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Maternity health reform has harmed women (but not obstetricians)
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Australians are fortunate in having a universal health service that provides care for everyone based on taxation. Naturally the health system needs regular “tweaking” to keep it working well for those who use it. However some of the adjustments of recent years are producing consequences in maternity care that are not only unplanned, they are very costly and producing unacceptable levels of morbidity in Australia’s healthy and wealthiest women. In a bid to raise the uptake of private health insurance which had reached an all time low in 1999, the Commonwealth government introduced an uncapped 30% private health insurance rebate. This encouraged any woman who could afford it to take out private health insurance. The intention was sound; that is young people use services less therefore their demand against funds would be lower than older and aging groups. However, childbirth is the most common cause of hospitalisation in Australia and subsequent claims have resulted in ever escalating direct and indirect costs. The beneficiaries of this funding adjustment are private hospitals and privately practicing obstetricians. They have by default become the chosen providers of maternity care, despite the fact that midwives provide a similar and safe service that is less costly. Paradoxically, private hospital care in association with private obstetric care in childbirth is associated with horrendously high rates of operative birth amongst low risk first time mothers. Research undertaken ten years ago, even before the government incentive to encourage women to take up private health insurance, showed that among low risk private patients under private obstetric care with an epidural, the most likely birth outcome was an instrumental delivery with an episiotomy. Among similar public patients, the most likely outcome was a noninstrumental vaginal birth without episiotomy. The second major adjustment to the health system which has had unintended consequences was introduced in 2004 in the form of the new Safety Net. This covers 80 per cent of out of hospital medical expenses for families once their out of pocket, out of hospital, expenses exceed $700 in a calendar year. Sadly this attempt to improve access has resulted in maternity services not currently providing value for money — either to consumers or to funding bodies. This is a particular issue for rural women. The advent of the Medicare Safety Net resulted in a rise of more than 250% in the earnings of private specialist obstetricians reported in the media in 2007 since the safety net was introduced. This increases pressure and costs on the health system as a whole. Some privately practicing obstetricians are charging $20,000 dollars for a normal birth and our health system pays the gap insurance to allow them to do so. Exacerbating these cost blow outs, operating rooms in both public and private hospitals are now so busy with operative birth that other necessary surgery is delayed or cancelled. In addition to this, large population based studies show increases of avoidable death and injury of mothers and infants associated with the trend to operative birth, especially caesarean sections. The injury again adds costs as babies spend avoidable time in hospital nurseries or women experience infections from abdominal wounds. This then is the paradox. Tweaks designed to improve our system have resulted in out of control costs, increased suffering and injury to women and infants, and obstetricians now expecting to earn a million dollars a year — most of which is coming from Government money (our taxes) via normal healthy women who do not need their care. These are important issues that deserve a thoughtful response from the Federal Government’s maternity services review. Professor Lesley Barclay, Associate Professor Sally Tracy and Associate Professor Sue Kildea are from Charles Darwin University, Darwin |
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26 Comments
… and yet low risk women who choose homebirth (such as myself), which has been proven in research to have drastically lower intervention rates than hospital birth (especially compared to private hospitals), have to fork out over $4000 to pay for an independent midwife to attend their birth.
Let’s hope this review brings about some positive change with improved health outcomes for mothers and babies, less costs to the public for unnecessary interventions and more choice for those who wish to birth in the privacy of comfort of their own homes!
I think this article makes some good points, although it’s important to note there are a number of drivers to operative delivery, including the legal system and women’s own preferences. And I’m afraid I simply don’t believe the million dollar income figure: maybe there’s one mad bastard who works 100 hours a week to earn that much, but it’s hardly representative.
Unlike the authors, I will declare my conflict of interest.
I am an obstetrician in private as well as public practice, and chair our peak lobby group.
This article is full of inaccuracies.
Obstetricians incomes have not increased 270%. Fees previously met by patient gap payments have been transferred to Medicares balance sheet via the Medicare Safety Net. The highest gap recorded by the HIC for safety net rebate in 2007 was $9000, with the average under $2000. The arms length cost of running my practice ( I employ a midwife tp work with me) with indemnity insurance is about $300,000 per year. Interestingly my total charges for delivery are about $3800,
Private patients do experience higher intervention rates for many complex reasons, but the in Australia risk adjusted major complication outcomes for them and their babies are significantly better than for public patients. Intervention rates are increasing everywhere in the world at similar rate to Australia’s increase, including counties where there is no significant private matenity care (UK) and where midwife led care is the norm (New Zealand, Scandinavia).
