The role of gynaecologists in women's health care - women's views

Transcription

1 International Journal for Quality in Health Care 199; Volume 10, Number I: pp The role of gynaecologists in women's health care - women's views ELINA HEMMINKI 1, SINIKKA SIHVO 1, ERJA FORSSAS 1, PAIVIKKI KOPONEN 2, ELISE KOSUNEN 3 AND MARJA-LEENA PERALA 1 'National Research and Development Centre for Welfare and Health, Health Services Research Unit, PO Box 220, Helsinki, 2 Department of Nursing Science, University of Tampere, PO Box 607, Tampere, Seinajoen terveydenhuolto-oppilaitos, Koskenalantie 17, Seinajoki and 3 Medical School, University of Tampere, PO Box 607, Tampere, Finland Abstract Objective. Reproductive matters are common reasons to use health services, and both primary care providers (general practitioners and public health nurses) and specialists (gynaecologists) can be consulted. The purpose of this study was to find out how Finnish women think about and use specialist care in reproductive matters; gynaecological health checks, contraception, and prenatal care served as examples. Methods. The data come from a questionnaire survey sent in 1994 to a representative sample (74% response rate) of year-old Finnish women (# = ). Results. Most (7%) women considered regular health checks by a gynaecologist important, and % had visited a gynaecologist regularly in the past 5 years. Healthier women and women having more education were more likely to visit gynaecologists regularly. Most women (6%) preferred a gynaecologist to a general practitioner for contraceptive matters, and % reported visiting one for their last contraceptive visit. Maternity centres with their public health nurses and general practitioners were the main source of prenatal care. Conclusions. The results suggest the need to study the benefits of regular gynaecological health checks, and to define the best provider in common reproductive matters. Evaluation should include organizational impacts, such as those of the division of work between primary and secondary health care and small area population responsibility. Keywords: contraception, gynaecological health checks, level of care, prenatal care Public health care in Finland has two basic principles: small area population responsibility in primary health care (i.e. general practitioners or teams are responsible for the care of people in a certain area) and referral (i.e. primary care physicians refer patients to specialists, mainly in hospital outpatient clinics) [1,2]. Public health care is funded mainly by tax money and administered by municipalities, even though user fees exist for some services. In addition to this municipality-administered public health care, there is privately administered health care, the costs of which are paid largely by public funds through national health insurance. Governmental policy documents acknowledge private health care by saying that it 'complements the public health care' [3]. Most private practitioners are specialists, and people thus have direct access to specialist care. Private care is especially common in the fields of gynaecology and ophthalmology [4]. Of all women's visits to private care in 1994, 30% were to a gynaecologist. The number of such visits was 0.45 million for the total female population of 2.6 million [4]. In 1996 most Finnish gynaecologists worked either solely (24% of the 46 active gynaecologists) or part time (69%) in private practice [5]. The numbers of specialists in general practice (17 active in 1996) or unspecialized physicians (6940) are much higher, but relatively fewer of them (4%) work solely in private practice [5]. Reproductive reasons represent a large proportion of physician visits for women of reproductive age. In Finland in the early 1990s, visits for contraception alone were estimated to represent 17% of all physician visits among 24-year-old females [6]. In the USA in , 29% of all ambulatory visits made by 14-year-old women were to a gynaecologist [7]. Many reproductive problems are such that women Address correspondence to Elina Hemminki. Tel: ( + 35) Fax: ( + 35) elina.hemminki@stakes.fi 59

2 E. Hemminki et al. themselves can identify the type of problem, and they do not need a medical expert to define it. In principle, both a general practitioner (or a public health nurse) and a gynaecologist can take care of common reproductive problems: contraception, maternity care, health checks, and vaginal infections. Direct access to a specialist in reproductive matters may be more convenient for women, and in cases requiring specialist care also cheaper in saving the cost of an intermediary visit []. However, in primary care matters the use of specialists may have three unintended consequences. First, it is usually more costly, and threatens the goals of equity in service provision []. Secondly, it may undermine the assumed benefits of small area population responsibility such as continuity of care from one health problem to another. Thirdly, it may influence the content of care by definingreproductive questions as gynaecological problems. The purpose of this study was to find out how Finnish women think about and use specialist care in reproductive matters. Three examples were chosen for closer scrutiny: gynaecological health checks, contraception, and prenatal Subjects and methods In 1994, a questionnaire was mailed to a random sample of 3000 Finnish women aged 144 years [9]. After two reminders, (74%) answered. The questionnaires covered various aspects of reproduction, including family planning, gynaecological