Marie O Connor
Marie O'Connor is a research sociologist, broadcaster and writer in Dublin who specialises in maternity care. She is the author of Birth Tides: Turning towards home birth. Pandora, London, 1995
BRITISH MIDWIVES lag behind midwives in other countries when it comes to professional autonomy. Speaking at a conference on evidence-based midwifery in London organised by Midwifery Today, Dr Marsden Wagner said that New Zealand midwives topped the league of 14 industrialised countries. They were followed by midwives in The Netherlands, Denmark and the UK. British midwives, however, were ahead of Swedish, Canadian, US, and German midwives.
New legislation on midwifery in 1990 had given New Zealand midwives powers comparable with those of family doctors in maternity care. Irish midwives, whose colleagues were on the verge of a national strike ballot in Ireland, were ranked 11th in the table. They listened disbelievingly as Marsden Wagner told his audience that New Zealand midwives were paid the same flat fee for birth as obstetricians and general practitioners. Midwives in Canada are also paid the same fee for maternity care as obstetricians and family doctors, a speaker from Ontario pointed out.
In Ireland, a labour ward sister can expect to be paid a maximum of I£24,000 pounds. Some consultant posts carry a starting salary of I£86,000 pounds, and this is exclusive of access to free hospital accommodation, staffing, laboratory and other facilities for private practice. The `active management' of women in labour is the norm in Irish maternity units, and the only clinical decision a midwife is allowed to make is whether or not to perform an episiotomy. According to Declan Meagher, one of the system's founding fathers at the National Maternity Hospital, one of the principal objectives of active management was to give consultant obstetricians a `role' in `each and every woman's labour'.
Some of the topics covered at the Midwifery Today conference included the threat posed by the untrammelled use of technology, the adoption of midwifery as the standard of care for birthing women, the need for midwives to be able to exercise professional autonomy, and building bridges, both political and administrative, between theory and practice. Practical workshops on topics such as breech birth, shoulder dystocia, prolonged labour, and physiological third stage were also a feature of the conference.
Turning from the thorny issue of clinical autonomy, the author of Pursuing the Birth Machine addressed a related topic: `Evidence shows primary care by midwives to be as safe or safer than primary care by physicians', he asserted. A search of the scientific literature, he said, failed to uncover a single study that demonstrated poorer outcomes for low-risk women with midwives than with physicians (Wagner, 1998). `Who is the safest birth attendant for low-risk birth - a midwife or a doctor?' he asked. Quoting a study of four million births in the United States analysed by birth attendant (MacDorman and Singh, 1998), the epidemiologist found that midwives had significantly better perinatal outcomes than doctors. `Compared with doctor-attended births, midwife-attended births had 33% lower neonatal mortality rates'. The study examined differences in perinatal outcomes between the two professions, matching the birth and death certificates of singleton, vaginal births from 35 to 43 weeks gestation, and excluding cases of social or medical risk. Midwives achieved better results than doctors, not only in terms of lower infant mortality rates (19%), but also as measured by a reduction in the number of low birth weight babies (31%).
In Ireland, this kind of statistical analysis would not be possible, for a variety of reasons. Obstetric outcomes remain a closely-guarded secret, known only to the Department of Health, and medical insurers. There is no institutionalised midwife-led care.
Only independent midwives offer midwife-led care. Should an independent midwife transfer a client during labour, she may be asked to retire to the hospital waiting-room. Independent midwives have no practising rights in hospitals. There are 15 independent midwives in the country; less than 200 women give birth at home every year. Hospital maternity care is pyramid-shaped, with a small number of predominantly male obstetricians (approximately 60) at the top, and 50,000 women (at a minimum) at the bottom. Midwives, working within medical protocols set down by obstetricians, make up the steeply sloping walls of the pyramid.
Recent obstetrical practices in the West had not improved birth outcomes, Marsden Wagner asserted. There had been no decrease, and there may have been a slight increase, in maternal mortality over the past ten years. Perinatal mortality rates had fallen slightly during the same period, but fetal death rates remained the same. Neonatal death rates had decreased slightly, but this fall was accompanied by `a probable increase in neurological damage'. Cerebral palsy rates had not improved: `Rates today are what they were thirty years ago'. Finally, obstetrics could not prevent the birth of small or very small babies: `Low birth weight rates have remained constant over the past twenty years'.
Later in the conference, in a wide-ranging paper entitled `Epidemics Uncovered', Dr Wagner summarised the current evidence on what he called `childbirth-related epidemics', namely, caesarean section, epidural anaesthesia, and ultrasound scans. Underlining the relationship between epidural anaesthesia and caesarean section, he said that while epidurals increased by four the risk of a forceps birth or vacuum extraction, they doubled `at a minimum' the risk of caesarean section.
Annual clinical reports are produced only by the three Dublin voluntary hospitals, and these have been copyrighted in recent years. There are no publicly available statistics, local or national, on caesarean section, epidural anaesthesia, ultrasound scanning, or indeed any other feature of obstetric practice. The prevalence or otherwise of such `epidemics' in Ireland is therefore impossible to determine.
