A New Low

Currently in Australia, where my sister is in training to become a midwife. Got into a discussion with her about some of the political and legal ramifications of midwifery, and asked her if she'd contribute a few thoughts. I will now yield the floor to another cranky member of the Low clan.

Midwifery has never been illegal in Australia but it is very much under the thumb of the medical establishment. Midwives in Australia have traditionally practiced more as Obstetric Nurses (Mum uses the terms “midwife” and “obstetric nurse” interchangeably describing herself as both, something that would make modern midwives cringe) and Obstetricians set the policies and protocols. Hospitals are staffed by midwives (in the US they use Labour and Delivery Nurses) and 2/3s of Aussie babies are caught by midwives, but the majority of midwives practice under a medical model.

I have been involved in the starting up of Midwifery led units and it has been very very interesting. We have started one in Wollongong but it is very much under the control of our Consultant. He still sets the criteria for women to be "on the program". In fact you need a consultation with him in order to get on to the program! This is ridiculous as it is within a midwife’s scope of practice to care for women autonomously throughout pregnancy and childbirth, referring to an Obstetrician if anything deviates from normal. Obstetricians are specialists in complications of pregnancy and birth and the evidence shows that when healthy pregnant women are under the care of physicians the outcomes are inferior to a matched group being cared for by midwives. It is this medicalisation of normal pregnancy that costs a fortune, does not improve outcomes, and leads to a lot of unnecessary intervention (Australia is approaching a 40% caesarean section rate!) with the sequelae that goes along with it.

Back to our local consultant…interestingly, one of the requirements to take part in the Midwifery Group Practice (or MGP) is three ultrasounds during pregnancy, (btw, evidence shows routine ultrasound in pregnancy does not improve outcomes). If you decline to have these you are kicked off the program. The clincher? He owns the local ultrasound clinic! Ka ching!

Our local MGP was supposed to be a 6 month pilot in Wollongong then move out to Shellharbour (where I live) and operate at Shellharbour Hospital with no Obstetrician on site (complications requiring Obstetric care would require transfer to Wollongong). That was 4 years ago. The outcomes of the program are of course superior to the outcomes of the obstetric led care in hospital (midwifery care is always superior to obstetric care :) ) but whenever there is talk of the program going to Shellharbour we have headlines in the paper: "BABIES WILL DIE SAY LOCAL DOCTORS". I kid you not. The doctors have repeatedly stopped the program moving to Shellharbour and it operates in Wollongong still.

The AMA continually uses scaremongering tactics, and the “Babies will die” comments are usual whenever a new midwifery led unit opens. In fact one Queensland obstetrician, former Queensland president of the AMA, made headlines when he referred to the Brisbane Birth Centre as “The Killing Fields”. The Brisbane Birth Centre has superior outcomes to the general labour ward care. This particular OB runs a private practice that is 100% caesarean section.

Interestingly, this man (his name is David Molloy) appeared on 60 Minutes in a Caesarean Section promotion piece describing the procedure as “the choice of the emancipated woman” and also as the safest way to give birth. He overstated the risks of vaginal birth and understated the risk of Caesarean Section. When asked about the 150% increase in emergency hysterectomy rates in Victoria (emergency hysterectomy is a risk of Caesarean Section) he replied that it is not an issue when Australian women are currently having an average of 1.7 children (I do wonder how he would feel about losing a sexual organ whether or not he wants more children). Current research indicates a 3 x maternal and neonatal mortality rate from CS. He did not mention this. He also stated that vaginal birth causes sexual dysfunction, incontinence, etc. He did NOT mention that the latest research shows that CS is NOT protective in pelvic floor dysfunction.

We had a case in Queensland where a woman, who had experienced 2 CS, wished to birth her next child vaginally. The hospital she planned to birth at pressured her for a CS stating that they were only willing to allow her to attempt a vaginal birth under very strict criteria such as continuous monitoring, being confined to bed, etc. They scheduled a CS for her but, feeling bullied, she informed them she would not turn up and made plans to birth in another hospital. The original hospital called DOCS on her(like your CPS) and they went to her home when she was in early labour (this is in direct contravention of the legislation which states that DOCS may intervene if an unborn baby is in harm’s way but SPECIFICALLY excludes the mother’s birth choices). She was able to fend them off and ended up birthing vaginally in the second hospital. Mother and baby were well.

David Molloy, then the Queensland president of the AMA (Australian Medical Association), was very vocal about this incident criticizing the woman for “risking her child’s life”. He stated that the woman had a 5-19% chance of her uterus rupturing resulting in the death of her baby. The actually risk of uterine rupture in a vaginal birth after caesarean is 0.4% with about 1 in ten of those cases considered “catastrophic rupture” resulting in the death of the baby. How can an AMA president get away with making such blatantly false and misleading statements to the press? No idea. I know a couple of people who wrote to the AMA about that specific statement and the AMA replied with “the doctor knows best” (I am paraphrasing of course!).

So you mention the AMA.… that is a small part of my experience with the AMA here in Australia. On a more positive note, I have seen the new president of the Royal Australian New Zealand College of Obstetricians and Gynaecologists in interview a couple of times recently and she is great. She was being interviewed about our soaring CS rates and she provided a very balanced and informative view on the risks and benefits of both. It is refreshing to see after hearing OBs like David Molloy advertise the procedure as safer and easier than vaginal birth (absolutely not true).

And that brings us to homebirth. When I was pregnant with Lucy I was reading a very mainstream pregnancy book and there was one paragraph in it about homebirth. It stated that for well women, home could be the safest place to birth your baby. I was outraged as EVERYONE knows that homebirth is foolish and risky and I intended to write the author a letter telling her how dangerous it was to publish such false and misleading information. So I looked up her references and was astounded at what I found. In study and after study homebirth has been shown to be as safe, or safer than hospital birth. Not only are the mortality rates similar, but in study after study the babies were in better condition at birth, mothers were in better condition, mothers experienced less PPD, higher breastfeeding rates, etc.

However, the exception is the Pang study. This study looked at out of hospital births in Washington state and, unbelievably, does not distinguish between planned and unplanned homebirths! The researchers looked at all births that occurred outside of the hospital but had no way of knowing which were planned homebirths with a midwife in attendance and which were BBAs (born before arrival - babies born on the way to hospital), unplanned homebirths, homebirths without a trained professional in attendance, whether the woman had had prenatal care, etc. Unsurprisingly, the Pang study shows that babies born out of hospital have a whopping three times the neonatal mortality rate as those born in hospital.

And this is the study that physicians always quote and that ACOG (the American College of Obstetricians and Gynecologists) has on their website. Of all the studies in existence on planned homebirth (I’ll send you a list of abstracts if you are interested) the Pang study is the single one that shows better outcomes in a hospital setting. And in spite of its flaws it is the one that is repeatedly quoted by physician groups.

Through out public health system midwives can only provide care under the supervision of a general practitioner or specialist obstetrician. This puts midwives on the same footing as nurses with NO midwifery qualifications and Aboriginal health workers! When a bill was proposed allowing midwives to bill the public health system for their independent services the physician associations kicked up a huge stink. It is ironic as midwives can be supervised by general practitioners with no obstetric qualifications or experience but cannot practice autonomously under our public health system.