checks, abortions, pregnancies, and infertility, with a focus on use of and opinions about health services. Age was calculated from each woman's year of birth. County and urbanism of the area of residence [10] were defined from the residential municipality. Respondents were asked the type of schooling they had completed, called 'primary', 'intermediate', and 'high school'. Occupations were coded according to the official Finnish classification []. Three of these classifications (upper white collar workers, lower white collar workers, and blue collar workers) also represent a social class gradient. Women were asked how many births, miscarriages, ectopic pregnancies, and induced abortions they had had. Using these data, three parity groups were defined: no (previous) pregnancy experience, only (previous) pregnancies which had not ended in birth, (also) one or more births. For health status, a global subjective estimate ('How would you rate your current level of health? 5 ), with options, 'good', 'fairly good', 'average', 'fairly poor', and 'poor', was used. The term 'public health nurse' used here also includes midwives. The frequency of using a gynaecologist because of pregnancy was estimated from the type of health facility the women had visited. In Finland, most maternity centres are run jointly by public health nurses and general practitioners, and apart from hospital clinics, gynaecologists are usually available only in private care. Hospital maternity clinics are staffed by gynaecologists, but use requires a referral from the maternity centre. The differences between groups were tested using % 2 -tests. Visiting a gynaecologist regularly and preferring a gynaecologist in contraceptive matters were studied as a function of various background characteristics of women, adjusting by logistic regression for other background characteristics. The background characteristics to be adjusted for were first entered in the model and then an odds ratio for each background characteristic in turn was calculated. Basic education (three groups), marital status (single, cohabiting, married, divorced, or widowed), type of residence (urban, semiurban, rural), county ( counties, Ahvenanmaa is combined with Turku and Pori), and parity (no pregnancy, no birth, birth/s) were used as categorical variables excluding women with missing information. Results Health checks When asked an attitudinal question about whether regular health checks by a gynaecologist are important for women in general, most women (7%) said Tes' (Table 1). Only 2% said 'No' and the rest chose the alternative 'Cannot say' (9%) or did not answer the question (1%). There was little variation by age, education, occupation, marital status, parity, or county; younger women and women with less education or in the lower occupational group chose the option 'Cannot say' more often than other women. Women were asked in an open question about reasons for their opinion. Of the few women (n 5Q) who did not consider such visits important, almost half (46%) considered it unnecessary medicalization. Some (14%) thought that a general practitioner could provide the same care, and the rest (%) gave other reasons, such as the expense, or did not give any reason (24%). Of the reasons given for the importance of health checks, the two first-mentioned (different) reasons were recorded, and classified into the groups given in Table 1. However, because of the various forms of expression used, this classification was not clear-cut and the table presents a simplification of the nuances. The most common reason was early diagnosis of diseases, which 10% of the women further specified to be cancer. Into the 'peace of mind' category were classified reasons like 'to be sure that everything is OK', 'for the sake of security'. In the 'prevention' category we classified reasons in which problems were not mentioned, but rather health, e.g. 'it is taking care of one's health', 'preventive health care'. The women were asked to indicate how often they themselves had visited a gynaecologist in the past 5 years. Most women had visited a gynaecologist, and more than half had done so regularly (Table 1). About one-third (31%) of the women had visited a gynaecologist occasionally and 12% had made no visits. Regular visits were most common among 2534 year olds. Adjusting for education, marital status, parity, county, and urbanism, did not change this finding (data not shown). Regular visits to a gynaecologist were more common among the higher educated, among women with pregnancies 60

3 Gynaecologists in women's health care Table I Percentages of women attributing importance to regular health checks by gynaecologists (for women in general) 1 who have themselves made regular visits to a gynaecologist in the past 5 years, by age Age (years) n Affirmed important Reasons cited 3 Early diagnosis Early diagnosis of cancer 'Peace of mind' Prevention Other Made regular GYN visits All 'Do you think that it is important for a woman to visit a gynaecologist (specialist in women's diseases) regularly even if she does not have any specific problems?' 