Anaesth Intens Care (1992), 20, 345-353

Surveys Obstetric Epidural Services in Rural South Australia R. W. WATTS· The Investigator' Clinic. Port Lincoln. South Australia

SUMMARY A survey 0/sixty South Australian country hospitals/ound that 35 units had more than 25 deliveries per year (total deliveries 4,247. which is 21.5% o/totallive births in South Australia during 1989). Twenty-five o/these units had an epidural service (71%) and the overall epidural rate was 16.7%, 9.5% provided by general practitioner anaesthetists and 7.2% by specialists. General practitioner anaesthetists were involved more in the medium-sized units (50-200 deliveries per year), whereas specialists provided more services in the larger regional units and the small units as visitors. The epidural rate varied between 6-20% depending on the size 0/ the unit. Most country regions in South Australia have reasonable access to an epidural service. The more geographically isolated areas are being serviced by general practitioner anaesthetists. Key Words: ANAESTHESIA: obstetric, rural services; ANAESTHETIC TECHNIQUE: epidural

According to the 1986 Australian Bureau of Statistics Census, 27.4% of the total South Australian population (1.34 million) live in the country. I Providing medical services such as obstetrics and anaesthesia to these people is a logistic problem because of the size and isolation of country towns. Country women prefer, and frequently insist on, delivering their babies in local hospitals. In 1989,24.8% of 19,739 hospital births occurred in country hospitals in South Australia. 2 There is limited information on obstetric anaesthesia coverage of this significant number of rural confinements. 3 A survey of all sixty rural South Australian obstetric units was undertaken to determine the availability of an epidural service for obstetric analgesia and anaesthesia. METHODS In early 1991 a questionnaire was sent to all rural hospital obstetric units in South Australia, requesting information regarding the number of confinements in the year 1990, the number of epidurals performed (in labour and for caesarean section) and who performed them (either general practitioner, anaesthetist or specialist). Questionnaires were posted to 60 hospitals; 54 (90%) responded. °B.Sc. (Hons.), D.I.P. R.A.C.O.O. Address for Reprints: Dr. R. W. Watts, 'The Investigator' Clinic, P.O. Box 1642, Oxford Terrace, Port Lincoln, S.A. 5606, Australia. Accepted for publication April 3, 1992 Anaesthesia and Intensive Care, Vol. 20, No. 3, August, 1992

The two level III Adelaide teaching hospitals were also surveyed for comparative data. RESULTS During 1990 there were 4452 deliveries in rural South Australia; 4247 occurred in obstetric units having > 25 confinements per year. Table I shows epidurals were available in 25 of the 35 units (71.2% availability). The overall epidural rate was 16.7%; 9.5% provided by general practitioner anaesthetists and 7.2% by specialist anaesthetists. Figure I shows the mean epidural rates compared with the number of deliveries per year. These range from 5.9% in units with less than 50 deliveries per year to 20% in the 101-200 deliveries per year group. Availability in each group is shown by the fraction at the head of each column. The hatched area shows the contribution by general practitioners. In the smallest units the epidurals were more often provided by a visiting specialist for elective caesarean sections, although three units in the (26-50) group had on-site general practitioner services. The availability in the (51100) group was 7/l 0 and 8/8 in the 101-200, where most epidurals were performed by general practitioners. Epidural services were available to all of the larger units where more epidurals were performed by specialists. Figure 2 is a regional map of South Australia showing the number of deliveries in each region,

346

R. W. WATTS 25

20

D Specialist

NT .---------------------------------,OLO 8

1

8

~GP

5

:? 0 W f-

«

a:

'5

NORTHERN 1049 ! 15.7% (9.0%)

WA

15 NSW

-l

«

a:

::J

7 '10

10

0

Pr Augusta

5

CL

112

W

5

0

~

26-50

(Total Deliveries) (434)



I

51-100

101-200

>200

(734)

(1209)

(1807)

/

/ 363 !EYRE 12.9% (0)

the epidural rate and the percentage provid~d by specialist anaesthetist (in brackets). The hl~est total epidural rate occurs in the central regIOns around Adelaide (21 %) and the lowest in the York and Lower North (5.8%). No data for metropolitan Adelaide were collected. Specialist epidural rates are highest in the central regions 10.2%, and lowest in Eyre 0% and So.uth East 0.1 %, regions most distant from Adelaide. Conversely, general practitioner epidural ~ates as expected are highest in these areas, 12.9% III Eyre and 13.3% in the South East. The epidural rate at Flinders Medical Centre was 57.5% for 2707 deliveries and 52.3% for 3062 deliveries at The Queen Victoria Hospital. TABLE I Survey of epidural services in sixty South Australian country hospitals for 1990 Deliveries (in units with > 25 confinements/year) total 4,247 (response rate 90%) Epidurals

%

General practitioner Specialist

399 303

9.3 7.1

Total

702

16.4

71.4%

Pt Pine

-~:J ~enm:rk ~' • Ade/a,de T

Pt Lmcoln

OBSTETRIC UNIT SIZE (ConfinementslYear) FIGURE I.-A comparison of epidural rate and size of obstetric units. Fractions at the top of each bar show availability, e.g. in the 26 to 50 delivery group, five of the 12 units have an epidural service.

