From MIDWIFERY MATTERS, Issue No. 87, Winter 2000
Marie O'Connor
MATERNITY CARE is in crisis throughout Europe, yet maternity policy rarely forms part of national or international health agendas. Some countries, notably Ireland and France, have been experiencing a veritable 'baby boom'. In some maternity hospitals, standards of service provision have been compromised to an unprecedented degree due to increasing demand, an escalating shortage of scarce resources, and in particular, a growing shortage of midwives. Such are the current shortfalls in tertiary care, both in Western and Eastern Europe, that the physical and, indeed, mental health of women in childbirth, and their babies, may be at risk.
Maternal mortality in European hospitals continues to be a matter for concern. In Ireland, maternal deaths accounted for 8% of all maternal negligence claims taken against obstetrician/gynaecologists from 1978-1998 (The MDU, Ireland, 1998). There is some evidence that shortfalls in standards of service provision may result in perinatal fatalities. In 1995, the British Confidential Inquiry into Stillbirths and Deaths in Infancy analysed the deaths of 873 normal term babies who died in labour: in over half of these cases, it was estimated that better care would reasonably have been expected to have made a difference to the outcome (DoH, 1998).
Little is known about the health of women after birth. For many women, the transition to motherhood can be difficult. Although no reliable national data exist, studies on postnatal depression give rates varying from 8% to 25% (O'Connor, 1995, p186). Postnatal depression is associated with the use of obstetric technology in birth (Oakley, 1992, pp277-279).
Although the promotion of breastfeeding forms part of health care policy in many Member States, breastfeeding rates continue to be low throughout much of Europe. In Member States where breastfeeding rates are lowest, such as Ireland, community-based postnatal care does not form part of official health care systems. Spiralling health care costs have led to the introduction of cost-cutting measures in tertiary care, such as early postnatal discharge, with mothers leaving hospital sometimes within hours of giving birth. Such measures, without the concomitant provision of midwifery services at community level, result in significant deficits in postnatal care for new mothers and their babies.
The 'new' public health, dating from the late 1970s, which recognises the right of citizens to autonomy in matters of health, transforming the 1950s curative, hospital-based approach into a strategy of prevention and promotion at community level, has yet to be fully implemented in most Member States. The recent EU Directive, adopted in June 2000 (2000/34/EC), will reduce the working time of doctors in training to 48 hours per week by 2009. This Directive is widely expected to result in the closure of obstetric units throughout Europe. In Britain, for example, plans for the closure of almost 200 obstetric units are well advanced. Despite the anticipated closures, however, maternity care policies in the vast majority of countries are still being framed within the traditional specialised medical, tertiary care model.
Maternity care is the only sector in health care where, with the exception of The Netherlands, the primary health care provider has been all but obliterated. Despite the fact that as many as 80-85% of women have uncomplicated pregnancies and births, many European national health and insurance systems favour specialist obstetric care for pregnant women. In some countries, official health care policy requires all healthy pregnant women to place themselves under high-technology, obstetric supervision. National health policies in these countries, centralising the services for birth, discriminate against childbearing women in rural areas. Centralising birth results in unplanned out-of-hospital births, which carry very high mortality rates. In addition, centralising birth results in the targeting of rural women for induction. Local obstetric protocols facilitate national health policies; women living in rural areas are often have their labour induced for geographical rather than medical indications. In Ireland, national data show that the rate of planned to unplanned out-of-hospital birth is one to one (O'Connor, 1992, pp10-11).
As health care budgets career out of control, the economic and social costs of this centralised model of maternity care for physiological birth are becoming increasingly unsustainable. Nonetheless, the provision of maternity care at primary level by midwives, a far more cost efficient option, is uncommon, except in The Netherlands. Within this specialised, tertiary care model, birth is treated as a medical problem. This has led to huge amounts of unnecessary and costly medical intervention. Rapidly rising caesarean section and instrumental delivery rates have become the norm throughout Europe.
