 738
Operations on fetus to facilitate delivery
7
11
145
1971.4
753
Other intrauterine operations on fetus and amnion
11,512
20,822
26,723
132.1
758
Obstetric tamponade of uterus or vagina
17
33
39
129.4
734
Medical induction of labour
28,768
33,670
47,544
65.3
739
Other operations assisting delivery
275
335
415
50.9
757
Manual exploration of uterine cavity, postpartum
176
230
264
50.0
752
Intrauterine transfusion
74
128
102
37.8
759
Other obstetric operations
246
279
291
18.3
727
Vacuum extraction
8,540
9,559
10,028
17.4
755
Repair of current obstetric laceration of uterus
253
281
291
15.0
Total
317,522
345,036
355,039
11.8
733 Failed forceps
697
745
775
11.2
730
Artificial rupture of membranes
68,454
74,396
75,564
10.4
751
Diagnostic amniocentesis
430
419
463
7.7
756
Repair of other current obstetric laceration
70,750
75,603
74,749
5.7
735
Manually assisted labour
14,624
16,932
14,699
0.5
742
Extraperitoneal caesarian section
6
6
6
0.0
732
Internal and combined version and extraction
111
138
109
-1.8
754
Manual removal of retained placenta
5,497
5,854
5,393
-1.9
741
Low cervical caesarian section
48,057
48,575
47,123
-1.9
744
Caesarian section of other specified type
17
25
16
-5.9
724
Forceps rotation of fetal head
3,625
3,484
3,389
-6.5
725
Breech extraction
1,597
1,672
1,449
-9.3
AMWAC 1998.6 159
721 Low forceps operation with episiotomy 5,818 5,376 5,162 -11.3 740
Classical caesarian section
400
477
352
-12.0
736
Episiotomy
29,778
28,828
26,204
-12.0
722
Mid forceps operation
13,568
13,168
11,649
-14.1
720
Low forceps operation
1,296
1,281
1,074
-17.1
723
High forceps operation
347
310
286
-17.6
750
Intra-amniotic injection for abortion
107
78
54
-49.5
729
Unspecified instrumental delivery
212
129
77
-63.7
726
Forceps application to aftercoming head
268
162
92
-65.7
743
Removal of extratubal ectopic pregnancy
310
164
82
-73.5
731
Other surgical induction of labour
1,315
1,677
347
-73.6
749
Caesarian section of unspecified type
207
85
52
-74.9
728
Other specified instrumental delivery
163
104
31
-81.0
Source: AIHW National Hospital Morbidity Database
Table I11: Percentage of gynaecological procedures (ICD-9-CM groupings) undertaken on private patients (a) sorted by extent of private involvement, Australia 1995−96 Procedure
% of
procedures on private
patients
Total
procedures (public&
private patients) (no.)
701
Incision of vagina and cul-de-sac
91.8
11,846
669
Other operations on fallopian tubes
91.3
5,840
699
Other operations on uterus, cervix, and supporting structures
88.1
4,957
661
Diagnostic procedures on fallopian tubes
85.0
514
659
Other operations on ovary
81.0
17,464
706
Vaginal construction and reconstruction
80.8
78
693
Paracervical uterine denervation
74.1
228
700
Culdocentesis
67.9
772
682
Excision or destruction of lesion or tissue of uterus
60.6
12,053
668
Insufflation of fallopian tube
59.3
12,291
670
Dilation of cervical canal
56.9
1,285
703
Local excision or destruction of vagina and cul-de-sac
56.6
5,213
709
Other operations on vagina and cul-de-sac
56.1
1,822
691
Excision or destruction of lesion or tissue of uterus and supporting structures
55.7
4,249
651
Diagnostic procedures on ovaries
55.5
965
681
Diagnostic procedures on uterus and supporting structures
55.5
66,759
652
Local excision or destruction of ovarian lesion or tissue
53.9
8,796
707
Other repair of vagina
53.0
4,039
704
Obliteration and total excision of vagina
52.9
85
674
Amputation of cervix
52.8
337
658
Lysis of adhesions of ovary and fallopian tube
52.7
4,832
705
Repair of cystocele and rectocele
52.2
17,362
708
Obliteration of vaginal vault
52.0
279
685
Vaginal hysterectomy
51.4
14,572
Total
51.3
536,950
689 Other and unspecified hysterectomy
50.9
505
695
Aspiration curettage of uterus
50.6
52,431
718
Other operations on vulva
50.4
125
675
Repair of internal cervical os
50.3
868
686
Radical abdominal hysterectomy
50.2
616
AMWAC 1998.6 160
696 Menstrual extraction or regulation 50.0 4 655
Bilateral oophorectomy
49.7
1,007
656
Bilateral salpingo-oophorectomy
