Maternity Services Gone Wrong
Twenty years ago while Minister of Health, I attended the launch of an interesting book. It was an historical work by Philippa Mein Smith about the period 1920-1939 when doctors gradually took control of childbirth in New Zealand and claimed that by supplanting midwives, hospitalising mothers, and using their superior medical skills, they had reduced the maternal mortality rate. In 1920 most women had their babies at home; 20 years later babies were usually delivered in hospitals, with the new Social Security Act paying doctors to provide the best professional care. According to the medicos, fewer women lost their lives as a result of these changes, and more babies survived. Not so, argued the book: it was little more than patch warfare, with a mostly male profession pushing away a female profession for no measurable health gain. It wasn't who did the deliveries, but the hygiene surrounding the process that had improved outcomes. The book's underlying argument was that midwives were just as capable as doctors in the new world of hygiene, and were preferred by women anyway. It fuelled the women's movement. Midwives set about gaining greater recognition of their skills, plus fees for non-hospital care.
One didn't have to be a feminist to realise there was probably something in the argument. And, at a time when money was tight, encouraging more midwifery was likely to cost the taxpayer less. I had recently been the victim of highway robbery when obstetricians, using a tribunal prescribed by law, had wrung a larger increase out of the Government than other professions were getting. By readjusting the birthing balance it seemed we might gain from competition between midwives and doctors. In the Nurses Amendment Act 1990 Helen Clark, who soon followed as Minister, let midwives undertake sole responsibility for childbirth once more. They gained the same status as doctors.
What followed this patch readjustment between the sexes has been a constant headache. Remember the water birth disasters? And the home birth craze? Today more than 90% of births are in hospitals, the rest at home. But about 2,000 doctors have edged out of maternity services altogether, leaving midwives responsible for most deliveries wherever they occur. Only 30 general practitioners in the country still provide delivery services. Registered specialists can charge a fee for private services on top of the benefit. But not GPs. Ironically, many of them are now women, but they have departed too because the money the government pays is skewed in favour of midwives. Doctors make more from general practice. Ever since 1990 politicians have favoured the polytech-trained, all-female midwives. But then payments had to be changed when they, in turn, did some highway robbery. And now that midwives monopolise deliveries, and competition has nearly vanished, they want more than the 17% increase they recently received. Oh deary me.
What seems to have happened is that the balance has swung too far away from the medicalisation of childbirth. There have always been high-risk deliveries, and there always will be. But rather too many are now handled in the first instance by people with fewer skills. Problems aren't always detected in time, as the Wellington coroner recently suggested in relation to the deaths of two home-delivered babies in his region. If a crisis occurs in a hospital, it can probably be dealt with by the duty doctor. The problem in these cases was with home births. The coroner suggested it was time to review maternity services, and he made several sensible-sounding suggestions about midwifery education that might minimise preventable deaths. Of course, one thing is certain: doctors won't return to maternity work unless there is some monetary recognition of their wider training and different, though complementary skills. Enabling pregnant women to choose from a wider range of experts will cost more, but only a little, as a payment experiment in Wairarapa shows. And there'll be fewer crises.
However, I don't have much confidence that sanity will prevail. The College of Midwives made an extravagant, seemingly contradictory attack on the coroner. The same zeal shown during their publicly supportable campaign 20 years ago will probably be used this time to stop an over-due reassessment of maternity services, and any re-balancing required. When governments allow monopolies to develop, particularly for outdated gender reasons, turf is never surrendered without a fight. It's time to get over such age-old patch warfare. This looks like another well-intentioned crusade that has been allowed to go slightly too far.