Since 1980, national caesarean rates in some countries have doubled, and in some hospitals, they have gone up four-fold. France currently has a national caesarean rate of 30% (Enfants, 2000), while the combined operative and instrumental delivery rate in Spain is 40% (Wagner, 2000). The variation in individual obstetric caesarean rates has been estimated at 0-50% (Sakala, 1993).
A call for the surveillance of operative births was made by WHO as far back as 1985 (WHO, 1985:21). Despite the considerable variation in local and national caesarean rates, neither local nor national surveillance systems have been implemented in Europe. Moreover, in many Member States, the collection and publication of data on operative and instrumental deliveries, both in publicly funded and privately owned hospitals, is discretionary.
The continuous use of electronic fetal monitoring (EFM) in labour is still commonplace in many countries, despite substantial evidence and national guidelines contraindicating its routine use (RCOG/NCT, 1993). EFM is used on 90% of all women in labour in Spain (Wagner, 2000). In Ireland, the routine use of EFM on admission to the labour ward (Cuidiu, 1999:12) has increased. Electronic fetal monitoring has been identified by British obstetrician/gynaecologists as one of the main factors in the growth of caesarean rates, second only to fear of litigation (Francombe and Savage, 1993).
Other intervention rates in maternity care continue to be high throughout Europe. The adverse physical and sexual consequences of episiotomy have been known for many years. Despite accepted evidence as to its futility in preventing perineal lacerations, episiotomy continues as an obstetric routine. The national episiotomy rate in Spain, for example, is 89% (Wagner, 2000).
Although high rates can no longer be regarded as good practice, the induction of labour continues to be common, as does acceleration of labour. Acceleration of labour is a cornerstone of the 'active' or aggressive management of women in labour so prevalent in many Member States. 'Active management' is a set of obstetric protocols standardising the medicalisation of first births. It comprises early amniotomy, high-dose oxytocin (Frigoletto, 1995) and one-to-one 'nursing', the term it uses to denote midwifery. At the National Maternity Hospital, a leading Dublin hospital dedicated to active management, 50% of all first-time mothers (Cuidiu, 1999, p35) have their labours artificially accelerated for 'failure to progress'.
The use of oxytocin is a central element both in the acceleration and induction of labour. Oxytocin, however, causes painful contractions whether or not a woman is in labour (O'Driscoll et al, 1993:176). Oxytocin can therefore be seen to increase the demand for epidural anaesthesia, as women under active management strive to make labour more tolerable. Epidural anaesthesia, however, is estimated to multiply by four a low-risk woman's chances of having a caesarean section (Frigoletto, 1994). Epidural anaesthesia is often accompanied by continuous electronic fetal monitoring, thereby compounding the risk of caesarean section in uncomplicated labour.
In any specialty, medical intervention inevitably leads to a proportion of iatrogenic damage. The adverse physical and sexual consequences of episiotomy have been known for many years. Despite accepted evidence as to its futility in preventing perineal lacerations, episiotomy continues as an obstetric routine. The national episiotomy rate in Spain, for example, is 89% (Wagner, 2000).
Since the beginning of the last century, infection, pulmonary embolism, anaesthesia accidents, and haemorrhage have been the principal causes of maternal death after caesarean section (Shearer, 1993, pp1226-1227). National surveys on maternal deaths in the United Kingdom (Hall and Bewley, 1999) show that while the mortality rate for all caesareans is six times that of vaginal birth, the fatality rate in elective caesareans is three times that of spontaneous or unassisted birth. The principal risks posed by caesarean delivery to the baby are iatrogenic prematurity and respiratory distress syndrome. National rates for caesarean babies admitted to neonatal intensive care are unavailable.
The absence of outcome-oriented research in maternity care means that national data quantifying morbidity, whether iatrogenic or otherwise, are often unavailable. Obstetric accidents, or 'adverse events' as they are known, lead to litigation, and litigation anxiety, in turn, increases caesarean section rates. The existence, if not the national scale, of iatrogenic damage can be gleaned from individual research studies, where these exist, and from malpractice insurance reports.