49.7
9,773
684
Total abdominal hysterectomy
48.7
19,371
654
Unilateral salpingo-oophorectomy
48.6
4,907
664
Total unilateral salpingectomy
47.8
901
713
Other local excision or destruction of vulva and perineum
47.4
5,097
717
Repair of vulva and perineum
46.7
928
690
Dilation and curettage of uterus
46.4
131,605
673
Other excision or destruction of lesion or tissue of cervix
46.2
33,039
653
Unilateral oophorectomy
46.0
2,554
692
Repair of uterus supporting structures
45.6
1,303
716
Other vulvectomy
45.5
220
710
Incision of vulva and perineum
45.3
1,299
687
Radical vaginal hysterectomy
43.3
30
697
Insertion of intrauterine contraceptive device
43.2
1,951
683
Subtotal abdominal hysterectomy
42.6
434
711
Diagnostic procedures on vulva
42.6
1,420
694
Uterine repair
41.1
107
712
Operations on Bartholin's gland
40.7
3,032
665
Total bilateral salpingectomy
40.5
749
714
Operations on clitoris
40.5
42
667
Repair of fallopian tube
40.0
1,680
672
Conization of cervix
39.1
4,680
719
Other operations on female genital organs
38.3
167
688
Pelvic evisceration
38.2
68
657
Repair of ovary
37.8
291
671
Diagnostic procedures on cervix
36.9
10,395
662
Bilateral endoscopic destruction or occlusion of fallopian tubes
36.5
19,980
666
Other salpingectomy
36.4
3,334
702
Diagnostic procedures on vagina and cul-de-sac
35.4
17,257
660
Salpingotomy and salpingostomy
34.4
1,669
650
Oophorotomy
34.2
895
663
Other bilateral destruction or occlusion of fallopian tubes
33.8
5,112
676
Other repair of cervix
33.8
308
715
Radical vulvectomy
33.3
93
680
Hysterotomy
27.7
65
Source: AIHW National Hospital Morbidity Database
(a) Private and public patients have been classifed according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and eligible other patients'.
AMWAC 1998.6 161
Table I12: Percentage of obstetrical procedures (ICD-9-CM groupings) undertaken on private patients (a) sorted by extent of private involvement, Australia 1995−96 Procedure
% of procedures on private
patients
Total procedures (public&
private patients) (no.) 728
Other specified instrumental delivery
58.1
31
723
High forceps operation
51.0
286
724
Forceps rotation of fetal head
50.2
3,389
720
Low forceps operation
50.1
1,074
742
Extraperitoneal caesarian section
50.0
6
722
Mid forceps operation
49.2
11,649
738
Operations on fetus to facilitate delivery
47.6
145
721
Low forceps operation with episiotomy
44.0
5,162
749
Caesarian section of unspecified type
42.3
52
741
Low cervical caesarian section
41.3
47,123
729
Unspecified instrumental delivery
40.3
77
740
Classical caesarian section
40.3
352
759
Other obstetric operations
40.2
291
727
Vacuum extraction
39.9
10,028
736
Episiotomy
38.7
26,204
733
Failed forceps
38.5
775
743
Removal of extratubal ectopic pregnancy
37.8
82
734
Medical induction of labour
37.5
47,544
750
Intra-amniotic injection for abortion
35.2
54
731
Other surgical induction of labour
34.9
347
Tot
Total
34.9
355,039
756 Repair of other current obstetric laceration
34.2
74,749
730
Artificial rupture of membranes
33.6
75,564
758
Obstetric tamponade of uterus or vagina
33.3
39
726
Forceps application to aftercoming head
32.6
92
744
Caesarian section of other specified type
31.3
16
732
Internal and combined version and extraction
30.3
109
754
Manual removal of retained placenta
29.8
5,393
725
Breech extraction
28.0
1,449
735
Manually assisted labour
26.4
14,699
757
Manual exploration of uterine cavity, postpartum
26.1
264
755
Repair of current obstetric laceration of uterus
22.7
291
752
Intrauterine transfusion
19.6
102
751
Diagnostic amniocentesis
17.5
463
753
Other intrauterine operations on fetus and amnion
15.0
26,723
739
Other operations assisting delivery
14.9
415
Source: AIHW National Hospital Morbidity Database (a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and eligible other patients'.
AMWAC 1998.6 162
Table I13: Projected (a) gynaecological procedures (ICD-9-CM groupings) for 1998 and 2018, Australia
1998
2018
Forecast growth
Procedure
forecast
(no.)
forecast
(no.)
