Doctors vs midwives

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.