Oxytocin, widely used both to accelerate and to induce labour, features strongly in obstetric negligence claims (The MDU, Ireland, 1998). Oxytocin has been identified as a salient factor in infant brain damage (Taylor, 1998, p7) and in intrapartum fetal deaths (DoH, 1995, 36-37). Maternal deaths have also been reported in connection with its use (Parke-Davis, 1993:1813). The response to oxytocin is highly idiosyncratic. Its American manufacturers, Parke-Davis, observe that the response depends on the sensitivity of the individual womb; they recommend fetal scalp electrode monitoring lest a woman's contractions become too powerful or too prolonged either for the baby or for the mother.
At the National Maternity Hospital, Dublin, where active management was developed, more than one newborn baby in six, nearly two thirds of whom are term - is admitted to intensive care following birth (Natiopnal Maternity Hospital, 1993, p 48) Clinical data show that respiratory distress syndrome, transient tachypnoea of the newborn, and sepsis are the principle indications for admission (Natiopnal Maternity Hospital, 1993, p 48). Staff at the hosptial are 'indemnified against cephalopelvic disproportion, rupture of uterus and injury to the child' (O'Driscoll et al, 1993, 55-56).
Within the spiral of intervention, with its pain-epidural-monitoring-caesarean dynamic, the waltz of obstetrics with litigation goes on: the more obstetricians intervene in birth, the more birth injuries occur: the more obstetricians get sued, the more they intervene. Litigation increases the cost of professional indemnity or malpractice insurance. In Britain, obstetric claims cost the NHS over œ150 million every year (Cumberlege, 2000). In 1999, in Ireland, medical indemnity for obstetrics and gynaecology currently costs the taxpayer œ17 million annually. Last year, malpractice insurance for obstetrician/gynaecologists increased by 88% (Irish Medical Times, 1999, 1), more than seven times the percentage increase levied on other medical consultants.
The State's response has been to propose no-fault compensation, aimed at infants brain-damaged at or around the time of birth. This scheme is designed to replace the concept of individual practitioner liability with the concept of enterprise or institutional liability underpinned by extensive risk management schemes. If introduced, enterprise liability is widely expected to erode even further the autonomy of midwives and of women in childbirth. Whether or not the scheme would improve the quality of care at or around birth is not known.
Caesarean sections have been estimated to cost three times more than vaginal births (WHO, 1986). Dutch health insurance data on the cost of birth shows that, in 1997 a caesarean rate of 9.5% accounted for 44% of the total cost of maternity care in Amsterdam, while home birth, at 26%, made up only 5% of the total bill for birth in that city (Klinkert, 1999). British figures show that an increase of 1% in the caesarean rate adds œ5 million to maternity care costs, which, as Baroness Cumberlege has observed, is the equivalent of 167 midwives (Cumberlege, 2000: 16). In France, Jean-Marie Clement, Professor of Hospital and Medical Law at Paris VIII University and former hospital administrator, estimates that birth in a French hospital costs between FF2,000-5,000 per day, according to hospital size: the larger the institution, the more expensive the birth (Clement, 2000).
Private obstetrics is lucrative. In Ireland, the private obstetric market is worth at least œ20 million annually, and this is divided among less than 100 obstetricians.
Obstetric malpractice suits also extend to mental health, a WHO Health21 target (WHO, 1998). Almost two-thirds of maternal negligence claims in Ireland are brought on the grounds of psychological injury, with, additionally, one woman in twelve claiming against obstetrician/gynaecologists for brain damage (The MDU, Ireland, 1998).
There is ever mounting evidence showing that primary care provided by midwives is as safe, or safer, than care provided by doctors. A recent American study of four million low-risk births (MacDorman and Singh, 1998) showed that the outcomes of midwife-led births were significantly better than those of medically supervised deliveries. The risk of having a neonatal death was 33% lower with a certified nurse midwife than with a doctor, while the risk of infant death was 19% lower in midwifery births than it was in physician deliveries.