2 Includes 10 women who did not give information on age. 3 Only the first two reasons mentioned by each woman's list of respondent were included. but no births, in the three most southern counties (Uusimaa, Turku and Pori and Ahvenanmaa, Hame), and among women with better subjective health; regular visits were less common among unmarried and rural women (Table 2). Of the women who considered regular health checks by a gynaecologist important, most (90%) had actually also visited a gynaecologist in the past 5 years, either regularly or a few times. Contraceptive services When asked whom they would prefer to visit for contraceptive matters, most women chose a gynaecologist, and only 4% a general practitioner; 7% chose 'does not matter', 3% could not say or did not answer the question. Preference for a gynaecologist was more common among women over 30 (data not shown), and among more educated and urban women (Table 3). The preferences by county varied from 90 to 73%. Differences by marital status, parity, and health were small, and after adjusting for other background characteristics, statistically non-significant. When asked a similar question about preference between private and public health care, fewer preferred private physicians (43%) than gynaecologists. One-third (32%) chose 'Family planning clinic' and 5% 'Other municipal health care' (health centre), 14% chose 'Does not matter', and the rest (6%) could not say or did not answer. The differences by background characteristics were similar to those found for preferences by the speciality of the physician (Table 3), but the differences by age (women under 25 years preferred private physicians less often) and county were larger. When asked the hypothetical question, 'Assuming that you wanted to get contraceptive pills, where would you prefer to obtain them (if they were available from all the places and persons listed below)?' most (5%) chose a gynaecologist. Very few (5%) chose a general practitioner. The rest chose over-the-counter purchase (1%), public health nurse (13%), Table 2 Proportions (%) of women making regular visits to gynaecologists in the past 5 years by women's characteristics, and adjusted odds ratios (95% confidence interval) 1 Total Education Primary Intermediate High school Marital status Unmarried Cohabiting Married Divorced or widowed Parity No pregnancy No birth Birth(s) Residence Urban Semiurban Rural Health Good Fairly good Average or (fairly) poor n % Odds ratio 1.33 ( ) 1.57 ( ) 2.53 ( ) 2.60 ( ) 2.31 ( ) 2.00 ( ) 0.1 ( ) 0.75 ( ) 0.56 ( ) 0.91 ( ) 0.56 ( ) 1 Adjusted by logistic regression for age and other background characteristics (besides health) in the table. Women with no information («= 44) excluded. 2» refers to the denominator. 'No information' and 'Do not know' groups are not shown. 3 Unadjusted proportions of women with regular visits. 61

4 E. Hemminki et al. Table 3 Proportions (%) of women preferring a gynaecologist in contraceptive matters 1 by women's characteristics, and adjusted odds ratios (95% confidence intervals) Total Basic education Primary Intermediate High school Residence Urban Semiurban Rural «2 % 3 Odds ratio ( ) 3.50 ( ) 0.60 ( ) 0.57 ( ) 1 'Where would you prefer to go for a contraceptive visit?' 2 'No information' and 'Do not know' groups are not shown. 3 Unadjusted proportions of women preferring a gynaecologist. 4 Adjusted for other background characteristics (age, education, marital status, parity, county, residence). Women with no information («= 44) excluded. or other oudets. The differences by age were relatively small, as were differences by the other background characteristics studied. In response to a question about the most recent visit for contraception, gynaecologists were the most common care providers (% of women); 30% had visited a general practitioner, 13% a public health nurse solely, and 3% other care providers. The use of a gynaecologist increased with age, and the use of public health nurses decreased. Women with high school education had visited a gynaecologist more often (60%) than women completing intermediate (46%) or primary (50%) school. A more pronounced trend was found by occupation: 67% of upper white collar workers made their most recent contraceptive visit to a gynaecologist as compared with 44% of blue collar workers. Of the women who preferred gynaecologists as careproviders in contraceptive matters (#=14), 5% had actually visited one for their most recent visit; others had visited a general practitioner (26%) or public health nurse (13%). Of the women who preferred a general practitioner (n = ) 72% had visited one and 13% had visited a gynaecologist. Of the women who gave no preference («=123), 59% had visited a general practitioner, and 23% a public health nurse. Prenatal care Almost all women in the study (99%) had visited a maternity centre during their current pregnancy or their most recent pregnancy ending in a birth. Only a fifth of the women had visited a private physician, most of whom were gynaecologists. However, due to referrals to hospital clinics (57%), more women had seen a gynaecologist at least once. Women with less education and women less than 30 years of age were less likely to have used a private physician. Women who had regularly visited a gynaecologist in the past 5 years were more likely to attend a private physician because of their pregnancy than women who had visited a gynaecologist only occasionally or not at all. Table 4 gives a summary of women's preferences and actual visits regarding reproductive questions. The opinions recorded show that a gynaecologist was always preferred to a general practitioner. In actual visits the differences between numbers of visits to gynaecologists and to general practitioners were smaller. Both in terms of preferences and actual visits the differences between private and public services were smaller, and in prenatal care public services dominated. Discussion Our survey showed that Finnish women considered gynaecologists an