By Martha Wilson, MD, FM-OB Fellow, UUMC and CHCs of Salt Lake City.
Upon graduating from family medicine residency two years ago, I left the US to work in New Zealand for 6 months for a small rural clinic in Gore, N.Z. near the southern tip of the south island. I delayed entering OB fellowship for a year to prioritize this experience, and although I knew I would gain a new perspective on the provision of primary care, I really had no idea what I would learn.
Having been trained in a typical U.S. model of care where most women deliver babies in hospital settings with operative availability, I was apprehensive about working in a hospital without surgical OB services. Most women in New Zealand deliver their babies with licensed midwives in small rural hospitals without operating rooms. The vast, sparsely populated landscape of New Zealand prohibits rural residents from seeking care in larger hospitals, and smaller hospitals cannot afford to hire a full staff of specialists. This system has worked for New Zealand for ages, and although their approach terrifies U.S. trained physicians, it is well tested and affords better pregnancy outcomes than the U.S. approach.
You could argue that the patients in New Zealand are healthier, and inherently carry less risk than U.S. patients, and this is probably partially true and very difficult to refute. I can tell you that New Zealanders are not universally healthy, and the country has its fair share of obesity, hypertension and metabolic disease. Despite this, the maternal death rate related to labor and delivery is two thirds that of the U.S., and the neonatal mortality rate is also slightly lower.
When I started work in New Zealand I tried to be in tune with my perspective. I continually asked myself whether I was afraid of this approach because it is actually wrought with avoidable risk, or rather because I had been trained within a different paradigm. In residency it was repeatedly confirmed for me that labor and delivery is unpredictable and can occasionally be downright terrifying. As a resident I learned to be cautious with labor, and often thought my patients were close to having a really horrible outcome even when they were probably far from it.
The New Zealand perspective, although it was hard for me to accept at first, became very comfortable for me with time. I provided medical consults for midwives who performed low risk deliveries, while more complicated pregnancies were managed and delivered by the obstetricians in our referral hospital 3 hours away. In the 6 months I spent in N.Z. (and the 20 years prior to my arrival), no women bled to death and no babies died in labor or had documented hypoxic injuries in our hospital.
I definitely am not arguing that we adopt the New Zealand model for obstetrical care in the United States, as our landscape and population should be expected to require a different approach to care. I do, however, think that it is helpful to be aware of the origin of our attitude towards what we see as the “right” kind of care, and to remember that there are vastly different approaches to obstetrical care with better outcome data than our own. I’ve found this experience to be really helpful in working along different types of providers in the U.S., and in having an open mind to varied models of care. As a Community Health Center family doctor, the type of care that I provide is inherently different compared for instance to the UUMC midwives, each model formed by the paradigm that trained us as providers, and each worthwhile and compatible with great outcomes.
Martha Wilson, MD is a Family Medicine OB fellow at the University of Utah School of Medicine.
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