From MIDWIFERY MATTERS, Issue No. 100, Spring 2004
A Global Witch-Hunt
Marsden Wagner has been involved in 20 cases of alleged professional misconduct
over the last ten years. His editorial in The
Lancet says that:
'There is a global witch-hunt in progress - the investigation of health professionals
in many countries to accuse them of dangerous
maternity practices. This witch-hunt is part of a global struggle for control
of maternity services, the key underlying issues being money, power, sex, and
choice.'
He pulls out common features of the cases he has been involved in. These include:
• imbalanced sex ratio - 70% were midwives and 85% were women;
• at least some of their practice is not mainstream - of the twenty accused,
15 practised home births, three practised
in alternative birth centres, and two were doctors in hospital practice.
•All of the midwives were in independent practice (despite the fact that
unorthodox providers are rarely sued by parents
whereas 70% of USA and UK obstetricians have been sued at least once).
• Evidence gathering. In most cases, the doctors notify the legal authorities
only after a perinatal death. One death, even
if not preventable and not the result of any mistake, suddenly negates years
of impeccable statistics.
• Consequences to the individual. If the accused loses, that often means
losing the possibility, at least temporarily, of
continuing to practise.
• Impact on other health professionals. Midwives in that country feel threatened
in their independent practice. Doctors are
afraid to support midwives or to go along with the wishes of their patients
when the requests are outside mainstream policy -
eg, water births.
• Loss of choice for women.
On the other hand, investigation of independent midwives and unorthodox doctors
can sometimes have the opposite effect,
leading to solidarity among midwives and between midwives and unorthodox doctors,
and women, irrespective of whether the
accused wins or loses. He continues: "The witch-hunt is part of a global
struggle for control of maternity systems and there are
several key issues, one of which is economic.
"As birthrates fall, the competition for pregnant patients increases, especially
in countries largely reliant on private medical
care; and as more and more countries move towards pluralistic health care systems
with private practice, maternity care
becomes more competitive. However, in the face of increasingly limited economic
resources, governments and insurance
companies are becoming more and more concerned with the waste associated with
high-technology, high-intervention
obstetrics. It is much more difficult for obstetricians to defend this expensive
type of practice when midwives and a few
doctors are meanwhile showing that a much less expensive type of maternity care
is equally safe. ...The witch-hunt is an attempt
to display lack of safety among the competitors.
"...A second issue is the control of maternity services. Until recently,
government regulations in most countries have given
doctors a monopoly in providing health services. But this monopoly can easily
be abused, especially behind closed doors. The
issue becomes one of peer control versus accountability to the public.
"Fortunately the pendulum is swinging, at least in some places, with the
coming of quality assurance systems that include
public accountability of health care and health care professionals. Maternity
services are in the forefront of the controversy
over peer control and public accountability because birth, like death, is a
deeply personal social and family event and does not fit
the doctors' disease model. So today the medical monopoly of maternity services
is coming into question and the witch-hunt is
one means of reasserting the orthodox doctor's control. Choice and freedom for
health care consumers are at issue here. In
the USA and UK, consumers of health care have been asserting themselves for
some time. The claim is made that the
obstetrician must protect the best interest of the fetus by overriding any woman's
choice not approved by orthodox
obstetricians. As pluralistic health care systems increase in Europe, so will
consumer choice; the witchhunt is one way of
limiting that freedom of choice.
"Choice and freedom for healthcare providers are also at stake here....
It is no coincidence that 90% of the accused in my
sample were involved in home birth or alternative birth centres. It is important
to distinguish between the quality assurance
function and the witch-hunt function so that the courts are not inappropriately
used for professional gain. When making that
distinction in a particular case, think about who might gain from a successful
prosecution; is the evidence brought against the
accused scientifically based? Whilst tribunals may have a declared function
to weed out true incompetence and protect the
public in the cases I describe the real function was to punish deviant professional
behaviour that could threaten the income,
practice style, prestige, and power of mainstream doctors.
"...Another issue is the two-hundred-year-old struggle of doctors to control
midwifery. It is no coincidence that 70% of the
accused in my sample are midwives, all in independent practice where they are
not under the immediate control of doctors.
Fear of being investigated by authorities is a strong deterrent to independent
midwives.
"Solutions begin with increasing the public's awareness of the witch-hunt
and its basis in political not medical issues.
"There should be no closed doors in health policy making, in health service
delivery, or when the behaviour of health
professionals is being judged. The evaluation of professional behaviour must
be based on deviations from practice based on
scientific evidence rather than on deviations from peer-controlled opinions
of what constitutes good practice."
from The Lancet - vol 346
LW updated April 18, 2004