Caesarean section significantly increased the risk of maternal death, he said. The former WHO Regional Officer for Maternal and Child Health said that, in the UK, the death rate for elective Caesarean sections was almost three times higher than that of vaginal birth. Marsden Wagner compared direct death rates per million maternities by mode of delivery in the United Kingdom. Data from the Confidential Enquiry into Maternal Deaths (Hall and Bewley, 1999) showed that the mortality rate for all Caesareans was six times greater than that for vaginal birth.
While the Freedom of Information Act (1997) has recently been extended to the Regional Health Authorities in Ireland, this extension applies only to a small number of maternity units throughout the country. All of the Dublin maternity hospitals, for example, continue to remain outside its scope.
Speaking on the issue of women's `right' to choose caesarean section, Marsden Wagner said that women's `choice' was limited to medically valid options: `No one can demand major surgery when it is not medically indicated'. Both doctors and women have rights in deciding a course of treatment: `Women have the right to refuse treatment even when medically indicated, but do not have the right to demand treatment which is not medically indicated'.
Citing episiotomy as one example of the ongoing gap between scientific evidence and clinical practice, he said that in Hungary the episiotomy rate was 100%. In a description of episiotomy reminiscent of Sheila Kitzinger's, he said that this practice was `the modern Western form of genital mutilation'. Asserting that episiotomy rates should never exceed 20%, he said : `The best evidence shows that it should never be more than 5%'. Closing the gap between the evidence for and against episiotomy and the practice of episiotomy, he concluded, is `as difficult and painful as closing the episiotomy wound'.
The episiotomy rates in Irish maternity units are unknown. They are not included in the Dublin hospitals' annual clinical reports.
Scientific medicine, Dr Wagner said, was evidence-based practice. `Standards of practice, however, were often not evidence-based.' British obstetricians, for example, identified litigation as the reason for the rise in caesarean rates in Britain. The former WHO director cited convenience as one non-medical factor which influenced practice: `Emergency c-section is more common on Monday through Friday, from 9 to 5'.
In an examination of: `non-medical determinants of standards of practice', Marsden Wagner said that `force of habit' determined physician choice of forceps delivery or vacuum extraction, and that the choice of induction versus c-section was often a matter of physician convenience. He identified fear of litigation as the driving factor behind routine EFM, a phenomenon which in turn was fuelled by commercial interests: `The companies which make electronic fetal monitors have had a huge impact on the use of electronic fetal monitors'. In a survey of British doctors' attitudes towards evidence-based obstetrics, only three out of four were aware of the existence of evidence-based practice. One obstetrician in four was familiar with critical literature reviews, while a similar proportion had internet access. Slightly fewer were familiar with computer science, and only 9% had access to the Cochrane database.
Faced with a difficult clinical problem, half of the obstetricians surveyed said they would consult a respected authority, one third would be guided by a textbook or guidelines, and 8% would use Medline.
Another speaker at the conference, Huguette Comerasamy, a lecturer in midwifery at Thames Valley University, explored the roots of midwifery knowledge. She examined the shifting paradigm from a woman-centred to a doctor-based approach. Could we say that the midwifery we have today is midwifery or obstetrics, she asked. She spoke about her rediscovery of traditional midwifery in her native Mauritius, emphasising the need to analyse and understand the evolution of midwifery in order to reclaim authentic practice.
In Ireland, the roots of midwifery practice have been lost. Folklore accounts of childbirth are rare: while Ireland has one of the richest collections of folklore in Europe, early 20th century collectors were male, and childbirth was a topic spoken of only among women.
`The autonomy of midwives is dependent on the autonomy of women, and the autonomy of women is dependent on the autonomy of midwives', Dr Wagner said. To practise the full range of midwifery care, midwives had to be autonomous, and not under the control of nurses and/or doctors. `There will be midwifery autonomy only when there is unity.'
Finally, on the cusp of the millennium, a translation from Irish of a birth in County Mayo:
After she went into labour, the woman was transferred from her usual bed, which was in the kitchen by the fire, to the floor, which was covered with straw. She put on her husband's jacket, an outsize flannel garment with sleeves, made of homespun wool, or bainin. As the great event drew near, the husband stood at his wife's back, and placed his hands on her shoulders while she was in a kneeling position on the floor. With words of faith, hope, and encouragement, he supported her morally and physically in her trial, while the midwife got on with the great task of bringing a new human life into the world.
Hall M, Bewley S (1999). `Maternal mortality and mode of delivery', Lancet, 354, 776, August 28.
MacDorman M, Singh G, (1998). `Midwifery care, social and medical risk factors and birth outcomes in the USA', Journal of Epidemiology, Community Health, 310-317.
Wagner M (1998). `Midwifery in the Industrialised World', Journal of the Society of Obstetricians and Gynaecologists of Canada, November 1998.
Midwifery Today's next European conference, entitled: Celebrate Diversity! An International Midwifery Model, will be held in Aachen, Germany, from 28 September - 2 October, 2000.
AH updated 8 February 2000