Contrary to what is usually promoted by the authors, evidence shows
1. Midwife care leads to very similar combined caesarean and instrumantal dlivery rates (1 extra unassisted delivery for every 20 to 30 births)
2. A twofold increase risk of a baby dying if the labour is cared for in a birth centre by midwives who do not also spend some time working alongside doctors.
3. Home births in Austraia to carry a threefold risk of a baby dying in labour comared to hospital birth in two large reviews running over several years, and twice the risk in the UK between 1999-2003.
Once such evidence is included in the debate, we might start meaningfully discussing women’s maternity care choices and to what extent maternity reforms have caused or prevented harm.
Dear Dr Pesche
Could you please provide references for your claims re homebirth safety.
Is it not misleading to quote the costs of indemnity insurance in your practice costs. As I believe the PSS meets 80% of premium costs above the 7.5% threshold of an Dr’s gross private medical income. Is this correct?
After all this support do you begrudge assisting midwives 7 years later? Do you think your clients deserve indemnity protection and clients of midwives deserve less?
It is foolish to comment on the instrumental delivery outcomes from midwifery care when to date the maternity system is still tightly controlled by medical practitioners, especially in birth centre environments that operate with obstetric protocols not based on evidence, rather the custom and practice of ‘overseeing obstetricians’.
As a mother and a woman of childbearing age I have the greatest interest and I declare that Australian women do not have choice in childbirth, Ian Haywood there is no way we can say women are choosing ‘operative birth’ when midwifery options are not funded or accessible. I thank you Dr Pesche for your concern, but I feel that as a woman who makes decisions about the wellbeing of my children day in day out that I am the best person to decide where and with whom I will share the intimate act of birth.
I can choose to terminate a pregnancy and yet when it comes to giving birth I have no choice.
I think the game is up. Finally it is time to bring birth back to women. Only Once Australian women can choose a midwife, GP or Obstetrician and once midwives are enabled to work to a full scope of practice can we actually determine what women want and the outcomes of midwifery care in Australia.
I too wish to declare a ‘conflict’ of interest - I am an advocate for informed choice in child birth.
Unfortunately it is Andrew Pesce and his ‘lobby,’ with a great amount of authority, who perpetuate ‘inaccuracies’ and half truths. While obstetrics is a necessary part of our health system we need to qualitatively examine our very high intervention rates (ie. why do caesarean section rates peak just before long weekends and public holidays?) and the kind of care implemented by obstetricians (medicalized/interventionist approach to birth).
Some interesting statistics: (from ABS)
In 2006, 30.6% of women gave birth by caesarean section - twice the rate of 1985
Women admitted as private patients were more likely than those admitted as public patients to have labour induced (35.2% and 19.6% respectively), and to have an instrumental vaginal birth (17.3% and 10.8% respectively) or a caesarean section (36.8% and 26.9% respectively).
In 2006, 47.5% of women who had an unassisted vaginal birth stayed in hospital two days or less following the birth, while 81.8% of those who had a caesarean section stayed four or more day.
What are the extra costs associated with caesarean section & medicalization of birth generally?
Independent (& not peer) review is the only effective way of addressing what has become a ‘culture of intervention’ in Australia’s maternal health system. Holland and NZ have extremely low intervention rates and public health systems that support home-birth.
While it is comforting to know that our first class health system is populated with dedicated and well intentioned medical professionals such as Mr. Pesce, it needs to be acknowledged that pregnancy is not an illness and birth is not a medical emergency.
