And yet midwives are allowed almost the same level of autonomy as a year 9 doctor – at least in terms of obstetrics.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.
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.
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.
The MacDoctor awaits the tidal wave of rabid midwife comments with anticipation.
- 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.
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?