Another unfortunate experiment?

by Leah Haines / 31 January, 2009
Top obstetricians say New Zealand's maternity system is an "unfortunate experiment" from which the rest of the world will learn

In 2001, unknown to most, Waitakere's maternity hospital in West Auckland had become so dysfunctional it was in danger of being closed down. While women continued to have babies there, the hospital was embroiled in a major inquiry into neonatal deaths; it had also received nine major patient complaints in three months and was facing several lawsuits, and it had suspended an obstetrician for incompetence. Despite dealing with low-risk births, Waitakere had a caesarean delivery rate that had hit 27% and its safety record was one of the worst in Australasia.

Waitemata District Health Board never told pregnant women how precarious its birthing unit had become. But some midwives quietly advised them to give birth somewhere else.

The view of these practitioners was it simply wasn't safe to have a baby at Waitakere.

Why? It wasn't because of bad sterilisation practices, widespread incompetence or even the workload. It was because obstetricians and midwives were at one another's throats.

Obstetricians were cutting babies out of women for fear of being held legally accountable for what would happen if they left them in the hands of midwives. Meanwhile, the midwives, trying to protect women from unnecessary intervention, became reluctant to hand labouring mothers to specialists, fearing the brutal treatment they might receive.

It was a turf war. The politics of the battle for birthing supremacy in which both sides claimed to have mothers' and babies' interests at heart appeared to blind them to the damage they were inflicting on those they were supposed to be helping.

Then something extraordinary happened. Relationships healed, caesarean rates fell to 15%, and babies born at Waitakere went from having some of the worst health outcomes immediately after birth to having the best in Australasia. "It was about having the courage to be wrong," says former clinical director Robin Youngson, who played a key part in the turn-around. It's a courage that offers tangible hope for our entire medical system.

The situation at Waitakere Hospital is just a snapshot of what can happen when two sets of professionals with almost diametrically opposing views on childbirth are thrust together and expected to come up with some sort of consensus.

Officially, this tension has been an irritant, but the Ministry of Health has allowed it to continue since maternity reforms of the 1990s resulted in most GPs abandoning obstetrics and giving midwives the autonomy that led to them being in charge of 80% of births.

You can see the tensions in the language of midwife leaders like Joan Donley, who once described obstetricians as "generals in the war against normal childbirth" and said "the medicalisation of birth is a form of aggression and violence".

And it's revealed in the more subtly coded attacks on midwives, such as the criticisms of the maternity system by obstetricians outlined below.

Health and Disability Commissioner Ron Paterson has described the difference as obstetricians taking a "risk-averse, interventionist approach" and midwives "a less-interventionist approach, to allow the normal physiological process of labour to proceed". The theory with the maternity reforms was that the two philosophies would be complementary - midwives would manage the bulk of births with their low-intervention, women-centred focus, but would transfer cases to obstetricians if births became complicated. In most cases that's exactly how it works. But the rub has been in what Paterson describes as an inability to agree at the high levels of the profession about when such things as transfer of care should happen.

This was revealed in his review last June into the brain injuries suffered by a boy deprived of oxygen when his mother was transferred too late from a rural birthing unit to a secondary hospital. Although the commissioner's midwifery expert described the midwife's treatment as "reasonable" and "close and appropriate", the commissioner's obstetric expert said, "By any First World standard, the care in this case is below what is generally considered acceptable."

As Paterson said, "it was a curious situation" when both sides were considered to be right.

It was seen again after a boy died during a breech delivery in Otago, which Paterson said was directly affected by the midwife/doctor communication breakdown. Police later charged midwife Jennifer Crawshaw with manslaughter, accusing her of allowing an unsafe natural breech birth to go ahead, but she was acquitted when evidence showed the mother had been well informed about the risks but wanted to go ahead without medical intervention.

When asked by the commissioner why she didn't at least have specialists on standby, Crawshaw said "the history of stand-up arguments between midwives and obstetricians in the corridors of Queen Mary" meant that was not realistic. They would have either wanted to intervene or refused to be involved because they couldn't.