Coincidentally, I had a piece in the Canberra Times yesterday, raising many similar issues as these authors. http://www.canberratimes.com.au/news/opinion/editorial/general/our-baby-boom-is-blowing-the-medicare-budget/1364494.aspx
As a mother of one and pregnant with my second, I cannot understand why improved models of maternity care for Territory women are taking so long. When my son was born just over two years ago I received one-on-one care from a known midwife through the Community Midwifery Practice (CMP). I assumed when I got pregnant earlier this year that I’d be able to access the same service, and that because the birth centre had opened, I would be able to birth there and not in the hospital. “I was absolutely dismayed to learn that case-load care, where you receive care from only one midwife, had been removed from the CMP. I then learnt that the only way to receive one-on-one care was through the homebirth program. Because homebirth midwives are employed by the Department of Health and able to provide care during labour at home for low-risk pregnancies, I assumed they’d be able to provide the same care at the birth centre, especially because it is two-thirds under-utilised. I was told that this wasn’t possible, and on writing to the Minister to ask why not, I have been told that I can use the birth centre if a CMP midwife is the lead midwife and my midwife can be a support person. I am absolutely outraged! My midwife has won the Department of Health Midwife of the Year award, is employed by the Department, receives public indemnity by being employed by the Department, she is allowed to provide one-on-one care at home during labour and birth, but she is not allowed to provide the same care in a birth centre that was built with public money and which is two-thirds under-utilised. Furthermore, there is a long waiting list of women trying to access the CMP, and the Minister knows this, so why should they fit my birth into their schedule when they don’t need to? In my mind, it’s quite simple. I am receiving care from a midwife employed by the Department, but she is not able to provide care in a birth centre which is managed by the same Department that employs her. More….
My declared conflict of interest is that I am 30 weeks pregnant and having to fight to receive midwifery-led care - my pregnancy is low risk, and my 2nd, so I definitely know what I want.
One of the incredible poor outcomes of the current funding model is that women can use private insurance to access obstetric care but not midwifery care - my experience is that midwifery care comes into its own during the postnatal period, and it is only effective when the mother has an existing relationship of trust based on the several months contact antenatally and of course at the birth. I don’t think it’s an accident that many of my friends who birthed without continuity of midwifery care rarely breastfeed for more than a few weeks.
I simply cannot believe that Australian women’s bodies are more prone to complicated pregnancy and labour, or that women who can afford private health insurance also have bodies that develop complications more readily - but this seems to be the conclusion obstetricians would have us believe by saying the higher rate of intervention in private hospitals, and in Australia compared to other countries, is health-related rather than systems-related.
In my battle for midwifery-led care, the overwhelming sense I get from the obstetricians is the belief that my midwife (or any other) will ignore signs of complication and refuse to let me see an obstetrican - in reality, in my last pregnancy my midwife was the one that convinced me I needed to be hospitalised when I developed highblood-pressure. And she is committed to me having choice - she wouldn’t refuse to do anything if that was what I wanted. Indeed, my experience is midwives are more aware of best practice, and what constitutes evidence, than obstetricians (e.g. one obstetrician I know tried to use a study based on n=15 to convince me that hospitalisation provided better outcomes than home based care - even an undergraduate knows better than that).
It seems the choice is - receive care from different people thoughout your pregnancy and the postnatal period, which we all know is not best practice, and birth in the birth centre, or receive care from one midwife who is known and trusted, but you aren’t allowed to choose where you want to birth.
In response to Dr Pesce who, as the chair of the peak lobby group for private obstetricians has a duty to reject our opinion of the wastage of private obstetrics. In declaring my interest as a researcher I must restate that our peer reviewed research published in the British Medical Journal in 2000 found categorically that after all the confounders had been controlled for, amongst low risk women the one constant variable associated with the increased rate of instrumental birth or caesarean section following an epidural was being classified as having private insurance or receiving care from a private obstetrician.
As a researcher I also reject Dr Pesce’s claim that babies born in birth centres in Australia are at greater risk of dying. In fact our recently published research based on national data showed a statistically lower rate of problems for mothers and babies who used birth centres in Australia.
Perhaps the peak lobby group for private obstetrics could publish some of their own research to substantiate their claims, rather than make arguments that are so patently driven by vested interests. Money speaks loudly - but not necessarily truthfully.
I have personally experienced this blow-out. When I sought obstetric care in 2000 my obstetrician billed me for each visit and my birth fee was billed to both Medicare and my private health fund. I remember having around $1000 of out of pocket costs. By the time I had my third baby in March this year, I had a bill for each visit, a $3000 “pregnancy management fee” which I was told that I had to pay before 34weeks and I was encouraged by the receptionist to “wait until I had reached the safety net” and then pay it on my next visit! I then also was quoted a birth fee again to be billed to both Medicare and my private health fund. That $3000 fee essentially is being met by the taxpayer if paid once the safety net is reached.
