11 Oct

Bad Birthing

Published by MacDoctor on October 11th, 2008
7 Comments »

The report (PDF) on the death of the baby who died during birthing in Kenepuru Hospital makes interesting reading. It rather blithely states that “Maternity services in the Wellington area are as safe as maternity services anywhere else in New Zealand”. This is rather like saying that, in the current economic crisis, New Zealand banks are no more at risk than American ones. No one will take any comfort from the remark. The report goes on to state:

“Relationships between health practitioners working across the spectrum of maternity care need to significantly improve in order to ensure seamless, safe and high-quality care for women. ”

Which means maternity services will improve when hell freezes over. Steve Chadwick’s attempt to improve matters by throwing money at it is doomed to failure. The damage to maternity will not be fixed by the simple application of money. There is a great rift between GPs and midwives that needs to be repaired first.

Let me start with a small piece of history. In 1990 the Nurses Act was changed to give midwives maternity-care status equal to that of doctors. For a while, this worked well, with the new midwives adding a personal touch to the experience of pregnancy and birthing. The net result, of course, was that woman accessed both a midwife and a doctor with the consequence being a swift increase in costs. Unfortunately, the National government of the time seized upon this new status to move maternity care away from doctors, in an attempt to contain costs.

Section 51 of the Health and Disability Act of 1993 insisted that there should be only a single lead maternity carer. This means that the GP could not see the client throughout the pregnancy then hand across to the midwife to attend the birth and the aftercare. The GP had either to do these things himself (which was not economically viable), or s/he had to pay a midwife out of his (meagre) LMC budget. The midwife, of course, could do everything. In the first arrangement, the GP was always available to help out , if things turned ugly. In the second arrangement (midwife only), the midwife was on her own and could only access emergency services.

The consequence is obvious. Inexperienced midwives functioning in isolation would occasionally make serious errors of judgement (which would, most likely, have been pick up by the GP and corrected). The fact that so few babies have died is actually a tribute to the level of expertise that midwives have developed in a relatively short time. However, it is no substitute for medical training – when things get complicated, you need a doctor.

At one time, many doctors were involved in maternity. It was the norm for your GP to be your maternity carer except around the (normal) birth. The GP would be able to spot the more complex birth and either attend himself, or refer on to an obstetrician. GPs regarded the removal of their services with great resentment and partially blamed the college of midwives who had pushed strongly for the LMC program.

Which brings us back to today. Dr Lynda Exton’s new book, The Baby Business, claims the maternity system has become more dangerous since the 1990 maternity reforms. She says:

“While midwives did a wonderful job, at least a third of women needed a doctor’s input during labour or birth and it was not acceptable that they now had to pay for that.”

Unfortunately, many cannot afford to pay for those extra consultations and end up not having them. In embarrassment, they also do not see their midwives again until they are in labour, making the medical situation potentially very dangerous. Dr Exton suggests:

“An independent national review of maternity service was needed as well as a national database giving women comprehensive information on birth scenarios, such as home births, caesareans and relative risks.”

That’s all well and good, but as far as I am concerned, the only solution would be the immediate repeal of the LMC system and a returned to shared collegial care between GPs and midwives. What is the response of the government and college of midwives?

“Health Ministry chief adviser for child and youth health Dr Pat Tuohy told the newspaper said he had not read Dr Exton’s book.

“However, information contained in promotional material for the book was “misleading, sensational and factually incorrect”. Data suggested the infant mortality rate was a record low, not worsening, he said.

“New Zealand College of Midwives chief executive Karen Guilliland said Dr Exton’s claims were not “what the published data shows”.”

Yes, a very measured response. And completely wrong. Both Tuohy and Guilliland overlook that deaths during birth caused by medical error are rare and are hidden in the overall figures for perinatal mortality (deaths within the first few days of birth). The data shows perinatal mortality going down. But that is because we are much better at predicting serious birth defects with ultrasound and other diagnostic tests. foetuses with defects incompatible with life are then aborted. Those with repairable problems are referred to obstetricians and neonatologists. This drops the mortality figures, but swallows up the midwifery disasters. I estimate about two thirds of these (admittedly rare) birthing deaths would be avoidable if doctors were brought back in the loop.

Most women appear to be happy with their midwives care. But most women would be happier with their GPs input included. I suspect so would most midwives.

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