Meanwhile, disagreement continues between the two professions over some fundamental things like the safety of vaginal breech births, the risks posed by caesareans (obstetricians say there is almost no risk to the baby), the mandatory use of vaginal examinations in labour, and more.

To the College of Midwives, the suggestion that this results in tension, let alone turf warfare, is a media beat-up that makes women scared of birth. Yet it's been highlighted in report after report by coroners and Paterson and most recently in a major review into Wellington maternity services, which found that, at a national level, the disagreements posed a "very high risk" to safety.

In the Wellington findings, reviewers point to "fundamental differences in the approach of obstetricians and midwives to management of a normal labour" that meant communication sometimes didn't happen when it was "needed to ensure the safety of mother and baby".

Part of the onus for solving this was put on obstetricians, who it said were losing the skills to manage a complicated vaginal labour because they were so used to resorting to caesareans, and who needed to spend time, while training, working with individual midwives so they could understand how a normal, natural birth worked.

As for the leaders of the two professions, reviewers found an "alarming" lack of any recognition among the colleges that a key role was "to work in a collaborative and supportive professional relationship with the other"; and finally that "there is a lack of respect, collegiality and collaboration between the obstetric and midwifery colleges that is reflected in some very poor relationships between individual midwives and obstetricians".

It was into this battleground that the Royal Australian and New Zealand College of Obstetricians and Gynaecologists late last year lobbed what some midwives fear could be the grenade that threatens to blow any consensus apart. In a submission to the Australian Government only just made public, the college described our midwife-led maternity system as an "unfortunate experiment" responsible for rising baby and maternal death rates, and a disaster that the rest of the world would learn from.

The words "unfortunate experiment" must have been carefully chosen and midwives say they are deeply offensive. "Unfortunate Experiment" was the title given to the 1980s exposé into the cervical cancer scandal at National Women's Hospital and the words have became synonymous with a woman's loss of power over her own body, specifically at the hands of gynaecologists.

Nevertheless, in a scathing blow-by-blow account of what's apparently wrong with our system, the college urged the Australian Government not to go down our route, blaming the New Zealand reforms for increased rates of caesarean deliveries and intervention, an erosion of collaboration and teamwork, the exodus of GPs from maternity care, a lack of choice for mothers now forced to take whichever midwife is available and the inability of hospitals to hold independent midwives accountable for safe practice.

The submission says our perinatal death rates for babies (585 "in-hospital" deaths in 2004) and mothers (four deaths in 2004) are higher than those of other developed nations and hints that a report on our perinatal and maternal mortality rates is being deliberately withheld. It also suggests the current model is causing more Maori and Pacific babies to die because of inherent inequities in the system.

"The New Zealand maternity system has been hailed by some as having introduced great benefits to the women of New Zealand," the submission concludes. "That is not a view held by this college. In summary, the New Zealand maternity reforms could in the future be viewed as an unfortunate experiment."

Pregnant women might expect such a comprehensive condemnation of our maternity services by our most highly trained maternity professionals would lead the Health Ministry and the Government to launch an immediate inquiry.

But new Health Minister Tony Ryall, himself prone to using the "crisis" word about maternity services while Opposition spokesman, is adopting a wait-and-see attitude while awaiting feedback on an "action plan" for maternity services that he'd previously written off as "a diversion".

The College of Midwives and the ministry have rejected the submission as mere patch protection and scaremongering by Australian specialists keen to keep their stranglehold on the sector as it considers reforms similar to ours.

"Obstetricians are attributing some of the difficulties we are having with our maternity system to our model of care when, from what I have seen, many maternity systems face similar difficulties, irrespective of their models," says Pat Tuohy, the Health Ministry's chief adviser for child and youth health. "Obstetricians in Australia dominate the maternity services there and I suspect that a suggestion that midwives can come and be on equal footing with them will not be well received."

While that might be true of Australian doctors, it's also true that the section of the submission warning of the New Zealand "disaster" was written by the college's New Zealand committee, and its head, Auckland obstetrician Gillian Gibson, stands by every word.