Where is the evidence for Dr Pesce’s claims? Without this, it really looks like he’s running a very selective arguement because some quick on-line searching doesn’t seem to produce any of the details he’s claiming. Or are we just supposed to believe that doctors are always entirely truthful?
What this article and the subsequent discussion highlights is how difficult it is for women to get accurate and unbiased information about their birthing choices. When looking for evidence to support making a decision about what type of care women want for themselves and their babies, women are confronted with a confusing mixture of personal experiences, ideology and attacks on alternative views which makes distilling the data from the opinions very difficult.
What makes it even harder for women to access their preferred type of care is that in many areas their choices are limited, for example, midwife-led birth centres are often forced to turn away women who seek this type of care, due to limitations of space, funding or workforce. This makes little sense if the available alternative is more expensive doctor-led and hospital-based care.
From a public policy perspective, it makes sense that funding for maternity services reflect community priorities and support the most cost-effective form of care. It is no surprise that the private health insurance rebate does not achieve this in relation to birthing services as it does not in any other area of health care.
In one sense it is healthy that there are different approaches to the provision of birthing services for women. Women are all different and there is no reason to think that they will all make the same choices about how and where to have their babies. What is important is that policies and funding decisions support women’s ability to make informed choices by giving them accurate and unbiased information, real options for their care and that there is an ongoing commitment to place women and their needs at the centre of the debate and not the interests of health care providers, health service managers, insurance companies or any other interest group.
It appears that Dr Pesce has conveniently neglected to quote the recently release Systematic Review of Midwife-led care versus other models for childbearing women (Hatem, Sandal, Devane, Soltani & Gates 2008) that examined 11 randomised controlled trials and included 12,276 women. The authors concluded that that women who received continuity of midwifery care were less likely to have a: antenatal hospital admission, epidural or any need any pain relief, episiotomy, forceps and vacuum birth and baby dying before 24 weeks of pregnancy. Women in the midwife-led care were more likely to have a: normal vaginal birth, feel in control during labour and birth, breastfeed and have a shorter hospital stay for the baby. None of these are trifling insignificant advantages, as you seem determined to portray them. The author’s conclusions were that ‘all women should be offered midwife-led models of care and women should be encouraged to ask for this option.’ It is sad Dr Pesce that you continue to misquote research. In response to your comments the authors have written previously and said: “It has come to our attention that our Cochrane review on ‘Home-like versus conventional institutional settings for birth’ (Hodnett et al, 2005) is being used to argue that home-like birth setting are not safe for women unless the midwives working there have a regular rotation to high risk delivery areas. This was not a conclusion of the review.” I think the shroud being waved is becoming rather threadbare. I think the arguments confirm a deep ‘FEAR’ (False Evidence Appearing Real). It is time for us to turn fear into a trust that is based on the evidence and the belief that women are inherently powerful and facilitating their power leads to the safest and most satisfying of birth outcomes. Playing ping-pong with statistics (even referenced ones) is futile – for, “It is difficult to get a man to understand something when his salary depends upon his not understanding it” (Upton Sinclair)
Re: Andrew Pesce’s comment that “Intervention rates are increasing everywhere in the world at similar rate to Australia’s increase…”
I wonder what reasons he could postulate for this increase in intervention rates? It goes back to the old question of nature vs nurture? Does he think there is some genetic reason that women’s body’s have suddenly lost the ability to be able to birth their babies without help from the medical establishment? If not, then the only other reason is the environment, which in this day and age is becoming increasingly medicalised.
He really should read the study “Rates for obstetric intervention among private and public patients in Australia: population based descriptive study” published in 2000 in the British Medical Journal which concluded “Among low risk primiparas, private patients in private hospitals were significantly more likely to have obstetric interventions compared with public patients and were less likely to have spontaneous onset of labour or a non-instrumental vaginal birth…”
It is a shame that more obstetricians do not read the works of Michel Odent, a pro-birth centre and pro-homebirth obstetrician who has intimately studied and respects the natural birth process!
This thread illustrates the difficulty in running evidence based health policy debates in the media.
The academic midwives who have failed to identify themselves as such should know the references for my statements.
For others
1. Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth (review) 2005 The Cochrane collaboration.
