Monday 7 June 2010


MacDoctor nicely points out the problems in New Zealand's lead maternity carer system. While some folks worry that American options too quickly downplay the potential for midwives and home birthing options, New Zealand has fully drunk the midwife kool-aid where a few sips would have been a bit more appropriate.

Writes MacDoctor:
And yet midwives are allowed almost the same level of autonomy as a year 9 doctor – at least in terms of obstetrics.

This is a rather horrific illustration of the underlying problem of the Lead Maternity Carer system. In 1995, the year before the LMC system was put in place, midwives were, for the first time, allowed to graduate outside of the nursing system. A separate course allowed them to become midwife instead of nurses, rather than in addition to nursing. Prior to 1995, a nurse had to have not merely graduated, but actually had to have a certain amount of experience before becoming a midwife.

I remember the midwives from my house surgeon days. They were tough older women who would not for a moment take any nonsense from a mere house surgeon. They would acknowledge the obstetrician as one would an equal – but they would follow his (usually his) orders immediately, without question. After all, he was a real doctor. These women all knew as much practical obstetrics as the obstetrician. They had experience.

The reforms of the 1990 placed inexperienced half-nurses into the same positions as these highly experienced midwives. All of these new midwives knew how to deal with a normal birth. Unfortunately, none of them know (at least initially) what abnormal looks like. You can see this obliquely in the first article but it is in the second article that you can see the disastrous natural consequence. When you have only really experienced normal, your brain tends to filter out the early warning signs of “abnormal” until it is too late. A more experience midwife would probably not have handled the situation that developed any better than the younger one, but the more experience one would have had the mother in hospital by the time things went pear-shaped. That’s the difference.

Of course, the 1996 Maternity Act made this situation much worse by essentially offering to pay midwives and GPs the same amount of money. The amount offered was more than reasonable by a midwife’s standards, but was barely worthwhile from a GP’s viewpoint. A GP could make a great deal more money with substantially less risk and inconvenience by sticking to his consulting room and leaving the delivery suite to midwives. And stick he did. GPs abandoned obstetrics in droves. By 2006 there were only 54 practicing GP obstetricians. I have no idea how many are left now, but I am willing to bet it is a lot less than 54.

The net upshot of this disappearance of the GP obstetrician is the rapid skill-and-knowledge-loss of obstetrics amongst GPs.
What's the result? There are a small number of highly qualified midwives: folks with a strong nursing degree topped up with midwife training. Folks like us (high social capital, high income) know to call around to book one of them in as soon as pregnancy is discovered; folks with low social capital don't bother 'till they're several months into their pregnancy and wind up with inexperienced and minimally trained midwives as primary carer.

MacDoctor advises:
  • Insist on a minimum of 2 years postgraduate nursing experience for midwifery and a further years attachment to a hospital birthing unit in a teaching hospital. Frankly, I would push to have midwifery made into a nurse-specialist field, but I realise that would cause a sudden shortage of midwives. Maybe later.
  • It should be possible to persuade some of the older midwives to come out of retirement to supervise the younger ones.
  • Allow GPs to charge above the midwife rate. There are many mothers who would prefer a GP but can’t afford to pay the entire amount of a GP-supervised confinement. There is no reason why the current maternity fee could not provide a part-payment.
  • Promote GP obstetrics again. You will have to do a lot of work here, as GPs have a tendency to think “once bitten, twice shy”. Bonus incentives for rural GPs to practice obstetrics comes immediately to mind. Paid refresher courses would be helpful.
  • It is time some real research into midwifery was conducted. Lets see some real evidence-based practice instead of the bizarre new-age claptrap that usually comes out of the mouths of modern midwives.
The MacDoctor awaits the tidal wave of rabid midwife comments with anticipation.
Stranger than the maternity system here is public acceptance of it. You can pay for a private obstetrician to share care with your (publicly provided) midwife: the very best one in town now charges a flat rate fee of $3000, all inclusive. We of course, being risk averse, hired the best one in town for both Ira and Eleanor's births. In 2008, the charge was $2000: on par with the cost of a bottom tier flat screen TV at the time. Now, the charge is a bottom end flat screen plus 3 years' subscription to the bottom tier Sky TV subscription. So we've hired the obstetrician twice and still have the shoddy old TV we bought when we moved here, without Sky. We all make choices. It's surprising that obstetrician rates haven't been bid up by more than they have been given what bottom tier midwife care is like.

