GPs and midwives still struggling to get on

By MATHEW DEARNALEY

Tension between doctors and midwives is flaring anew, in the absence of an early Government response to calls to boost payments for maternity services.

Free maternity care remains a national icon and is beyond political challenge, says a stocktaking report prepared by the Health Funding Authority before it was wound up in December.

Key recommendations from that report appear to be in limbo. The Government is not ruling out increases in payments, but doctors and midwives want urgency, especially as the report acknowledges concern about whether a viable maternity workforce can be maintained.

What shape are maternity services in?

Although the report says the number of "lead maternity carers" (the midwife or doctor primarily handling each case) is relatively stable at 1442, that is only because midwives have moved out of hospitals into self-employed practice to replace general practitioners.

Hospitals have had to recruit replacements overseas, while polytechnics cannot find applicants to fill midwifery courses.

The need for better payments is about all the two professions can agree on, and the Government's reticence is helping to reopen wounds from past battles, which saw midwives emerge as the leading maternity carers of at least 57 per cent of women after an exodus of GPs offering obstetric services.

The Medical Association remains concerned about a rundown in specialist skills, especially in rural areas now that GPs have largely quit the contest in cities. It says midwives cannot be as alert as its doctor members to signs of medical complications.

A threat by all three of Queenstown's GP obstetricians to withdraw from maternity services prompted association chairwoman Dr Pippa MacKay to renew fire against "dangerous and blinkered ideology."

More rural women will have to be sent to cities to give birth, she says, rather than risk losing their babies or their lives.

But the College of Midwives wonders why Dr MacKay has chosen to daub on her warpaint now, particularly as New Zealand's death rate for perinatal babies - those still in the womb or under a week old - continues to decline. The death rate, which provisionally stands at nine in every 1000 births for 1999, ranks us in the best one-third of OECD countries.

GPs and midwives seem to have been scrapping for ever. How did it start?

Until Helen Clark introduced the Nurses Amendment Act in 1990 as Health Minister, all births, including those at a woman's home, had to be supervised by doctors.

The law change allowed midwives to operate as independent providers of pregnancy and childbirth services without doctors looking in on them.

But some women continued to receive parallel care from both midwives and doctors. Annual payments to the two groups ballooned from $50 million to $90 million in the three years to 1993. Such costs and concern at a lack of clear accountability (delays caused by conflicting opinions between midwives and doctors were blamed for some cases of severe infant brain damage) prompted a review.

How did the present scheme emerge?

In 1996, a pioneering system was introduced. Under it a pregnant woman is invited to choose the professional who will take overall responsibility for her primary maternity care. That professional hires the services of others as needed.

Her lead maternity carer can be an independent midwife, a hospital midwife, or a GP with obstetrics skills. Or she can choose a specialist obstetrician, as long as she is willing to top up the Government's contribution.

Whoever she selects receives bulk payments from the Government for five modules extending from the middle stage of pregnancy to four to six weeks after childbirth. That lead carer is billed for all extra subcontracted primary care maternity costs incurred on the way.

The overall sum ranges from $1396 for an urban woman who has given birth before, to $2163 for the rural homebirth of a first child.

But while midwives can handle the entire pregnancy unaided if there are no complications, GPs chosen as lead carers must still hire midwives as subcontractors, often having to resort to hospital staff after finding independent practitioners unwilling to work for them.

In so doing, the doctors must fork out considerable chunks of their fees, which are identical to those of midwives and have similarly remained constant since 1993, apart from better rural travel allowances.

The scheme has caused deep resentment among many doctors, who complain about being sidelined by the midwives with whom they say they once worked in cordial and mutually respectful partnerships.

Longstanding patients are prevented from visiting them for second opinions, they say, with midwives likely to withhold payments if they do.

Only 16 to 20 per cent of GPs now offer maternity services.

Who, if anyone, is to blame?

College of Midwives president Sandy Grey, who practises in West Auckland, says doctors were withdrawing from maternity services long before the lead carer scheme, especially with an increasing reliance on medical centres for after-hours cover.

She believes midwives are taking the rap unfairly, but usually get good cooperation from obstetricians and other specialists to whom they have no hesitation in referring women as soon as any concerns arise.

Such referrals are paid for separately from the Health Ministry's secondary-care budget, and she can think of few cases where a woman under a midwife's care would have cause to visit her GP as well.

She says a midwife can deal with most pregnancy-related ailments in the first instance, at no cost to the woman. However free maternity care does not extend to unrelated conditions which must be referred to doctors at the patient's expense.

Problems arise, she says, when a woman turns up at a GP clinic without first telling her midwife, and the doctor demands repayment for what was an unnecessary consultation.

Do mothers like the service now?

Although the lead maternity scheme was promoted as giving women more control over their pregnancies, Dr MacKay says they have been left with fewer options. Many who would prefer to remain with their GPs can no longer do so.

As one of just 14 Christchurch GPs still practising obstetrics, she says her beef is not with the midwives, but with a flawed scheme which is all about curbing Government costs and which impedes rather than promotes teamwork.

When the National Health Committee reviewed maternity services in 1999, it found 75 to 94 per cent of women satisfied with the service throughout their pregnancies, childbirth and postnatal home visits. But about one-third complained of being unable to get the lead maternity carer they wanted in the first place. They also expressed concern about tension and lack of communication among service providers.

Is there any alternative?

Kumeu GP William Ferguson has recently started offering his patients maternity services again after having to turn them away in recent years because he was unable to cover costs under the standard lead maternity care contract.

He is one of about 20 GPs in Auckland and Northland who have joined a South Island-based scheme which he says offers about 10 per cent more than the standard contract, as well as a partnership with midwives which respects the roles of both.

He says the scheme began in Otago after the 1996 changes, when what was then the Southern Regional Health Authority faced a boycott unless it agreed to a realistic arrangement.

Although the HFA report recommends removing price differences between contracts, Dr Ferguson says 30 per cent of the country's 57,000 annual births are now covered by non-standard arrangements and any changes would spark a rebellion.

He advises the Health Ministry, into which the Health Funding Authority has been absorbed, to back off or risk losing those few doctors still struggling to offer their patients a throughout-life service.

How have maternity service budgets fared through the years?

They have been fairly stable since 1994, when annual spending rose from $318 million to $369.5 million before easing to $344 million in 1995-96. The budget was $358 million last year, but $13 million remained unspent.

Health Ministry maternity manager Barbara Browne, who wrote much of the report, emphasises that last year's underspending did not lead to service cuts.

One of her report's key recommendations is for a $3.6 million boost (after GST) to the Health and Disability Services contract fees, including an increase from $24.60 to $29.50 for single consultations in the first stage of pregnancy.

The Medical Association says the recommended increase would still leave doctors out of pocket compared with the $32.60 subsidy they receive for children under 6.

What else does the HFA report suggest?

Priorities include expanding the Health Ministry's consumer information service and a postgraduate course to teach rural maternity workers emergency skills.

But doctors say emergency courses can be no substitute for the loss of obstetrics skills from rural areas.

The report also proposes guidelines to control the use of caesarean sections, which rose last year to account for 19.2 per cent of all New Zealand births.

* How can you get information about maternity services? Ask your GP or a midwife directly, or ring the Health Ministry's maternity consumer line for an information kit or a list of lead maternity care providers in your area. The telephone number to call is0800-MUM-2-BE (0800-686223).