Hodnett ED. Continuity of caregivers during pregnancy and childbirth 2005 The Cochrane Collaboration
2.Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth (review) 2005 The Cochrane collaboration. John Wiley & Sons.
3. Bastian et al “Perinatal Death associated with home birth in Australia: population based study .BMJ Volume 317(7183) 27 1998, 12th Report of the Perinatal and Infant Mortality Committee of Western Australia, Deaths 2002-04 ; Intrapartum Care of healthy women and their babies during childbirth, National Institute of Clincial Excellence UK Sept 2007
Everything I stated is based on statistically significant differences documented in these papers. One can ignore statistically significant findings if they don’t suit one’s arguments, but it surely must be an inconvenience that they remain facts.
7 of the 11 “midwife led care” groups in the Cochrane review quoted by Dahlen in fact included scheduled routine visits with doctors for between 2 and 6 visits per pregnancy, so I am not sure what aspect of such care contributed to the outcomes.
My practice costs quoted are net costs after government indemnity subsidies. At no stage have I opposed govenment indemnification for midwives, in fact it is absolutely essential that the government provides this.
In coninuously denigrating serious and respectful attempts to debate health policy by the medical profession as nothing other than promotion of self interest, you deny the women of Australia a proper debate, and force them to make political rather than health care choices
Another perspective on this unfortunate area of conflict between obstetricians: midwives: consumers of healthcare. It’s a shame that issues of combined care and responsibility so frequently degenerate into arguments over “turf”, and that “evidence” in the literature, frequently contradictory and always overlapping, is so often used as a weapon rather than an education.
Another group of care providers may not fit so clearly into the “dark knight” corner alluded to by Prof Tracy and co-writers, and that is the obstetricians providing care in the public system, of whom some are academics. Collaboration is possible with the right amount of respect, and there are successful models of care that involve all in the provision of maternity care with overlapping and symbiotic roles. Frequently it is the public obstetricians who are providing medical assistance and review to those pregnancies that require that level of help, without compromising the primary care role of the midwives themselves.
Unfortunately the NSW medical system does so little to encourage trainees to work in public or academic practice. It is an astonishing failure of our system that many large teaching hospitals are unable to fill public or academic specialist posts with suitable candidates. These posts would be snapped up in other countries, but when there is such financial disproportion between public and private practice, there is little incentive for trainees to remain in the public system.
We must remember the futility of public arguments over pregnancies and the fact that this simply denigrates all. As obstetricians, we (I’m an academic one) should “take a hard look at ourselves” as a speciality, and try to work out what it is that may drive women away from our care. Equally, midwives need to approach the current potential for changes in maternity provision in a mature manner, and work with obstetricians (where this is possible) to design a collaborative role for the future.
As all who contribute to
The authors title for this article was ‘Unintended Consequences’ and it was never meant to reignite the turf wars nor to be disparaging of our obstetric colleagues. It was meant to highlight the inadequacies of our current funding system. As a practicing midwife, academic and researcher my interests have been in service provision for rural and remote families and Aboriginal and Torres Strait Islanders. One of the unintended consequences of the current funding system, I believe, is to exacerbate the inequitable distribution of the workforce. Increasing remoteness is associated with less uptake of private health insurance, less obstetricians per thousand women and poorer maternal and perinatal health outcomes. One could argue that rural and remote Australians should have increased access to obstetricians yet these areas will never be able to compete with the wages available in the cities under the current funding system. Another example of a funding item meant to increase services (only available in rural and remote areas) is the Medicare Item (16400). This allows doctors, who do not have to have obstetric training, to claim Medicare for nurses, who do not have midwifery training and may be living in another town, to provide antenatal care on their behalf. To date we have no research on the consequences of this initiative but it does not auger well.
previous comment truncated…….Where I intended to finish, which would clarify my position was:
As all who contribute to this discussion should identify their biases, I am pleased to be in a position of working collaboratively with Prof Tracy in a teaching hospital that allows midwifery-led group practice with non-judgemental obstetric assistance when needed, in the context of an NHMRC Trial. It is possible, works very well, leads to highly satisfied consumers and is positive for all.
It is little wonder that women are unable to make truly informed choices when statistics from peer-reviewed studies can be cherry-picked and manipulated at will. I’m confused as to how Dr Pesce believes the studies he quoted actually support his argument.
