I was fortunate to be awarded the RCOG travel grant to be the UK participant in the 22nd European Meeting and Exchange Programme of Trainees in Obstetrics and Gynaecology, Estonia (Tallinn) on 5–9 May 2012.
Background to Estonia
Estonia (officially the Republic of Estonia) is a state in the Baltic region of Northern Europe, bordered to the north by the Gulf of Finland, to the west by the Baltic Sea, to the south by Latvia and to the east by Russia. It became part of the European Union in 2004. The official language is closely related to Finnish. Estonia is a democratic parliamentary republic divided into 15 counties. The capital and largest city is Tallinn. With a population of 1.29 million, it is one of the least-populous members of the European Union. Estonia has the highest gross domestic product (GDP) per person among former Soviet Republics. Estonia is listed as a ‘High-Income Economy’ by the World Bank and as an ‘advanced economy’ by the International Monetary Fund; the country is an OECD member. The country is ranked highly for press, economic and political freedom with democracy and education being considered very important in the country.
In terms of health indicators, the average life expectancy in Estonia is 73.2 years, compared to an average of 78 years in the European Union. Women as a group live longer than men and have lower mortality rates for all the main causes of death. However, women have higher reported rates of morbidity and utilisation of health care services (especially around childbirth), and they can be more affected by social welfare policies than men. Since the 1980s, the maternal mortality rate has declined noticeably from 38.5 to 16.0 per 100 000 live births between the mid-1980s and the late 1990s. Despite this improvement, it is still almost three times the EU average of 6.6 per 100 000 live births. In the countries of central and Eastern Europe and in the newly independent states, induced abortion was commonly used as a contraceptive method due to lack of modern contraceptives. Estonia had some 35 000 induced abortions per year in the 1980s but the annual number of abortions halved from 29400 in 1990 to 14500 in 1999. However, the proportional decline in the number of live births has been as large, so the Estonian number of induced abortions per 1000 live births has remained at the same high level.
Modern contraception has become more common in Estonia. The use of oral contraception increased from 4% to 15% among women aged 15–49 years between 1992 and 1999. Since 1987, the crude live birth rate has almost halved from 16.2 per 1000 population to 8.7 per 1000 in 1999. The Estonian natural growth rate became lower than the EU rate in 1990, and it has been negative since 1991.
I arrived into Tallinn the day before the exchange commenced so that I could acquaint myself with the city. The following day I was met by my host Annemai Marston (who had previously been to Nottingham in 2011 for the ENTOG exchange held in the United Kingdom) and had completed her obstetrics and gynaecology training two years earlier. She kindly took me to her apartment where I was to be staying and then showed me around the city briefly. On the first evening, there was a drinks and dinner reception in Tallinn which had been organised by Liina Rajasalu who was the chair of the local organising committee. At this event, I had the chance to meet the 18 trainees from different European countries who had also arrived to participate in the exchange and also meet a group of Estonian trainees and fully qualified specialists. Many of the other trainees who were attending the exchange were heavily involved in their own national trainee committees and had attended previous ENTOG events. We were told that the exchange would take place over three days at four different hospitals in Estonia. The majority of us would be remaining in Tallinn; however, two small groups would be going to two different hospitals in different parts of Estonia, Tartu and Parnu.
I was to be based at the West Central Tallinn Hospital and would be accompanied by two other trainees – one from Latvia (Nina) and the other from Lithuania (Ruta). Both Nina and Ruta were very keen to share their own experiences of training in their countries and to compare with mine in the United Kingdom.
Training to become an obstetrician and gynaecologist in Estonia
There are between 120-140 students that enter Medical School at the University of Tartu. The undergraduate programme lasts 6 years and upon completion students have to undertake a competitive examination to apply for postgraduate specialist training. Each year there are 6-7 entrants into obstetrics and gynaecology who are allocated to different hospitals depending on the mark they achieve in the examination. Currently, there are 36 trainees in obstetrics and gynaecology but this includes those that are on maternity leave. At any one time, there are about 20 active trainees in three teaching hospitals (East Central Tallinn Hospital, West Central Tallinn Hospital, Parnu Hospital) and one at the University Hospital (Tartu University Hospital).
All trainees have a directed programme which involves 16 months in obstetrics (divided into 10 months of delivery ward, 5 months of antenatal care and 1 month of neonatology), 12 months of gynaecology (divided into 8 months of operative gynaecology and 4 months of gynae-oncology), 10 months of outpatient obstetrics and gynaecology which includes a dedicated period of 2 months of ultrasound diagnostics. Trainees also have the opportunity to sample other specialties related to obstetrics and gynaecology for four months such as dermatology, urology, breast diseases as well as general surgery and urology. Rather than a competency based training programme, they have to achieve a set number of operative procedures in both obstetrics and gynaeocology. Trainees are expected to work 32 hours a week (a mixture of on call and elective activities) and earn around 750 Euro/month. They remain in one institution for their whole training period but do have the opportunity to undertake fellowships in other countries. Once they have completed their training, they can either remain in their hospital as a specialist or enter the private sector as an independent provider.
