06 Jun

The Hole in Maternity (Updated)

Published by MacDoctor on June 6th, 2010
82 Comments »

Once more the maternity system in New Zealand is under fire in the Dominion post, with a couple of articles involving the death of newborn babies. In the first article, the newborn died from haemorrhagic disease (excessive bleeding) because the parents refused to allow their child to have vitamin K. Too much internet disinformation can be hazardous for your child’s health. The midwife in question was criticised for not answering the parents questions on vitamin K apparently because it was week 28 and she customarily gave that information at week 36. The baby was born on week 35 (five weeks early). I hesitate to criticise the midwife here, but excess rigidity shows an excessive reliance on normality. There was absolutely no reason not to discuss vitamin K at the time requested by the parents and it may have prevented them misinforming themselves.

The second article is far more tragic. A newborn died unnecessarily and a mother was severely compromised and almost killed. The mother still has severe ongoing problems. The midwife was just seven months out of college.

In contrast, a newly graduated doctor is heavily supervised for two years before being allowed to handle patients without senior input. And the medical course is twice as long as the midwifery course and contains two years of patient contact as a student.

And yet midwives are allowed almost the same level of autonomy as a year 9 doctor – at least in terms of obstetrics.

This is a rather horrific illustration of the underlying problem of the Lead Maternity Carer system. In 1995, the year before the LMC system was put in place, midwives were, for the first time, allowed to graduate outside of the nursing system. A separate course allowed them to become midwife instead of nurses, rather than in addition to nursing. Prior to 1995, a nurse had to have not merely graduated, but actually had to have a certain amount of experience before becoming a midwife.

I remember the midwives from my house surgeon days. They were tough older women who would not for a moment take any nonsense from a mere house surgeon. They would acknowledge the obstetrician as one would an equal – but they would follow his (usually his) orders immediately, without question. After all, he was a real doctor. These women all knew as much practical obstetrics as the obstetrician. They had experience.

“

The reforms of the 1990 placed inexperienced half-nurses into the same positions as these highly experienced midwives

”

The reforms of the 1990 placed inexperienced half-nurses into the same positions as these highly experienced midwives. All of these new midwives knew how to deal with a normal birth. Unfortunately, none of them know (at least initially) what abnormal looks like. You can see this obliquely in the first article but it is in the second article that you can see the disastrous natural consequence. When you have only really experienced normal, your brain tends to filter out the early warning signs of “abnormal” until it is too late. A more experience midwife would probably not have handled the situation that developed any better than the younger one, but the more experience one would have had the mother in hospital by the time things went pear-shaped. That’s the difference.

Of course, the 1996 Maternity Act made this situation much worse by essentially offering to pay midwives and GPs the same amount of money. The amount offered was more than reasonable by a midwife’s standards, but was barely worthwhile from a GP’s viewpoint. A GP could make a great deal more money with substantially less risk and inconvenience by sticking to his consulting room and leaving the delivery suite to midwives. And stick he did. GPs abandoned obstetrics in droves. By 2006 there were only 54 practicing GP obstetricians. I have no idea how many are left now, but I am willing to bet it is a lot less than 54.

The net upshot of this disappearance of the GP obstetrician is the rapid skill-and-knowledge-loss of obstetrics amongst GPs. Most rural hospital doctors have a seriously diminished obstetric ability, simply because they hardly ever see any obstetrics. Unfortunately, this lack of GP and rural doctor experience coincides with the loss of the older, more experienced midwives from rural practice. New, inexperienced midwives are rapidly filling the gaps. But now they have no GP back up.

There is a third, more subtle, problem in Maternity. The bypassing of nursing meant that women with a very anti-doctor viewpoint could become nurses without encountering said doctors. These women were predominantly militant feminists as this piece of feminist rhetoric from Karen Guilliland, of the New Zealand College of Midwives illustrates:

“The process of a government funding agency defining childbirth as a life process rather then a medical event and giving midwives, general practitioners and obstetricians equal status in the provision of services around childbirth was a major triumph for women in general and the women dominant profession of midwifery.”

See anything about improving health care or reducing infant mortality in there? Me neither.

This anti-doctor mindset is just one more issue preventing the inexperienced midwife from seeking help in a timely manner. It may be a small issue, but it is most certainly a real one.

Interestingly, the paper from which I lifted the Guilliland quote is an unpublished (AFAIK) paper by Andrea Kutinova of the Department of Economics, University of Canterbury. It ably demonstrates that the neonatal mortality rate of GP-supervised births is about 10% less than that of midwife-supervised births, despite the obvious caveat that women going to GPs for their maternity care tend to be those with potential birthing problems.

I’m betting this will not be a popular paper in midwifery circles.

I’ve seen a bit of raving about this issue in the blogosphere of late, attempting to blame Labour. Unfortunately this is an issue that can be laid squarely on the shoulders of the last National administration. While the feminists may have been delighted with the idea, the Maternity Act was little more than a cost-saving measure. And a very poor one at that. This means that it is up to National to grab the nettle firmly and extract it, no matter how often it stings. It is, afterall, all their fault.

MacDoctor’s advice, Mr Ryall, FWIW:

Insist on a minimum of 2 years postgraduate nursing experience for midwifery and a further years attachment to a hospital birthing unit in a teaching hospital. Frankly, I would push to have midwifery made into a nurse-specialist field, but I realise that would cause a sudden shortage of midwives. Maybe later.
It should be possible to persuade some of the older midwives to come out of retirement to supervise the younger ones.
Allow GPs to charge above the midwife rate. There are many mothers who would prefer a GP but can’t afford to pay the entire amount of a GP-supervised confinement. There is no reason why the current maternity fee could not provide a part-payment.
Promote GP obstetrics again. You will have to do a lot of work here, as GPs have a tendency to think “once bitten, twice shy”. Bonus incentives for rural GPs to practice obstetrics comes immediately to mind. Paid refresher courses would be helpful.
It is time some real research into midwifery was conducted. Lets see some real evidence-based practice instead of the bizarre new-age claptrap that usually comes out of the mouths of modern midwives.

The MacDoctor awaits the tidal wave of rabid midwife comments with anticipation.

Update:

It seems the plot thickens somewhat as it has been revealed that the original midwife had addiction problems. While this does not automatically cast doubt on her mentoring abilities, is certainly raises doubts about her ability to judge her young protégé’s competence. The real question , of course, is why the midwifery council allowed her to mentor.

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