Doctors vs midwives

A highly qualified, well educated woman, labouring with her first baby, presents to a birthing centre after a stuff-up with her home birth midwife. The midwife couldn't attend, but left detailed instructions with the patient. The membranes rupture and thick meconium pours out.

The pleas of the staff (birth centre midwives as well as doctors) for foetal monitoring go unheard. Hospitals are, after all, centres for 'birth rape', and this mother is determined to not allow a brutal violation of herself and her child to occur.

Several hours pass. The staff become deeply distressed. Decelerations in the foetal heart with contractions are occurring, and the risk to the foetus is increasing. Finally, a caesarean section is performed, but the baby has died by the time delivery occurs. The cause: birth asphyxia.

A noted home birth advocate gives birth at home, with no assistance, in a practice called free birthing. After 2 days of labour, the child is born terminally asphyxiated. The baby girl dies in the ambulance on her way to hospital. The free birth advocates and the coroner's court are at each other's throats. The mother claims that the stillbirth of her child was less traumatic than her first, hospital, birth.

Who is to blame for these tragedies?

I am an obstetrician, and a mother. It would therefore be expected that I would be critical of both these cases. I am expected to espouse the medical model of care, involving a birth in hospital, rapid recognition of foetal distress, timely intervention and a safe mother and child at the end of it all. It is easy, and even expected of me, as a member of the medical establishment to suggest that the patients were the cause of their own downfall, that they made foolish choices but I believe the case is not that simple.

If I walk into any bookshop and ask for the pregnancy and birth books section, I can pretty well guarantee that of the books available, a large majority will be biased towards active birth, water birth and home birth. All of the books that are biased in this way will state that women can give birth naturally, that their bodies are designed to give birth and with will power, any child can be born normally.

The actual statistics on this subject, however, are troubling.

If, for example, we look at mortality in childbirth in the late 19th century, when the first reliable records were kept, we find that maternal mortality rates were 500 per 100,000 births per pregnancy. Given that the average number of pregnancies may have been as high as eight, this gave a cumulative lifetime risk of around 1 in 25 of death related purely to pregnancy.

Today's equivalent can be seen in sub-saharan Africa, where maternal mortality is estimated at 1:16 per life time, or Afghanistan, where birth can only be attended by women, and women are not allowed any education in literacy, let alone birthing practice, and the lifetime risk is 1:6.

Interestingly, the fall in maternal mortality noticed in the late 1800s is now considered to be almost solely due to the practice of midwifery and the presence of skilled attendants at most births. At this time, patients attended to by doctors had a much higher mortality than those attended by midwives. It is possible that the divide between doctors and midwives may well have originated in these times.

A further, much greater fall in mortality, however, was recorded in the 1930s, when access to antisepsis, antibiotics and caesarean section improved very markedly. From that point, maternal mortality fell to very low levels across the developed world, and has remained low since. This fall in mortality was largely due to interventions by doctors becoming much more effective.
It is far more difficult to get statistics on infant death, but it is clear that the time surrounding birth and the first week of life is the most risky for all infants. In the 1800's, up to one third of children did not survive their first 5 years. The rate now of perinatal mortality is around 3 per 1000 births.

It is most likely that neonatal and infant mortality fell for much the same reasons as maternal mortality - better attendants, birth care, antisepsis and antibiotics.

The rise in caesarean sections has long been justified by doctors, by pointing out the decreases in perinatal mortality which have resulted, both in maternal and neonatal deaths. Many midwives however, feel the opposite; that caesarean sections are an over medicalisation of a natural, safe process.

Currently, ascertaining the reasons for the rise in the incidence in caesarean section has been problematic, with the incidence of caesarean section rising to almost 30% of births. The reasons for this are undoubtedly complex, with factors such as increasing maternal age, the increase in obesity and subsequently of diabetes, the sedentary nature of much of the female population, the increasing number of multiple births and IVF pregnancies, etc.

Whilst increasing medicalisation of pregnancy and childbirth may well play a role in this also, the overwhelming likelihood is that we are simply looking at a different population giving birth than ever seen before. Sitting at the heart of this debate is the increasingly entrenched positions of doctors and midwives on opposite sides of the issue, which benefits no-one, and is more likely to increase perinatal mortality than decrease it.

The homebirth debate is typical of these ancient, calcified hostilities. On the one hand, we have the Denmark experience, where a substantial majority of births occur at home, under the care of highly trained, competent, hospital backed midwives.

Until very recently, perinatal mortality was thought to be not significantly different from that of hospital birth, with clearly much lower intervention rates. A 2005 American study backed this, with perinatal (infant) mortality 'not significantly greater' than hospital birth (this actually reads greater, but chance may explain this result).

There are two disturbing counterpoints, however. A 2010 study from the Netherlands suggested that low-risk mothers who had homebirths were at statistically greater chance of perinatal loss than high risk mothers who delivered in hospitals. There are one or two potential sources of bias in the study, but the study was published in BMJ, one of the world's most prestigious journals.

The second, and far more important from the Australian perspective, was published in 1998 and clearly demonstrated that perinatal mortality was much higher in Australian homebirths than hospital births; to an unacceptable degree. On analysis of the stillbirths and neonatal deaths (no mothers died, but a number of babies did), most of the excess mortality was due to delivery of high risk pregnancy at home, that should have been delivered in hospital.

In the 80 breech (bottom first) deliveries that occurred at home, 2 babies died. Other deaths occurred when there were either clear indications that delivery should occur in hospital (this included twins and some preterm deliveries), labours that should have been induced because the pregnancy was very overdue (which increases mortality sharply), or clear signs of foetal distress were ignored by the mother and her birth attendant.

I am inclined to be sympathetic in relation to those poor mothers who lost their children; after all, if you walk into a bookshop to buy a book on birthing, and then read it, you can hardly be responsible for the lack of balanced debate you find. And if a health professional you trust tells you it is safe to deliver at home, again, you would have no reason to doubt.

So I believe that we in the medical profession are partly to blame for these incidents, not because we encouraged such incidents, but because in our silence, we gave tacit consent.

The hospital training system is both onerous and time-consuming. Strength of personality is recognised and often rewarded, but social commentary and activism are seen as slightly unusual and/or dangerous. And so the doctors we train to save mothers and babies speak not. Too time-poor, too frightened, too resistant to acknowledging that midwives have an essential role in prenatal and labour care.

Too frightened that if WE give an inch, THEY will take a mile.

We do not court the middle, the sensible midwives, without set-in-stone, us-versus-them viewpoints and suggest that they sensibly conduct homebirths. We allow the untrained, unaccredited health workers to practice without making any effort to stop them, and when we do, the constant, low-key current of antagonism that exists between doctors and midwives allows the rational voices to go unheard.

We are entrenched in a battle, with both sides taking ever more extreme positions, but in truth, when two extremes sharply exist, the truth almost certainly lies somewhere in the middle. We need acknowledgement from the midwifery profession that doctors do, in fact, care for patients, and with few exceptions, are trying very hard to keep caesarean section rates down.

We, in turn, should acknowledge that midwives have something to teach us about keeping our hands off until intervention is actually required. It would be a good compromise for a start if we acknowledged midwives' primacy in caring for uncomplicated patients, and if they in turn stopped referring to our concern with safety as 'playing the dead baby card'.

We need to stop being hostile and irrational in our discourse. It is time that both sides engage in rational debate, not only in policy and health care initiatives, but also in the suburban bookshops, where expectant mothers take their first, hesitant steps into the one-sided politics of birth.