The practice of obstetrics and gynaecology in Estonia
In 2010 there were 15748 deliveries divided between 17 delivery units in Estonia. The three largest units (two in Tallinn and one in Tartu) delivered over 2000 babies each, there were 4 units delivering between 500-1000 babies (of which one was a private unit), and 10 units delivering less than 500 babies (of which one was private). The figures quoted for caesarean rate were about 15-18% (of which 50% were elective) and for operative delivery about 6-7% primarily with the use of suction cup rather than forceps delivery. In terms of delivery to discharge time, they also had a minimum discharge period of 6 hours if uncomplicated, but they endeavoured to discharge most women between 2-3 days post-delivery.
During my time at West Central Tallinn Hospital, I had the chance to observe a wide range of gynaecological operative procedures and some ultrasound diagnostics. Sadly, I did not have the chance to observe any deliveries as there were no women in labour during my time there! I had the chance to assist in minor gynaecological procedures such as diagnostic laparoscopy, hysteroscopy and also a caesarean section for undiagnosed breech presentation in labour. In Estonia, they will deliver breech presentation vaginally if the woman is willing.
The hospital had three operating theatres (for obstetrics and gynaeoclogy), eight delivery rooms, two post natal wards, one antenatal ward and one gynecological inpatient ward. There was less of a disposable culture with reusable scrubs but broadly speaking, the antenatal screening programmes, surgical skills and post-operative management were very similar to my experiences in the United Kingdom. A daily handover took place in the morning with all doctors attending from the previous night shift and all doctors for the day shift. The main differences I noted, were the fact that the partner is not allowed in the theatre during caesarean section (with epidural/spinal), two port laparoscopy was used for operative procedures without uterine manipulation, scrub nurses clean and drape all patients and the fact that forceps delivery is extremely rare in Estonia. One interesting thing I noted was that since the three operating theatre share resources, there may be difficulties in obtaining equipment if all theatres are being used at the same time. This was evident during the caesarean section in which I assisted where there was a need for diathermy, but since this was being utilised in another theatre, we had to do without diathermy and use sutures to ensure haemostasis.
I did have the chance to meet the Assisted Reproduction Team at the hospital. Due to its very low birth rate, Estonia has had very pro-natal politics and currently all women aged up 41 years have the opportunity to have unlimited cycles of IVF which are reimbursed by the Government. In 2011, at West Central Tallinn Hospital, they undertook 160 cycles of IVF resulting in 29 pregnancies. They are allowed to return three embryos and are looking into single embryo transfer due to the high prevalence of multiple birth rate. One interesting factor was that sperm donation is legal in Estonia, however as Ruta (from Lithuania) explained, not so in her country, hence many women come to Estonia to obtain sperm for IVF.
During my time in Estonia, I had the chance to observe the practice of obstetrics and gynaecology in a completely different environment to my own. I met and spoke to a huge variety of trainees from different countries in Europe where we compared and shared our clinical, educational and personal experiences of our training. I came away with a great appreciation of my own competency based training programme, the structured and stringent criteria that I have to achieve not only with clinical experience but also in terms of knowledge acquisition in terms of obtaining the MRCOG. However, I was in awe of the ability of most trainees in Europe to use an ultrasound machine with such ease and comfort, something which we seem to struggle with in the United Kingdom.
I am very grateful to the RCOG for the opportunity to attend this ENTOG exchange, and also to the local organising committee for an interesting European meeting in Estonia where we discussed the challenges of multidisciplinary working and also the problems of undermining and bullying in workplace. I remained in Estonia to attend the 22nd European Congress of Obstetrics and Gynaecology which was yet another informative experience. The chance to meet and listen to leaders in the field of gynae-oncology, perinatal medicine, reproductive medicine and urogynaecology was helpful to improve and enhance my own practice. I have already started to implement some of the things I learnt during this time in my own clinical practice.
The ENTOG exchange was a tremendous opportunity to meet other trainees in very different environments who face the same challenges with their patients, the health care systems and just managing their own careers. I was made to feel very welcome by the trainees from Estonia and also their colleagues at West central Tallinn Hospital. The social events that were organised were a chance to get to know each other but also to discover the beautiful medieval city of Tallinn. I feel that I have made friends in different European countries and we have come away buzzing with ideas for collaborative studies and projects. I returned to the United Kingdom inspired to contribute to educational and training matters and with greater passion for my profession.