So, what if the college is right, and the maternity service is an experimental time bomb, using women and babies as its guinea pigs?

"The fact is," says Rob Buist, former Health Ministry principal medical advisor and now chief of obstetrics at New South Wales' Royal Hospital for Women, "we just don't know."

Buist is one of several specialists and epidemiologists approached to ask if the reforms had led to an improvement or deterioration in outcomes for babies. The frustrated responses were almost all the same: we don't have the data to say.

Late last year, Cindy Farquhar, the chairwoman of the Perinatal and Maternal Mortality Review Committee (PMMRC), wrote to the college, saying aspects of a letter it sent to members, which preceded the submission, were wrong. She wrote that it was not justified to hold midwifery care responsible for any rise in maternal deaths. Data hadn't even been collected in a way that allowed comparisons to be made.

In what some say is an extraordinary omission by the Health Ministry, it launched New Zealand into some of the most dramatic public health reforms ever seen, without following that up with data to show if it works.

Tuohy says the changes were not designed to improve outcomes for babies. "The systems change was not set up to reduce perinatal mortality [death in the first month of life], for example," he says.

Asked if it wasn't logical to expect that better outcomes would be the measure of success for the reforms, he says, "If it was set up to lead to better outcomes as measured by perinatal mortality, then you would be quite right. But then I have not read anything which suggests that people said, 'Our perinatal mortality is appalling; we must do something to fix it; let's bring in the LMC model' - I don't think that was the reasoning applied 20 years ago." Rather, he said, reforms were solely about providing women with continuity of care throughout pregnancy and birth.

Part of the solution to the data gap will be PMMRC's first major report - still not released, though due four months ago. But it won't tell us the things Buist and co say we need to make a really good judgment about the success of the switch to midwifery-led care - for example, about those babies born alive but damaged by birth. (A special PMMRC sub-committee to look into incidents of oxygen deprivation has only recently been set up.)

The College of Midwives collects its own data, which it says shows the reforms have been a success. Its statistics show perinatal mortality for both Australia and New Zealand hovers at about 10 per 1000 births, and has done for several years.

Although caesarean rates have risen, New Zealand's rate - at nearly 24% - is still lower than Australia's average of 31%, and the rate of increase has been slower than those in the UK and the US, which are both also 31%.

And the College of Midwives points to a recent Cochrane database of systematic reviews that found midwife-led modes of care resulted in better outcomes than other models.

These outcomes for women included being more likely to have a vaginal birth without analgesia, feeling in control of labour, and initiating breastfeeding. However, it's unclear if the Cochrane review considered whether those women choosing midwife-led care tended to be those likely to have an uncomplicated birth.

There is other information. A draft study by Andrea Kutinova, a University of Canterbury associate professor and an expert in the economics of childbirth, reveals that babies whose mothers registered with GPs had about a 10% greater rate of survival than those with midwives. But she's reluctant for much to be made of that until her report is completed later this year.

Anyway, says Buist, "raw perinatal mortality and raw maternal mortality is not the answer. We're looking for a rare bunch of outcomes. The majority of baby deaths actually have nothing to do with the core maternity system, and that's the real problem."

Adds the college's New Zealand Committee head, Gillian Gibson: "Deaths [are] the worst possible outcomes. It's just how many other babies out there got close to that, or who ended up with injuries or who were near misses, that's really what we'd like to see collected."

So, in a vacuum of agreed facts, and in a vacuum of trust between the professions, serious accusations can be made without proper scrutiny, further eroding confidence.

And the most important part of this erosion of trust is that of mothers themselves.

Often, midwives blame "sensational" media reporting of baby deaths for this.

"The thing that pisses me off is the women we see coming in completely terrified of going into labour because of a story they've read," says one midwife, who works in a major public hospital.

"At the end of the day, babies do die and we hate that. No one goes into this job wanting to harm anyone and sometimes you feel that's how the media is portraying you."

She blames the "attacks" from media and obstetricians on a history of the undermining of midwives that stretches back hundreds of years.

Yet mothers also blame the lack of respect among the professionals for creating fear.

