3.5. Gynaecologists and obstetricians, and midwives
Gynaecologists are concerned with the
functions and diseases specific to women, especially those affecting the reproductive
system, while obstetricians specialise in pregnancy and childbirth. A doctor will often
specialise in both these areas, and the data reported in this section does not distinguish
between the two. Midwives provide care and advice to women during pregnancy, labour and
childbirth and the post-natal period. They deliver babies working independently or in
collaboration with doctors and nurses.
In countries with a medicalised
approach to pregnancy, obstetricians provide the majority of care. Where a less
medicalised approach exists, trained midwives are the lead professional, often working in
collaboration with other health professionals such as general practitioners, although
obstetricians may be called upon if complications arise. Regardless of the different mix
of providers across countries, the progress achieved over the past few decades in the
provision of pre-natal advice and pregnancy surveillance, together with progress in
obstetrics to deal with complicated births, has resulted in major reductions in perinatal
mortality in all OECD countries.
In 2009, the number of gynaecologists
and obstetricians per 100 000 women was the highest in the Czech Republic, Greece, Italy
and the Slovak Republic (Figure 3.5.1). These are all countries where
obstetricians are given a primary role in providing pre-natal and childbirth care. It was
the lowest in Ireland, New Zealand, Canada and Japan.
Since 2000, the number of
gynaecologists and obstetricians per 100 000 women has increased in most countries, with
an average growth rate of 1.5% per year during that period. The number of gynaecologists
and obstetricians has remained relatively stable in Estonia and France, while it declined
significantly in Japan and Poland (Figure 3.5.1).
The number of midwives per
100 000 women was highest in Australia, Iceland and Sweden in 2009 (Figure 3.5.2). Iceland and Sweden have traditionally had a large number of
midwives assuming primary responsibility for pre-natal care and normal delivery (Johanson,
2002). On the other hand, the number of midwives per capita is the lowest in Canada, Korea
and Slovenia. While the number of midwives per women has increased in Canada and Slovenia
over the past decade, it has fallen in Korea. This decline has coincided with a continued
reduction in fertility rates in Korea. In Estonia and Hungary, the number of midwives per
capita also decreased between 2000 and 2009. In Hungary, most of the reduction occurred
between 2006 and 2007, as the number of beds in maternity wards was cut by more than
one-third in the context of a health reform.
In the Netherlands, the number of
midwives has been growing faster than the number of gynaecologists and obstetricians over
the past decade and the number of births in hospitals attended by midwives rose from 8%
in 1998 to 26% in 2007 (Wiegers and Hukkelhoven, 2010).
The relative mix of providers has both
direct and indirect implications for the costs of pre-natal and natal services. Services
involving midwives are likely to be cheaper. This reflects in part the lower training time
and hence a lower compensating pay for midwives in comparison to gynaecologists and
obstetricians. Additionally, obstetricians may be inclined to provide more medicalised
services. A study of nine European countries found that the cost of delivery is lower in
those countries and hospitals that employ more midwives and nurses than obstetricians
(Bellanger and Or, 2008).
There is little evidence that systems
that rely more on midwives are less effective. A review of a number of studies finds that
midwife-led models of care resulted in fewer complications (Hatem et al., 2008). Another review found that midwives are equally effective in
providing pre-natal care and advice in the case of normal pregnancies (Di Mario et al., 2005), although support from obstetricians is required
Definition and comparability
The number of gynaecologists and
obstetricians combines these two specialities.
The figures for gynaecologists and
obstetricians, and for midwives, are presented as head counts, not taking into account
full-time or part-time status.
The number of midwives in Canada
may be understated, as they may undercount the number of personnel actively practicing
midwifery in provinces/territories where there is no regulation requiring licensure as
a condition of practice. In Austria, the number of midwives only includes those
employed in hospital, resulting in an under-estimation of 40 to 50%.