important source of care: most women considered regular health checks by a gynaecologist important and they preferred to consult gynaecologists over general practitioners in contraceptive matters. Women favoured gynaecologists' services more than they actually used them. Gynaecologists' services were especially sought in the public sector, because the wish for private service was less common than the wish for specialist care. These findings raise the following questions: (i) Are regular health checks of fertile age women by a gynaecological specialist useful?; (ii) Is a medical specialist needed for contraceptive advice and prescribing?; and (iii) What implications does the discrepancy between women's wishes and actual service utilization have for health education and service provision? The main argument for health checks presented by the women was the importance of early detection of diseases, many specifically mentioning cancer. In Finland there are nationwide cervical cancer and breast cancer screening programmes, and campaigns for self-breast-palpation. Some work-places and health centres arrange general health checks. We found no studies showing or studying the usefulness of regular health checks by gynaecologists in preventing future health problems in these circumstances. Women visiting a gynaecologist had had more kinds of screening examinations, e.g. blood pressure measurement, and breast palpation [9], but these could equally well be done by a general practitioner or a public health nurse. Health checks may be providerinitiated: gynaecologists encourage women to come for regular health checks [12]. With the exception of sterilizations, all major contraceptive methods used in Finland are also provided by general practitioners. In most municipal family planning clinics general practitioners work together with public health nurses and most of the counselling and checks are done by public health nurses. In outpatient contraception services specialists are needed only in certain exceptional cases. However, half of the women reported that they had visited a specialist for their last contraceptive visit. Thus either specialists' services are better, women experience them to be better, or women wrongly assume the need for a specialist. The quality of services by different care providers has been studied separately [9]. The results showed that the quality of services measured 62

5 Gynaecologists in women's health care Table 4 Summary table of women's preferences for and actual visits to different care providers and care sites (% of women) Regular health checks important 1 Visited regularly 2 For contraceptive visits, prefers 3 To obtain oral contraceptives, prefers Last visit for contraception 4 Visits during latest pregnancy Gynaecologist GP Private Public 'Do you think that it is important for a woman to visit a gynaecologist (specialist in women's diseases) regularly even if she does not have any specific problems?' 2 Regular visits in the last 5 years. 3 "Where would you prefer to go for a contraceptive visit?' 4 Only women who had made a visit for contraception (visits to student and occupational health care centres not shown as they may be public or private). 5 Only women who had been pregnant (specialist/non-specialist provider determined from place of visit). by what had been done did not vary much, but women were more satisfied with specialist care. Another reason why women may feel a need for specialist care is that women consider gynaecologists as their primary care physicians. In the USA, gynaecologists have successfully campaigned to be seen and classified as women's primary care physicians [7,13,14]. However, two factors present an obstacle to this arrangement. Gynaecologists are not well trained for primary care tasks [7], and an essential feature of primary care continuity of care for various types of health problems [,13] is lost. A further possibility is that women specifically looked for private care in order to have more control in matters dealing with intimate issues. Choosing a gynaecologist would then be secondary to choosing private care, because most private practitioners in Finland are specialists rather than general practitioners. However, the preference for private care in contraception was much lower than the preference for a specialist, therefore this explanation cannot cover everything. An interesting comparison to family planning was provided by prenatal care. On average, prenatal care can be considered more demanding for a service provider than contraception, and in many countries gynaecologists/obstetricians are actively involved in care provision. In this study, most women had relied on municipal maternity centres with their public health nurses and general practitioners for prenatal care, and many fewer had visited a specialist in the private sector. Based on a previous study [15] it can be assumed tfiat the number of visits to specialists is also very small compared with visits to a public health nurse. This comparison speaks to a perception bias among women emphasizing gynaecological care in contraception: maternity centres are an established and well-accepted form of care, and thus widely used []. Municipal family planning clinics were introduced in the early 1970s, but were never advertised as 'every woman's place', and some health centres have even restricted their family planning services to specific subpopulations. The image of municipal family planning clinics is likely to be less attractive than that of maternity centres which have a long