1998 to 2018
(per cent) 715
Radical vulvectomy
98
147
49.6
708
Obliteration of vaginal vault
294
438
49.0
709
Other operations on vagina and cul-de-sac
1,915
2,776
44.9
705
Repair of cystocele and rectocele
18,274
26,200
43.4
688
Pelvic evisceration
71
102
42.3
704
Obliteration and total excision of vagina
89
126
42.0
674
Amputation of cervix
355
495
39.4
707
Other repair of vagina
4,240
5,828
37.5
716
Other vulvectomy
230
314
36.7
686
Radical abdominal hysterectomy
647
878
35.7
656
Bilateral salpingo-oophorectomy
10,404
14,034
34.9
687
Radical vaginal hysterectomy
32
42
34.3
711
Diagnostic procedures on vulva
1,481
1,965
32.7
655
Bilateral oophorectomy
1,067
1,395
30.7
685
Vaginal hysterectomy
15,359
19,703
28.3
692
Repair of uterus supporting structures
1,350
1,684
24.8
706
Vaginal construction and reconstruction
81
98
21.8
689
Other and unspecified hysterectomy
534
647
21.2
684
Total abdominal hysterectomy
20,527
24,831
21.0
680
Hysterotomy
67
81
20.4
683
Subtotal abdominal hysterectomy
459
549
19.6
681
Diagnostic procedures on uterus and supporting structures
69,947
83,619
19.5
653
Unilateral oophorectomy
2,676
3,186
19.0
717
Repair of vulva and perineum
956
1,131
18.3
682
Excision or destruction of lesion or tissue of uterus
12,636
14,813
17.2
714
Operations on clitoris
43
50
16.5
672
Conization of cervix
4,860
5,638
16.0
713
Other local excision or destruction of vulva and perineum
5,221
6,032
15.5
654
Unilateral salpingo-oophorectomy
5,153
5,935
15.2
710
Incision of vulva and perineum
1,334
1,525
14.3
Total
556,291
633,907
14.0
665 Total bilateral salpingectomy
784
891
13.7
690
Dilation and curettage of uterus
136,472
155,104
13.7
671
Diagnostic procedures on cervix
10,711
12,171
13.6
670
Dilation of cervical canal
1,326
1,499
13.0
702
Diagnostic procedures on vagina and cul-de-sac
17,742
20,051
13.0
673
Other excision or destruction of lesion or tissue of cervix
34,091
38,302
12.4
703
Local excision or destruction of vagina and cul-de-sac
5,346
6,004
12.3
651
Diagnostic procedures on ovaries
998
1,120
12.2
718
Other operations on vulva
128
142
11.5
664
Total unilateral salpingectomy
939
1,040
10.7
712
Operations on Bartholin's gland
3,133
3,449
10.1
694
Uterine repair
110
120
9.1
676
Other repair of cervix
317
345
8.8
719
Other operations on female genital organs
171
185
8.1
652
Local excision or destruction of ovarian lesion or tissue
9,038
9,682
7.1
700
Culdocentesis
789
842
6.7
AMWAC 1998.6 163
696
Menstrual extraction or regulation
4
4
6.7
658
Lysis of adhesions of ovary and fallopian tube
4,990
5,323
6.7
650
Oophorotomy
921
978
6.2
691
Excision or destruction of lesion or tissue of uterus and supporting struct
4,346
4,584
5.5
666
Other salpingectomy
3,417
3,575
4.6
657
Repair of ovary
298
312
4.6
693
Paracervical uterine denervation
232
242
4.2
697
Insertion of intrauterine contraceptive device
2,009
2,094
4.2
695
Aspiration curettage of uterus
53,008
54,961
3.7
699
Other operations on uterus, cervix, and supporting structures
5,111
5,284
3.4
659
Other operations on ovary
17,970
18,557
3.3
701
Incision of vagina and cul-de-sac
12,206
12,597
3.2
661
Diagnostic procedures on fallopian tubes
528
542
2.7
660
Salpingotomy and salpingostomy
1,702
1,747
2.7
662
Bilateral endoscopic destruction or occlusion of fallopian tubes
20,620
21,013
1.9
675
Repair of internal cervical os
888
904
1.9
668
Insufflation of fallopian tube
12,557
12,787
1.8
669
Other operations on fallopian tubes
6,003
6,112
1.8
667
Repair of fallopian tube
1,729
1,754
1.4
663
Other bilateral destruction or occlusion of fallopian tubes
5,257
5,331
1.4
Sources: AIHW National Hospital Morbidity Database and ABS population data.
(a) The projections have been based on morbidity data for 1995Β96.
Table I14: Projected (a) obstetrical procedures (ICD-9-CM groupings) for 1998 and 2018, Australia
1998
2018
Forecast growth
Procedure
forecast
(no.)
forecast
(no.)