Midwifery has also been shown to have salient advantages in the area of preventive health. Modern obstetrics has failed to reduce the number of low birthweight babies being born. In Britain, where the percentage of low birthweight babies is higher than it is in Albania or Latvia (Cumberlege, 2000), Ann Oakley has demonstrated that the provision of social support by midwives has a markedly beneficial effect on the physical and emotional health of high- risk mothers and on their babies' well-being: these effects are still measurable one year after birth (Oakley, 1992, pp 277-79). In the United States, MacDorman and Singh (1998) showed that the risk of having a low birthweight baby was 31% less with a certified nurse-midwife than with a doctor. Small babies are associated with significantly increased perinatal mortality rates.
Recognising (ten Hoope-Bender, 1997) that midwifery care can result in shorter labour, less medication, and fewer interventions such as surgical or operative deliveries, WHO (1996) has concluded that midwives are the most appropriate, and cost-effective caregivers in normal pregnancy and birth.
Whatever the benefits of midwifery care, laws and regulations discriminating against midwives are widespread throughout Europe. National health and insurance systems sustain medical monopolies, even at primary health level, in areas of midwifery expertise such as antenatal care. In many countries, official health care policies prevent midwives - the specialists in normal birth - from assuming responsibility from the care of healthy women in childbirth.
Structural and legal barriers to midwives' equality in the workplace are common. Many midwives are forced to work as obstetric nurses, and births become deliveries conducted according to obstetric protocols. In many Member States, midwives are hindered from practising their profession to the full. European Directives on midwifery, adopted 20 years ago, have yet to be fully transposed into national law. In some States, for example, midwives do not have prescribing rights, although such rights are to be inferred from the Directive of the European Parliament and of the Council of 21 January, 1980 (80/155/EC).
In Ireland, where midwives are governed by nurses, midwives are further prohibited by the Nursing Board from 'prescribing' non-prescription or 'over-the-counter' medication to their clients (An Bord Altranais, 1999:13). Midwives in Ireland who work at primary care level lack the basic requisites to practise their profession. They are obliged to beg, borrow, or contrive to get essential drugs, and other requisites necessary for the safe practice of their profession.
Most European midwives do not have hospital 'privileges', that is, the right to admit a client to hospital, to assume responsibility for her care, and to discharge her thereafter. Many midwives do not even have referral rights, that is, the right to refer a midwifery client to another professional practitioner. Nor are midwives commonly allowed to certify a woman's unfitness to work in pregnancy, or after the birth of her baby. While midwives are generally permitted to notify births, they are usually precluded from signing perinatal death certificates.
In some countries, there is a growing midwifery shortage. In Britain, for example, only 34% of registered midwives are currently in practice (Emerton, 2000, p19). Working conditions are poor for many midwives, and unequal pay structures persist in many countries. National health and insurance systems continue to discriminate against midwives - equal pay with doctors for equal work, or for work of equal value, which was introduced in New Zealand in the 1990s at primary health care level, is virtually unknown in Europe.
There is further evidence to suggest that European midwifery is lagging behind midwifery in other parts of the world. Most European midwives, with the exception of The Netherlands, have yet to be given equal powers and responsibilities with general medical practitioners in maternity care. In Ontario, Canadian midwives were given such powers as far back as in 1994 (Shroff, 1997, p205-239).
European midwifery, in contrast, is distinguished by discriminatory short-term, temporary, and part-time work contracts; non-recognition of years spent working in the home, or abroad by public service superannuation schemes; lack of parity with other health professionals in areas such as pension entitlements; lack of career development and inequitable promotional opportunities. In England, in recent years, the proportion of midwives working part-time has increased to 40% (Sandall, 1995).
Pervasive discrimination in the workplace is leading to increasing discontent. Hospital midwives frequently complain of bullying in the work place (Commission on Nursing, 1998, p181), a command and obey model of management, a preoccupation with hierarchy and bureaucracy, and a tendency towards information control (ibid, pp123-125), within an overall culture which can no longer distinguish between midwifery and nursing. All of this has led to low morale among midwives, and high migration from the profession.