I can't help but wonder whether folks put far too much confidence in the government seal of approval that comes with the publicly provided midwife. If folks weren't provided a midwife by default, mightn't they put the tiniest amount of thought into considering their midwife's qualifications and consider hiring an obstetrician?


  1. You state that “MacDoctor nicely points out the problems in New Zealand's lead maternity carer system.” It seems to me that MacDoctor has alleged that there are problems with New Zealand’s lead maternity carer system, but provided no sound evidence in support of what is essentially nothing more than his opinion.

    It may or may not be the case that some midwives are acting as lead maternity carers without adequate experience. If so, then the answer to the problem is more experience and/or training for midwives. It is illogical to suggest that involving GPs again is an essential part of the solution.

    You assert that people with low social capital are ending up “with inexperienced and minimally trained midwives as primary carer.” Do you have any evidence that backs up that assertion?

    You also imply that there is such a thing as bottom tier midwife care, and that it is bad. Again, can you provide any evidence in support of this, other than anecdotal?

    I accept that there may be problems with some midwives, and the problems may be widespread enough such that something needs to be done about it. But I do not accept the rantings of the likes of MacDoctor as evidence for that.

    I never had an obstetrician, and also do not have a flat screen TV or a Sky subscription. Given the choice though, I would have chosen the flat screen TV, simply because I believe that an obstetrician would have provided me with no benefit over and above that of a competent midwife.

    In my experience (and I am talking about a reasonable sample size here) midwife care is vastly superior to GP care. I have 7 children, 3 of whom were born in the days of GP care, and 4 of whom were born in the time of independent midwives. I think my opinion is worth something.

    I have added a (lengthy) comment to MacDoctor’s blog, if you are interested.

  2. MacDoctor does point to Andrea's working paper - she's very careful and is making sure to get everything right before sending it off; I'm pretty sure that her main results will prove pretty robust though. Bet: I'd go as high as 5:1 that Andrea's results hold up and are published in a good econ journal.

    Unfortunately, the only evidence I have on uptake of different quality midwives by decile is anecdotal: I wish that kind of data existed! When we booked in with a midwife when Sue was 1 month pregnant, though, we had to call around about 25-30 before we found someone with a proper nursing degree who wasn't already booked up; we had the very strong impression that leaving it even that late was very risky. I'd be willing to make a bet though: if the data exists, it'll show that high decile folks are more likely to wind up with a nursing-trained midwife than are low decile folks. I'd go as high as 4:1 on that one.

    Better trained midwives with a proper internship period would be one decent solution. But it worries me a bit that the current pay system seems designed to drive GPs out of the market.

    I have no problem with folks choosing competent midwives instead of an obstetrician or GP, and especially for second or third births. Had everything been really smooth easy sailing with Ira, we might well have decided to go with only our very good midwife for Eleanor. But Ira came via emergency caesarean after being too big to exit the normal way; we were very very glad to have an obstetrician we knew and trusted performing the procedure. Given that experience, there was no way we were going other than with the obstetrician and, again, we were very glad to have done so. Eleanor was bigger than Ira so again came via emergency caesar that wound up proving to be on the "very difficult" end of the range for the obstetrician; again, very very glad we went for shared care.

    Had we already had three without complication, I'd have been with you in picking the flat screen.

  3. Dragonfly
    I think my opinion is worth something.
    But mine, according to you, is mere "ranting". Interesting.

    PS at 7 kids, I would go with the flat-screen TV too...