1998 to 2018
(per cent) 738
Operations on fetus to facilitate delivery
147
152
3.3
750
Intra-amniotic injection for abortion
55
56
3.2
759
Other obstetric operations
296
305
3.1
758
Obstetric tamponade of uterus or vagina
39
41
3.1
753
Other intrauterine operations on fetus and amnion
27,012
27,822
3.0
731
Other surgical induction of labour
352
362
2.8
735
Manually assisted labour
14,893
15,270
2.5
732
Internal and combined version and extraction
111
114
2.5
730
Artificial rupture of membranes
76,574
78,438
2.4
755
Repair of current obstetric laceration of uterus
296
303
2.4
757
Manual exploration of uterine cavity, postpartum
268
274
2.3
734
Medical induction of labour
48,237
49,326
2.3
Total
360,290
368,366
2.2
736 Episiotomy
26,583
27,173
2.2
756
Repair of other current obstetric laceration
75,875
77,504
2.1
733
Failed forceps
786
803
2.1
743
Removal of extratubal ectopic pregnancy
83
85
2.1
754
Manual removal of retained placenta
5,482
5,597
2.1
727
Vacuum extraction
10,181
10,394
2.1
721
Low forceps operation with episiotomy
5,240
5,349
2.1
751
Diagnostic amniocentesis
474
484
2.1
739
Other operations assisting delivery
422
430
2.0
729
Unspecified instrumental delivery
78
80
2.0
722
Mid forceps operation
11,834
12,064
1.9
AMWAC 1998.6 164
720 Low forceps operation 1,092 1,113 1.9 725
Breech extraction
1,474
1,503
1.9
724
Forceps rotation of fetal head
3,445
3,511
1.9
723
High forceps operation
291
296
1.8
741
Low cervical caesarian section
48,005
48,842
1.7
740
Classical caesarian section
360
366
1.7
744
Caesarian section of other specified type
16
17
1.7
749
Caesarian section of unspecified type
53
54
1.7
726
Forceps application to aftercoming head
94
95
1.5
752
Intrauterine transfusion
104
106
1.5
742
Extraperitoneal caesarian section
6
6
1.4
728
Other specified instrumental delivery
32
32
1.3
Sources: AIHW National Hospital Morbidity Database and ABS population data. (a) The projections have been based on morbidity data for 1995−96.
AMWAC 1998.6 165
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AMWAC 1998.6 166
Enkin M, Keirse M, Renfrew M, Neilson J, (1996) Guide to Effective Care in Pregnancy and Childbirth, New York Eagly A H, (1987) Sex differences in social behaviour: A social-role interpretation, Lawrence Erlbaum: New Jersey Fondren L, Ricketts,T, The north Carolina Obstetrics Access and Professional Liability Study: A Rural/Urban Analysis, The Journal of Rural Health 1993:129-37 Greenberg, D, Hochheiser, L, Family Practice Resident=s Decision making Regarding Future Practice of Obstetrics, Journal American Board of Family Practice, January-February 7: 25-30, 1994. Greer, T, Baldwin, L, Wu, R, Hart, G, Rosenblatt, R,.ΑCan Physicians Be Induced To Resume Obstetric Practice? Journal of American Board of Family Practice July-August 5:4 407-412 1992 Hays, R, Veitch, C, Cheers, B, Crossland L, Why Doctors Leave Rural Practice, Australian Journal of Rural Health (1997) 5, 198-203 Innes K, Why are GP’s Ceasing Obstetrics? A Study of Victorian General Practitioners who have Ceased Obstetric Practice 1989 - 1996, 1996. Nesbitt, T, Arevalo, J, Tanji, J, Morgan, W, Aved, B, Will Family Physicians Really Return to Obstetrics If Malpractice Insurance Premiums Decline? Journal of American Board of Family Practice July-August 5:4 413-418 1992 Nesbitt, T, Baldwin, L, Access to Obstetric Care, Primary Care, 20:3, September 1993 509-522 Health and Community Services, Birthing Issues - A Rural Perspective, Background Paper, Prepared by Review of Professional Indemnity Arrangements for Health Care Professionals. Department of Health, Housing, Local Government and Community Services, December 1993. Watts, R, Marley, K, Beilby, R, Doughty, M, Doughty, S, Training, Skills and Approach to High-risk obstetrics in Rural GP Obstetricians, Australian and New Zealand Journal of Obstetrics and Gynaecology (1997) 37:4:424-426 Woollard, L, Hays, R, Rural Obstetrics in NSW, Australian New Zealand Journal Obstetrics and Gynaecology 33:3, 240-242, 1993
AMWAC 1998.6 167
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