In 1999, in a break with tradition, Dutch midwives, in an endeavour to secure better pay and working conditions, marked the advent of the new millenium with a midwight strike (de By, 2000). Overworked, and underpaid, Dutch midwives point out that, in recent years, there has been an increasing shortage of new midwives. With a caseload average of 155 clients per annum (Klinkert, 1999), many are suffering from burnout. The home birth rate in The Netherlands has fallen from 60 to 35% over the past 25 years (de By, 2000).
WHO has recently described midwives' lack of influence on national health care policies as an 'anomaly' to be corrected (WHO, 2000). Invisibility is a major difficulty for midwives, and for midwifery. In many countries, educational requirements underpin and reinforce the overshadowing of midwifery by nursing. Despite the fact that nursing and midwifery are two separate and distinct professions, entry into midwifery is often restricted to qualified nurses. In some countries, midwifery is officially classified as a medical profession. In Ireland, the term nurse may legally refer to a midwife (Nurses' Act, 1985). Furthermore, Irish medical practitioners are legally deemed providers of midwifery services (Spruyte and Wates v Southern Health Board, 1988). In Britain, legislative change weakening the already fragile boundaries around midwifery, and leading to the submergence of midwifery within nursing, has recently been proposed (NHS Executive, 2000).
In some Member States, the adoption of 'gender mainstreaming' in the public service requires that a gender perspective should be built into state policies, services, and structures to make them 'gender sensitive'. Gender mainstreaming, however, has yet to lead to equality of midwifery representation in maternity care. Midwifery is often 'represented' by nursing, and equality of representation with nursing and medical interests is rare. In some countries, midwives lack both the regulatory and trade union structures which would enable them to participate effectively in planning. Throughout most of Europe, midwives are excluded from policy-making, overshadowed by adjacent professions such as nursing, and obstetrics. This exclusion is evident in regulatory bodies, professional associations, government ministries, maternity hospitals, university faculties, and in health and other agencies.
The non-representation of midwifery in elected and appointed bodies at local, national, and international levels has serious implications for the development of woman-centred maternity care.
Neither has gender mainstreaming led to adequate consumer representation in maternity care. The democratic deficit extends from service providers to service users who are themselves female. Women, as 'patients', are often denied choice and freedom in birth. Midwifery is almost exclusively a female profession, while obstetrics is, in the main, a male occupation. The adoption of a gender perspective would suggest that, at this most female time of their lives, women have the right to a choice of midwife as well as a choice of doctor.
In some Member States, both midwifery and consumer representation in maternity care policy structures are virtually unknown. In addition to the relative powerlessness of being a patient, many women face additional barriers in childbirth because of poverty, ethnicity, language, religion, sexual orientation, disability, migrant, or refugee status. These barriers reinforce these women's primary exclusion as full and equal participants with providers in maternity care.
Some women still lack control over the services they receive for birth, finding themselves excluded from the decision-making process by midwives who themselves are powerless to offer alternatives to medical management. This exclusion from decision-making of both service providers and service users, reproduces, and is reproduced by, their joint exclusion at higher levels, in a process of mutually reinforcing circles of powerlessness. Gender equity has yet to be brought into the birth chamber.
Marie O'Connor
Dublin, November 2000
Written at the behest of Pegasus, the Academy for the Further Education of Midwives, and The European Workgroup of Independent Midwives.
Correspondence concerning this article should be addressed to Marie O'Connor, Director, European Institute of Midwifery, 42 Rathdown Road, Dublin 7, Ireland; emaruan@gofree.indigo.ie.
The author wishes to thank Philomena Canning, Director, European Insititute of Midwifery, Dr Jo Murphy-Lawless, Dr Paul O'Connor, and Colm MacGeehin, Solicitor, for their comments, suggestions and advice.
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This article was originally published in Midwifery Matters ISSUE 87 Winter 2000, p14-18
LW updated December 30, 2005