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Birthing sweet
Adam Cresswell
10sep05
YOU would have thought a baby bonus would be a godsend for midwives,
but an Australian baby bonus - the original one, back in 1912 - more or less
killed off the profession at a stroke. In that year the Labor government of
Andrew Fisher passed the Maternity Allowances Act, which entitled each new
mother regardless of income to a payment of five pounds.
Before that, most people came into the world thanks to a midwife. But
the bonus, which was more than enough to cover a doctor's fee, vastly
increased the numbers of people, especially poorer people, who could afford
to engage doctors - who were then angling for a bigger slice of the birthing
action. By 1923 the bonus was only payable if the birth had been handled by
a doctor.
Today's midwifery advocates look back at that point as ``the death
knell for midwifery'', and the Act certainly made Australia a world leader
in the race to sideline midwife-led birthing - which continued to have a
significant, if shrinking, role in Britain for two or three more decades as
hospital infection rates continued to pose a threat.
But the end result was largely the same - the invention of antibiotics
in the 1940s transformed infection control, and by the 1970s hospital birth
was becoming de rigeur, even in Britain.
In Australia, hospitals now have cornered the market in birthing: 97.2
per cent of the 250,758 births in 2002 took place in hospital wards. Only
2.1 per cent, or 5379 births, took place in midwife-run birthing centres
attached to hospitals, and almost none - just 522, or 0.2 per cent of the
total - took place at home.
The recent controversies about midwives have focused on the safety of
stand-alone midwife-led units - those not sited adjacent to fully equipped
hospitals. But while midwives and some obstetricians continue to argue that
issue, pressures are growing here and overseas for a greater use of midwife
services.
Some state Governments, led by NSW, are expanding midwife-led centres,
and the federal Government is also considering creating a Medicare rebate
for midwife care.
Talk to almost any woman who has had a midwife manage their birth and
it's hard to see why this has not happened already. Most new mothers have
little but praise for them.
Heather Hillam, of Sydney, gave birth one week ago to her and husband
Howard's first child, Emily, at the delivery suite of her local public
hospital. The delivery was handled entirely by a midwife, and Hillam says it
was the midwife's support that allowed her to give birth without any pain
relief.
She was so impressed she says she'll ``definitely'' choose to have a
midwife deliver her next child (although she will again opt for a hospital
setting where back-up is available).
``The surprise for me was that I just didn't realise the level of
skill that midwives had,'' she says. ``I pictured them almost as womanly
support, but the midwife who was with me throughout the whole birth ... she
left me feeling secure and safe. I think it's easy to underestimate the
skill and knowledge that they have.''
Such enthusiasm is reflected by experience in Britain, which has been
actively encouraging midwife-led care since the government published an
influential report, Changing Childbirth, in 1993.
Consultant obstetrician Rick Porter is director of maternity services
at the Royal United Hospital in Bath, southwest England, and runs one of the
country's most developed midwife-led services. His one service, which has
several midwife-run stand-alone units in surrounding communities, accounts
for 16 per cent of the 10,000 births in British community midwife units
annually.
A strong supporter of midwife care, he says the Bath service has
``extraordinary'' public backing: for every patient who complains, there are
between 40 and 60 others who have taken the trouble to compliment the
service in writing. (As Porter drolly adds, thanking people is ``not an
English habit''.)
He thinks birthing passed from midwives into hospitals in Britain,
Australia and other places as a result of ``an abuse of the concept of cause
and effect''. According to Porter the obstetricians and policy makers of the
day noted that as more births were being done in hospitals, perinatal
mortality rates continued to fall, and ``made the jump'' to saying the move
to hospital birth was responsible for bringing death rates down.
``So by 1970 ... they said `if we completely expunge community births,
then we're going to be even better'. And of course they were right - over
the next 30 years maternal and perinatal mortality did fall, but what they
forgot to work out was whether it had anything at all to do with universal
hospitalisation,'' he says. ``There isn't a causal relationship, or at least
there is, but it's not half as strong as those who started the policy
actually believed.''
Interestingly for Australia, Porter says a crucial factor that shaped
the 1993 Changing Childbirth report was that doctors were unable to provide
a shred of evidence to the parliamentary committee to justify universal
hospitalisation for women in labour. Since the report, Porter says the
number of midwife-run birthing centres alongside British hospitals has
"mushroomed". But it proved a turning point in other respects.