tradition of providing services to all pregnant women. In most Finnish municipalities, specialists in outpatient care are available only in the private sector, and their services cost women more than municipal health care. We found differences by social class, with women from higher social classes and urban areas having used more specialist care. This may indicate that financial and distance barriers prevented other women using such services equally often, and that direct access to a specialist increases inequity in health services []. An alternative explanation is that the use of gynaecological services is on the increase, and women from higher social classes began this trend earlier than other women, as suggested by the innovation diffusion theory [17]. Student health care services with gynaecological services may teach women in academic settings to use specialist care after graduation. Differences by age are difficult to interpret because they may have resulted from age as such (different needs in different ages), from varying services provided for different ages (e.g. school, student, and occupational health care), or from a cohort effect. Even though gynaecologists were frequently used for health checks and contraception, many more women would like to be able to use their services. To close the gap between women's wishes for specialist care and actual use of services, either women's perceptions have to change through health education, or existing non-specialist services have to be better promoted, or new, more attractive non-specialist services must be provided, or the availability of publicly funded specialist services should increase. The first step should be to find out, for different reproductive phenomena, what extra benefits and risks result from the care given by a specialist as compared with that given by a general practitioner or public health nurse, or as compared with no professional care at all. Based on the results of such studies, health education to increase or decrease use of professional care, and specialist care in particular, and further education of professionals could be undertaken. Provider-initiated services 63

6 E. Hemminki et al. should be avoided, especially now when many physicians are not fully employed: medicalization and oversupply of services are likely to result. Reproductive health services are important because of their contribution to the quality of life of most women of reproductive age. Visits to reproductive health care providers are also important because of the number of such visits women make and because they are often the first regular contact with health care. They may influence subsequent service utilization patterns, both of the women themselves and, later, of their families. If an aim of the national health service policy is to provide 'personal physicians' in primary health care and continuous care [2,1], the organization of reproductive services within it should be carefully thought out. The common use of specialist care is likely to undermine the 'personal physician' principle and it costs women more. Whether it is useful in terms of health gains is currently unclear and requires further study. Acknowledgement The authors thank Liina Hemminki for coding. References 1. Hemminki E. Special features of Finnish health services. Themes 3/1995. National Research and Development Centre for Welfare and Health, Helsinki, Hermanson T., Aro S., Bennett C. L. Letter from Helsinki. Finland's health care system./ Am. Med. Assoc. 1994; 271: Ministry of Social Affairs and Health. Health for all by the year Publication series Helsinki, 1993; 9: Social Insurance Institution. Unpublished statistics: Reimbursement of specialist services 1994 (in Finnish). Helsinki, Finnish Medical Association. Physician Survey Statistics and unpublished data (in Finnish). Helsinki, 1996, Sihvo S., Hemminki E., Koponen P. et al. Contraception and use of services (in Finnish). Aiheita 27/1995. Stakes, Helsinki, 1995, p Hale R. W. The obstetrician and gynaecologist: primary care physician or specialist?^/*./ Obstet. Gynecol. 1995; 172: 1.. Starfield B. Primary Care. Concept, Evaluation, and Policy. New York: Oxford University Press, Hemminki E., Sihvo S., Koponen P., Kosunen E. Quality of contraceptive services in Finland. Qual. Health Care 1997; 6: Statistics Finland. Area classifications, municipalities 1994 (in Finnish). Handbooks 2. Helsinki, Statistics Finland. Socioeconomic classification 199 (in Finnish). Handbooks 17. Helsinki, Weingarten M. A., Reinitz A., Hart J. Attitudes to primary-care gynaecology among family physicians and gynaecologists in Israel. Scand. J. Prim. Health Can 1992; 10: Bartman B. A., Weiss K. B. Women's primary care in the United States: a study of practice variation among physician specialties. / Women Health 1993; 2: Horton J. A., Cruess D. F., Pearse W. H. Primary and preventive care services provided by obstetrician-gynaecologists. Obstet. Gynecol. 1993; 2: Hemminki E., Malin M., Kojo-Austin H. Finnish prenatal care: from primary to tertiary health care. Int. J. Health. Serv. 1990; 20: Hemminki E., Gissler M. Quantity and targeting of antenatal care in Finland. Ada Obstet. Gynecol. Scand. 1993; 72: Topo P., Koster A., Holte A. et al. Trends in the use of climacteric and postclimacteric hormones in Nordic countries. Maturitas 1995; 22: Kokko S. New developments in the public primary social and health services in Finland. Dialogi IB, pp Helsinki: National Research and Development Centre for Welfare and Health, Received in revised form 24 July