News > NZ DOCTOR Editorial 12th October 2016

NZ DOCTOR Editorial 12th October 2016

Babies and bathwater – keeping the perspective

By Barbara Fountain

Wednesday 12 October 2016, 3:14PM


IN PRINT: Twenty years ago I wrote my first editorial. It was about maternity services. Or, to be more accurate, maternity services funding. As altruistic as are many of the wonderful people who work in our health services, money matters a lot, not only because it keeps our services financially viable, but also because it delivers judgements about who and what is important.

In 1996, the money issue was the ability of both GPs and midwives to claim for providing maternity care and attending a delivery. There were some seemingly successful shared-care schemes at the time, notably in Wellington and in the south, but health authorities wanted an across-the-board bulk funding arrangement so they could control the maternity budget. Shameless irony only bureaucrats and politicians can muster

With the shameless irony only bureaucrats and politicians can muster, the proposal was couched as offering women choice.

That choice was limited in primary care to a GP or midwife, but not both, as a “lead maternity carer”. The rest is history. The number of GPs delivering babies declined dramatically, and midwives became the main provider of primary maternity care.

I think some people mistakenly view the time of shared care as a sort of golden age of maternity services in New Zealand – although a short-lived one. Midwives only gained the right to work independently in 1990 and shared care, or more precisely shared-care funding, was dumped in 2002.

I know there were good working partnerships involving GPs and midwives, but the shared-care arrangement also buried (alive) any simmering issues of power and control harboured by the two professions.

Today, the lead maternity carer is precisely that, the person responsible for ensuring the safe care of the mother and delivery of the baby. For most women, that person is a primary care midwife.

In 2014, the most recent year for which the Ministry of Health has complete figures, 59,494 babies were live-born, most women received primary maternity care from an LMC midwife and most women gave birth at a secondary or tertiary maternity facility.

The seemingly illogical absence of most GPs, and high-profile cases of what other media like to call “botched deliveries” by midwives, have ensured a sense of disquiet has regularly surfaced in some circles. Disquiet continues

Fast-forward to the recent internationally published finding by University of Otago researchers of an unexplained excess of adverse events in midwife-led care compared with medical-led care – even when confounding factors are taken into account – and that disquiet continues. However, the research splits pregnancy care into the two groups based on the person a woman is registered with at the beginning of her pregnancy, so can’t take into account other practitioners subsequently involved. Essentially, it can make no assumptions about the model of care.

The overall rate of adverse outcomes in maternity care in this country is low, and other research has found high patient satisfaction with midwife-led care and lower intervention rates.

This new research reveals a need to ensure there are no avoidable adverse outcomes occurring, and the Ministry of Health is investigating further. No particular desire to return to perceived golden age of maternity care

Some people suggest the findings provide evidence of a need to return to a perceived golden age of maternity care. They do not. The lack of a GP obstetrician workforce and of any particular desire by young GPs to take up delivering babies is an immediate obstacle; but, more to the point, a workforce is already trained and professionally suited to leading primary maternity care – midwives.

However, as much as midwifery needs to maintain its professional independence, general practice does have a crucial role in maternity services. The population funding model puts an onus on general practice, be it the GP, practice nurse or nurse practitioner, to keep women healthy, and that includes during pregnancy. This is supported in part by government funding in the first trimester.

Both professions need new recruits; the average age of a GP is about 50, a midwife about 47.

It’s well past time that the machinations of bureaucrats-past were put to rest, and the professions supported each other in the care of their patients.