25/35 Units

\/fr ,~~yalla.

YORK & LOWER NORTH 359 I 5.8% (3.0%)

~1;R3roo

CENTRAL REGIONS 857 ! 21% (10.2%) 140

Kilometres

). Murray

fABrrdge ~ ~

MURRAY LANDS 571 ! 10% (2.8%)

/ /!.

/ )1~;;,nti,e,

I /

SOUTH EAST - / 1000! 13.3% (0.1%)

FIGURE 2.-A epidural service atlas of rural South Australia showing number of deliveries/epidural rate/ (percentage performed by specialists), for each region. Map design after Chan and Scott 2. (Note: Data from metropolitan Adelaide is not included.) DISCUSSION The provision of safe and effective obstetric epidural services to geographically isolated areas of Australia is a unique and challenging problem. This survey showed that in rural obstetric units with more than 25 deliveries per year, the epidural rate was 16.7% compared to a rate of over 50% at city Level III hospitals. There are obvious reasons for this difference. Low-risk obstetrics is practised in country areas whereas obstetric problems such as pre-eclampsia and twin pregnancies are referred to Level III hospitals and often require epidural analgesia. Epidurals are freely available in teaching hospitals, provided by 'in-house' staf~ who .are immediately available for post-InsertIOn responsibility, often not the case in the count~. Despite the problems posed by a remote settlllg there is a surprisingly high availability (71.4%) of epidural services, in fact all units having more than one hundred deliveries per year have an epidural service. Even more surprising is the number of GP anaesthetists who provide these services, considering there is no formal GP anaesthetic qualification in Australia. Most GP anaesthetists administering epidurals have either trained overseas or spent time in specialist training programs. Anaesthesia and Intensive Care. 1"01. 20. No. 3, August. 1992

RURAL OBSTETRIC EPIDURAL SERVICES

Paech and Godkin (1991)3 found a similar high availability in rural and regional hospitals in Western Australia where general practitioners serviced 19 of 20 units. The epidural rate in these hospitals was mostly in the 0-10% range, which is less than the mean of 20% found in this South Australian study. A similar survey in the United Kingdom in 1985 4 found district hospitals with 500 to 1000 deliveries per year had epidural rates of 0 to 35%. The frequency of performing an epidural is critical to the maintenance of the skill and, in units with fewer than 100 deliveries per year the ongoing experience is probably just adequate, although Levison and Shnider (1986), 5 in an American editorial, expressed some concern about units delivering fewer than 500 babies per year. They did however acknowledge that the situation may be different for geographically isolated areas. This study found that a significant number of epidurals were performed in units with fewer than 100 deliveries per year, 5.9% in the 26 to 50 group and 8.3% in the 51 to 100 group. With infrequent application of technique, there must be some concern about maintenance of skills in these groups. To overcome this problem, practical postgraduate updates must be available to committed GP epiduralists. The epidural technique should also be applied to other areas of anaesthesia in order to maintain skills. Otherwise patients requiring obstetric analgesia in smaller units should be referred to larger units as often happens. It is interesting and not surprising that the highest epidural rate occurs in the central regions around Adelaide where specialist contribution is also higher (10.2%). Conversely the more distant regions of Eyre (0%) and South-East (0.1 %) have little specialist input. Like general practitioners, specialist anaesthetists are reluctant to leave the city perhaps for similar reasons such as isolation

Anaesthesia and Intensi.e Care, Vol. 10. No. 3. August, 1991

347

from family and peers, limited workload and occasionally the possibility of professional conflict with GP anaesthetists. It is clear from this study and that of Paech and Godkin (1991) that GP epidural anaesthesia is widely practised in rural areas. I believe general practitioners have a major role to play in the moderate-sized, geographically isolated units (51200 deliveries/year) and a supportive role to specialists in larger units (more than 200 deliveries), where often the specialist is in solo anaesthetic practice and it is impractical to provide total epidural cover. These views are reflected in current practice in South Australia. The relevant professional colleges must therefore address the issues of training and maintenance of skills for the rural general practitioner anaesthetist in order to maintain safe and effective services. ACKNOWLEDGEMENTS

I wish to thank Mrs Helen Reidy and Mrs Anne Home for their secretarial assistance. I am grateful to the country doctors and midwives who responded so helpfully to this survey. This project was supported by the General Practice Evaluation Program. REFERENCES

1. The Australian Bureau of Statistics 1986 Census. 7-page format. 2. Chan A, Scott J. Pregnancy Outcome in South Australia 1989. Epidemiology Branch, South Australian Health Commission, 1991. 3. Paech MJ, Godkin R. A Survey of Epidural Analgesia Practice in Western Australian Obstetric Units. Anaesth Intens Care 1991; 19:388-399. 4. Frank M, Heywood A, McLeod DM. Survey of the practice of epidural analgesia in a regional sample of obstetric units. Anaesthesia 1988; 43:54-58. 5. Levison G, Shnider SM. Obstetric Anaesthesia cover - a continuing problem. Editorial. Anesthesiology 1986; 65:245-246.

Obstetric epidural services in rural South Australia.

A survey of sixty South Australian country hospitals found that 35 units had more than 25 deliveries per year (total deliveries 4,247, which is 21.5% ...
343KB Sizes 0 Downloads 0 Views