Editorial: Midwives' record under fire

A Wellington coroner has revived a debate about childbirth that ought to have been resolved by the experience of 15 years. It is that long since midwives were given the right to compete with doctors in the provision of maternity care, and most doctors have long since quit the field. Now an inquest into the deaths of two babies in Wellington has caused coroner Garry Evans to call for an urgent review of midwifery training, with a reintegration of doctors into state-financed maternity services, a national audit of births and more clinical supervision of graduating midwives.

General practitioners welcome the coroner's call but the College of Midwives says he has over-reacted to two rare mistakes. The new Minister of Health, Pete Hodgson, has asked his officials to investigate whether a review is warranted. Published figures would suggest it is not. The number of early neonatal deaths, which may not be a reliable indicator considering advances in life-prolonging technology, has not risen appreciably since midwives came to dominate the service. In 1991 there were 3.4 deaths per 1000 births, in 1995 there were 2.3, 1997 recorded three and 2001, 2.5. There is plenty of anecdotal evidence from GPs about the failings of midwives but no public clamour for change from parents and parents-to-be.

In fact, the main problem of late has been a dire shortage of midwives in many districts, caused in part by the 20 per cent pay increase won by nurses, which made specialising in midwifery services less attractive. The Government has responded by boosting the fee it pays midwives from next month, at a cost of $18 million a year.

But it would be too much to hope that facts and figures might settle this debate. To many it is an issue loaded with differences of health philosophy, values and even gender. Childbirth, in one view, is a normal, healthy procedure that had become unnecessarily dependent on medical supervision and assistance. Maybe so, say others, but it is better to be safe than sorry if it turns out, as it did in the Wellington cases, that midwives failed to spot complications needing a doctor's attention.

The temptation for a Government presented with an issue such as this is to try to satisfy both sides. That is what happened when Helen Clark, as Minister of Health in the previous Labour Government, opened the door to midwives. Women were able to have their pregnancies monitored by both doctors and midwives, with the result that hospital midwives left the public sector in droves to set up in independent practice and the cost of the maternity benefit went through the roof.

To contain the cost, the next Government set up a system of "lead carer", which could be either a doctor or midwife who would engage other specialists as the lead carer thought sensible. The payment system satisfied the independent midwives but not general medical practitioners, who steadily withdrew from the services. Of the 600 GPs offering maternity care in 1997, only 20 still do so today. If people are willing and able to pay for specialist obstetric attention throughout a pregnancy, they can get it. But if they want the state's free maternity services, they have almost no choice but to put their faith in a specially trained nurse.

If two neonatal deaths, dating from 2001 and 2003, cause the Clark Government to reconsider this arrangement, the cost escalation is likely to return. GPs will need a better rate than they have been offered and the Government will feel obliged to offer the same rate to midwives. But the coroner was lacking solid data to support a review, hence his accompanying suggestion of an audit of births. The audit at least should be done. It is needed to ease the minds of prospective parents and confirm that the vast majority of available midwives are sensible and safe.