"What it did was make people realise that midwives could call the
shots in many respects, and I think it did in many (if not most) maternity
units change the relationship between midwives and obstetricians forever.
"It became unacceptable for obstetricians to adopt this condescending
posture as regards midwives. It would be wonderful if I could say that was
universal, and it certainly isn't - because just as is here, there will be
obstructive obstetricians anywhere you care to mention."
In Australia, some believe there is another potential driver that may
explain the reluctance of some obstetricians to cede a greater role to
midwives - unlike in Britain a large proportion of births in Australia are
handled in the private sector, 31 per cent in 1996-97.
A paper published in the British Medical Journal five years ago
(2000;321:137-41) compared the experiences of low-risk women giving birth as
public and private patients, and found rates of obstetric interventions -
such as forceps or vacuum deliveries, epidurals and caesareans - were
significantly higher among private patients.
Among low risk private patients between 10.9 and 12.3 per cent of
births were delivered by caesarean, while among public patients the rate was
8.5 per cent. The epidural rate was between 35.2 and 50.8 per cent among
private patients, and 25.1 per cent in the public sector. The authors noted
that while "a rate of intervention that is appropriate or reasonable is
unknown, there are no obvious clinical reasons for intervention rates to be
higher in private than in public patients".
Doctors in the private sector are paid on a fee-for-service basis for
each consultation and procedure, usually a mix of money from Medicare,
private health funds and patients themselves. By contrast, public hospital
staff specialists are paid a salary and have nothing to gain by carrying out
more procedures.
Andrew Bisits, a staff specialist and director of obstetrics at John
Hunter Hospital in Newcastle, NSW, was one of the driving forces behind the
setting up of the second stand-alone midwife-led birth centre in NSW, at
Belmont just south of Newcastle.
He says a single caesarean might be worth about $1000 in the pocket to
a private obstetrician.
But while he agrees there were "blatant" cases of overservicing 10 to
15 years ago, these days he thinks by far the major driver is a fear of
being sued and doctors' wishes to "cover your backside, just in case
something bad happens".
"Obstetricians are being more and more paralysed and paranoid (fearing
litigation) - the caricature is that all they feel they can do is a
caesarean," he says.
Bisits says midwives will "absolutely" be used more in the health
system generally and agrees the attitudinal shifts that started to happen in
the UK after Changing Childbirth are increasingly evident here.
But overseas examples may carry some warnings for Australia when it
comes to expanding midwife care.
In New Zealand, over 70 per cent of births are handled by midwives
after legislative changes turned private midwifery into an attractive option
for midwives and patients.
But Bisits says the downside was that GPs were sidelined, and now had
a fraction of the role in antenatal care they once did. The risk was that
some problems or risks might be missed, he said.
More seriously, the New Zealand system had created financial
incentives for midwives to initiate interventions, with the result that some
midwives "are almost behaving like obstetricians", he says. "The curious
thing in New Zealand is that despite a midwifery-focused maternity service,
the caesarean rate is higher than ours," Bisits says.
Porter says Bath's midwife services, for all their success, cannot
demonstrate a much lower caesarean rate either. But he thinks the shortage
of medical specialists, including obstetricians and paediatricians, will
continue to drive increased use of midwives, here as in Britain.
Hospitals in areas with the worst shortages, he says, are "faced with
a stark choice . . . either close, or reinvent the unit".
This is the sort of choice facing Camden in southwestern Sydney, where
another midwife-led unit is under consideration.
"In many respects the far easier option, is to close . . . and say to
the community, 'well tough - we can't staff it'. As you can imagine that
goes down not terribly well with anybody.
"Civic pride is so deeply embedded and connected to your hospital,
that if you start ripping out the entrails of that, by taking away something
as emotive as the maternity unit, you seriously are getting at the soul of a
community."
In London, even the biggest, most advanced hospitals seen as the
bastions of specialist obstetricians such as Queen Charlotte's, have set up
midwife-led units, which now handle up to 800 births a year (compared to
about 200 at Belmont and Ryde, set up in Sydney last year).
"Now what this is showing is that really the idea of midwife-led units
just being little diddly units where they deliver a woman every other
Thursday in a month with an R in it, is an outmoded concept," Porter says.
"These can be busy units, but they can still retain the flavour and the
concept of midwife-led centres. I think it's really exciting."
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