News > Media release 28 September 2016 > Response to NZ Herald

Response from Karen Guilliland, chief executive, New Zealand College of Midwives to questions from New Zealand Herald about Comparison of Maternity Care Models study.

Limitations

Firstly the research is reassuring in that the incidence of adverse outcomes is very low and comparable with all similar countries so this is not a new finding as New Zealand is noted for its excellent maternity service.

The study is methodologically limited to only the data it could access and therefore its analysis is weakened considerably because the researchers couldn’t measure all the contexts/circumstances that women and babies are in. They couldn’t tell individual women’s education or income levels, whether they lived rurally or remote rurally, if they lived in violent circumstances, in appropriate housing or if they had existing medical conditions other than diabetes and high blood pressure.

In addition, this study mainly looks at the women under the care of midwives and these women are more likely to be rural, remote rural, Māori, Pasifika, younger, book with an LMC later, smoke, be obese and sicker. These are all well known risk factors that cause the adverse outcomes described. Unfortunately the study could only identify the care giver at registration in early pregnancy. There was no way they could identify whether women had referrals in pregnancy or labour so the results don’t tell us who was managing care and what assessments etc were undertaken by other practitioners. Therefore there has been an assumption that there were not any others involved in care decisions.

The study is not comparing two models of care as there is really only one…obstetricians always have midwives providing care on their behalf and midwives also call on obstetricians when needed.

It does flag the question of whether LMCs can sustain good outcomes.

What we are likely to be comparing is the difference between women who live in a big cities (mainly Auckland) and who can pay thousands of dollars and afford to have a private obstetrician. Those women do not have the same delays in waiting for an obstetrician opinion in a busy and short staffed hospital setting. In other words the study is comparing the rich with the poor.

The College has warned the government for many years that the public health system has been seriously underfunded which means it cannot sustain the level of emergency response it requires and which the public expect. In fact it has taken court action to get its concerns heard. The primary LMC system relies on the acute response services hospitals are required to provide. The primary and hospital services run parallel and the consultant service must be immediate and effective for the maternity service to work well overall. Unfortunately over the years reviewed in this study the consultant service response was seriously under pressure as shown by the tertiary DHB reviews and today it is worse.

All tertiary hospitals (the emergency system hospitals for maternity) have staff shortage problems both with not enough midwives/doctors or the wrong skill mix. Midwifery has the lowest staffing ratios of all professions in the health system. This means the staff are not available for midwives to consult with or transfer care to in a timely way. The inequity of funding for mothers and babies is impacting on the ability of midwives to sustain the service by creating inappropriate delays in seeking second opinions or emergency action. Some LMC midwives are expected to stay and wait with their client for hours in an effort to get an obstetric response. Rural women have to travel hours because primary birthing units have been closed. Ambulances are difficult to access and most DHBs are not prioritising maternity services. There is no tertiary maternity hospital with an onsite consultant obstetrician after hours or in the weekend. Given only 31% of babies are born in office hours this is a serious mismatch in staffing.

The private obstetrician (often this is the same obstetrician providing the public obstetrician services on a part time basis as well) can walk past these barriers for their clients. All women should be able to have this level of response when needed and for many years they did. Increasingly the only experienced person available is the hospital midwife and /or the LMC midwife and so they are filling in the gaps that rightfully belong to the DHB and government.

Need for further research

Most research reveals the need for further enquiry. This is no exception and we suggest that further effort be put into an examination of resourcing for our maternity service.

ends