"For me, there won't be a next time," says Amelia, a young mother who claims to have nearly bled to death after doctors bullied her and her midwife into an unnecessary induction. The baby survived, but she was diagnosed with post- traumatic stress disorder.

"For most people, having a baby is something they do a few times in their life. I just feel quite robbed."

The Midwives College points to the latest Maternity Satisfaction Survey that shows 94% of women felt communication between their lead maternity carer and obstetrician was either satisfactory or excellent. But printed directly underneath those findings is a postscript: "Poor communication amongst professionals was commented on spontaneously by a large number of women as problematic for them. Miscommunications and arguments amongst professionals, frequently in front of the woman and often during labour and delivery, caused some women major distress and resulted in them losing confidence in the professions and feeling unsafe."

At a forum following a recent screening of a film about natural birth, two senior midwives told the audience they resorted to "deception" and "subterfuge" so obstetricians would not intervene in births that the doctors would likely think too risky but which the midwives believed the mothers would be able to be manage naturally.

There have been several cases highlighting failures to hand over to specialist care. And there is mounting international evidence that obstetricians are overusing and misinterpreting fetal heart-rate monitors and carrying out unneeded caesareans.

A senior clinician, who can't be named because he hasn't got permission to use the information, pulled daily obstetrics statistics from his unit and found huge discrepancies in rates of caesareans on different days of the week depending on which obstetrician was on duty. Some regularly performed double the number of caesareans, suggesting many operations may not have been strictly necessary.

And the Waitakere situation shows this may in part come down directly to the relationship between the doctors and midwives on duty.

So, where in all this is the truth for mothers? Because, as Buist says, "midwives and doctors have -

always been at each other's throats", should women not be entitled to demand good, objective information about their birth options and at the very least a truce?

The Health Ministry hopes unified standards of care will soon be drafted along the lines of those developed by the UK's National Institute of Clinical Excellence. These are non-compulsory standards in all aspects of maternity care and have been signed up to by all players in the sector.

And peace? All you need for that, says Waitakere's Robin Youngson, is the courage to say you're wrong.

Which is what happened in 2001 when Youngson, an anaesthetist who was then clinical director at Waitakere Hospital, called in facilitator Don Reekie to try to sort out relationship problems in its maternity unit.

In a nutshell, says Youngson, midwives and doctors had created a pattern of behaviour and belief about one another that was constantly reinforced in a sort of nightmarish spiral.

Independent midwives, with a focus on natural childbirth, had come to expect that every time they called on an obstetrician, the doctor would perform a caesarean, so they didn't tend to call on them until there was a crisis.

Says Youngson: "The doctors have only one way to respond to that, which is to take the mother urgently to the operating theatre and rescue her and baby from sometimes great danger."

So, this reinforced the midwives' belief that obstetricians only wanted to strip a woman of control and perform surgery, while at the same time underlining the doctors' belief that midwives didn't care about safety and would do anything to ensure a vaginal delivery.

To end the nightmare, Youngson and Reekie held an intervention nicknamed "the Big Day Out", which, through roleplaying and follow-up weekly and monthly forums, changed how the health professionals viewed one another.

One midwife who roleplayed an obstetrician declared she had "never before realised that obstetricians cared about mother and babies as she did". Obstetricians were less forthcoming with their epiphanies, but trust was restored, the "last-minute" crisis response stopped and safety rates improved. Caesarean rates fell from 27% to 15%.

Reekie was also asked to sort out problems between midwives and obstetricians at both Hutt Valley Hospital and the Otago District Health Board. It appears there was success, but neither apparently achieved the results seen at Waitakere.

The answer at Waitakere, says Youngson, was not in the methodologies and evidence-based guidelines the health system seems stuck on. "But a lot of the difficulties and risk for patients we have actually come down to the quality of interpersonal relationships.

"All the work we did at Waitakere cost about $2000, and I don't believe that any other maternity unit in Australia or New Zealand has seen such an impressive improvement in results over a sustained period of time with such a tiny intervention. I think it's just because we had the courage to get to the heart of the matter."

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