Hodnett et al (2005) states: “when compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction.” True, the authors also warn that caregivers and clients should be vigilant for signs of complications, but surely this why we have consultation, referral and best practice guidelines.
Bastian et al (1998) found that the higher perinatal death rate in Australian home births from 1985 to 1990 was partly due to the inclusion of predictably high risk births. At no point is it stated that home birth for a ‘normal’ or ‘low risk’ pregnancy poses a greater risk to the baby, in fact in listing the study’s key messages, BMJ acknowledges that “home birth for low risk women can compare favourably with hospital birth.” The authors also acknowledge that “Australian women, like women elsewhere, will continue to give birth at home,” and that “they and their infants are entitled to effective care and support in their choice.”
Surely it all comes down to just that – choice. If a woman receives comprehensive and accurate information (not just cherry-picked statistics manipulated to fit the care provider’s agenda) about the potential risks and benefits of ALL available birthing options, it is her right to then weigh those risks and benefits and make an informed decision.
Constantly dredging up dated and selective home birth statistics is a handy way of drawing attention away from the issue of access to continuity of care by a known midwife for all women, regardless of setting. I suspect everyone involved is onto this by now.
I would like to turn this discussion into a positive one. As a woman, mother and midwife I have had the privilege in my career to work with some wonderful obstetricians. What sets these men and women aside are they are committed firstly to women and secondly to establishing effective collaborative and respectful relationships with everyone they work with. Most of all they don’t see women as a means to make them feel more powerful, nor do they see midwives as a group they feel the need to suppress and dominate. One of the obstetricians I grew to regard most highly used to say the most important thing you need to learn in this job is to make women your friends and respect and trust midwives. How simple this is, yet sadly it is often the lesson we find hardest to learn. Alec is right, we don’t value the obstetricians that work in the public system enough. They often deal with the most complex cases and limited resources yet enable outcomes that are amongst the best in the world. They deserve to be valued and rewarded so we don’t continue to loose their skills to private practice. Great obstetricians in the public system with a commitment to excellent evidence based health care, without the complications of money coming in the picture, are a valuable group of professionals we need to cherish. So I would like to pay credit to all the wonderful obstetricians I know work so hard in the best interests of women in the public system and support and respect midwives, seeing them not as competitors but as professionals that ultimately make their job easier.
I agree that our health system has gone awry in its funding and incentives to increase membership of health funds. As a father of four children (three born at home), I feel doubly ripped off. We have private health insurance, and yet we have had to bear the full cost of engaging our midwife. Our homebirths kept hospital beds free for those who truly needed them, and each saved tax payers several thousand dollars. Meanwhile, had we chosen to birth our children with a private obstetrician, we would not be so far out of pocket even if my partner had to have a caesarean. Through taxation, the people of Australia all chip in to cover the costs of hospital births. While I don’t believe that hospital birth options or care with obstetricians should be abolished, I reject the suggestion that there are greater health risks posed by the alternative models of care, and I think that the people of Australia should be free to make an informed choice about where and with whom they birth their children. Dr Pesce’s arguments and references for his strong words have largely been dealt with by others like Kylie Sheffield. As for the ‘inconvenience that [statistically significant findings] remain facts’ - if Dr Pesce thinks that evidence can be equated with truth (and findings with facts), then he needs a refresher in both philosophy of science and statistics.
It’s an interesting debate on all comlpicated fronts, women consumers of maternity services; professional providers; political and bureacratic heirarchies and institutions. Problem solving can be quite simple. Back to the future with the benefits of current knowledge, wisdom and experience. I am a lucky and most priveleged midwiife, having worked a large part of my career with some amazing medical colleagues (GP’s and Obstetricians). Mutual respect for each others skills was (and could still be) the key compenent of how we solve this 21st Century mess of the health industry. The most important key to all of this is the women and when we learn the simple skill of listening and responding to women, it will be easy to right balast of this listing ship. The last 22 years I have had the privelege of working in a personal relationship with women, some up to baby number six in our partnerhsip. In our ‘zest to be the best ‘we have taken from women the most precious and important experience of their life, the enjoyment (for most) of pregnancy, the beauty of the womanly art of birthing and the incredible will and skill of the newborn to find its way to the breast soon after birth, all in the name of survival and continuation of the species. I put to my obstetric colleagues these challenges. Let the past go, meet with us around the table, talk about the way forward AND MOST OF ALL INCLUDE THE WOMEN. Together, without power, control and with a mulititude of trust we can lead the politcal debate, turning the tables, returning to the respect and trust we once had , making this lifetime journey powerful for all women, regardless of what type of care they need. And for the 21st Century I ask our obstetric colleagues to consider - coming out of your institutional life, join us in the home or on country with with the women, experience first hand the incredible mammalian ability of women to do what they know best, giving birth to and breastfeeding their babies, most often unassisted
Andrew Denton, of course evidence is not the truth, but evidence it is, and we should consider it when informing ourselves and making health care decisions. Of course women should have the choice to birth at home, and whether a woman births at home or in hospital,by far and away the most likely outcome is a healthy happy mother,and baby. All recent evidence however points to a two to three times higher risk of the baby dying if born at home. The Bastian study should have alerted us that home birth may carry the potential for higher risk. It was published in 1999. And yet in between 2000 and 2004, home births in WA recorded a three times higher mortality than hospital births. Should not women be aware of this, as much as they should be aware that they may be more likely to experience intervention if they receive private obstetric care?
There is nothing disrespectful in asking that data such as this be acknowledged and discussed, rather than ignored or dismissed out of hand. Obstetricians have nothing but the highest respect for midwves and in the vast majotiy of cases that respect is returned. I don’t understand why discussing evidence regarding relative risks of various models of care is seen as disrespectful, especially when the initial presumption is that higher intervention rates are not improving some outcomes.
I initially contibuted to this thread because I wished to address the inaccuracies in the original article. The fact that the authors’ original title was editorially sensationalised is evidence itself of the problems in debating health issues in the media.
The subsequent responses lead me to realise that perthaps the best I can hope for is that serious questions raised regarding the safety of our maternity care which many appear to take for granted are discussed repectfully, and without the ideological rhetoric which should have no place in health care debate.
Hello Andrew (Pesce). I have not had the pleasure of meeting you; I have read some of your writings. It seems pertinent at this point to ask you: wouldn’t it be better if we put aside gender battles and the negative arguments? My intellectual and emotional self tells me, it would be most beneficial for women and the health system if we redirected our energies toward repairing the silver thread that once united us. Political and professional writings remind us we are not communicating well enough through the entirety of our professions. In modern times, hierarchical structures within micro managed bureaucracies annul equality of our skilled partnerships. There maybe pockets of us working together, but realistically in the majority of situations inequalities exist. Medicine reserves financial and economical dominance of the health system by controlling entrée to Medicare – medical dominance persists. To continue the status quo is irresponsible management of the Australian health system. And we must continue to remind ourselves, just like other species, we are not perfect. We cannot ever guarantee perfection for every woman or baby. Being human means mortality and morbidity is a fact of life. We have no reason to play the blame game. What we can do is: regenerate partnerships, revere our complementary skills and manage the health system with equality for the benefit of all Australians.
Midwife and PhD student
I don’t want to get in to the midwives versus obstetricians tussle other than to observe that it would make sense for obstetricians to manage complicated high risk pregnancy in view of their lengthy training and relative high cost to the community to produce, and for midwives to manage low risk pregnancies. However, the perverse funding arrangements we enjoy and particularly the Medicare Safety Net have resulted in obstetricians moving to private practice to manage predominantly normal pregnancies. To paraphrase Dr Danny Challis, Director of Obstetrics at the Royal Hospital for Women in Sydney, we now have a system where the tax dollars flowing to a private obstetrician to manage normal pregnancies would pay for 5-10 staff specialist obstetricians to manage high risk complicated pregnancies in our maternity hospitals. The relative pay differentials (~$150K vs up to $1 million) have resulted in few obstetricians choosing to remain in the public hospital system in NSW. As a result there are serious staffing shortfalls and often the few who choose to work in the public system are newly specialised obstetricians or foreign trained specialists who cannot get full registration. So the least experienced obstetricians work in a public system managing higher risk patients while the most experienced specialists earn a subsidised fortune in the private sector managing pregnancies where their skills are generally not required. I don’t think women, or the taxpaying public, are getting the best deal in this system.
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