I am on holiday, in a resort among the hills of all places, and I walk into the local dairy (Bodega if you are American) for some liquid and see the front page of the Otago Daily Times. It is about the midwives being hurt that their statistics are not as good as obstetricians.
On a retrospective analysis of adverse outcomes in New Zealand. The context is that the midwives, during the 1990s, wanted to move childbirth “from the medical model of care” because ideology. The then minister of Health (and future PM) Helen Clarke, agreed. This led to General Practitioners (GPs) getting out of the baby catching business and the shared care model — where the midwife and GP working as a team from antenatal care to post delivery — dying out because only one of these “health care practitioners” (the same woman hated the word doctor) was paid the sum for care (and then had to pay out everyone else).
The mother of my kids spent most of her 20s working in neonatal intensive care units. We had an obstetrician. Because the midwives scared us. It turned out we were correct.
In 1990, New Zealand adopted a midwife-led model of maternity care, giving midwives the ability to practice autonomously and be fully reimbursed by the government, offering patients free care. As a result, more than four out of five New Zealand mothers use midwives throughout pregnancy and delivery, with doctors generally only getting involved when there are risk factors. Wernham and colleagues examined data on all 244,047 full-term births, with no major fetal or neonatal congenital, chromosomal, or metabolic abnormalities, that occurred in New Zealand over the five years spanning 2008 through 2012 and compared adverse outcomes for newborns born to mothers under midwife-led care to outcomes with doctor-led care at first registration. The outcomes included oxygen deprivation during delivery, an infant’s size, stillbirths, mortality, and neonatal encephalopathy—a condition that can result in brain injury, as well as Apgar scores—a measure of infant well-being immediately after delivery.
Compared with the midwife-led model and after adjusting for demographics, socioeconomic factors, and pre-existing conditions, the researchers observed lower odds of some adverse birth outcomes when maternity care was managed medically, including 55 percent (95% confidence intervals [CI] 0.32–0.62) lower odds of birth related asphyxia, 39 percent (95% CI 0.38–0.97) lower odds of neonatal encephalopathy, and 48 percent (95% CI 0.43–0.64) lower odds of a low Apgar score at five minute after delivery. There were no significant differences between the midwife-led and doctor-led births for neonatal mortality and intrauterine hypoxia. The study was limited by the lack of data on adverse events for mothers, its retrospective design, and that the demographics—while adjusted for—were different in the two groups.
The authors say: “Despite New Zealand having overall internationally comparable maternity outcomes, the findings of this study suggest that avoidable adverse outcomes may still be occurring.”
In an accompanying Perspective, Ank de Jonge and Jane Sandall discuss the discrepancy between the new study and a 2016 Cochrane systematic review that found no increase in adverse events with midwife care.
If you look at the article in the paper, you will note that Wernham, the main author, was a midwive, and is sensible in her comments. But Guilliand is one of the architects of this system, and she hates any critiques of it. She now wants the obstetricians on duty at all times for her midwives.
As if. I have a long memory. Including her telling obstetricians, female ones included, that they were sexist for questioning if the midwife-led services were putting women and babies at risk.
The trouble is that she’s not smart enough to see the implications of her policies. Midwit decision making has consequences.
New Zealand’s maternity system changed in 1990, and this had ”occurred rapidly”, the study says.
”There is a need to understand the reasons for the apparent excess of adverse outcomes in midwife-led deliveries in New Zealand.”Despite a radical change in the way maternity care was delivered, there has never been a full and proper evaluation to ensure the maternity system in New Zealand is safe,” the study says.
Co-author Ellie Wernham, a master of public health graduate and former midwife, said it was possible better initial assessments were needed to ensure women who needed an obstetrician were assigned one.
But the aim of the study was not to compare midwives and doctors, it was to compare different models of maternity care, she said.
”I’m fully supportive of midwife-led care and have seen first-hand the many benefits that midwife-led care can bring. The overall aim of this research is to improve the current maternity system. It’s not to revert back to the system we had in the 1980s where it was medically led and associated with a bunch of other problems,” Ms Wernham told the Otago Daily Times.
College of Midwives chief executive Karen Guilliland said the study showed private maternity care was better funded and resourced than the public system.
”Most of our maternity hospitals are understaffed and often struggle to provide immediate response when midwives request medical input. This means that often women in labour have to wait to see a specialist, causing unacceptable delays for them and their babies.
”None of our main maternity hospitals have an obstetric consultant on site after hours or weekends, which are when the majority of births occur.”
The Association of Salaried Medical Specialists (ASMS) have considered what having senior doctors on duty means. Because that is what emergency medicine does. Their position paper notes:
For physicians working in hospital emergency departments, the realities of their jobs require work outside of ‘normal’ working hours. Night shift work is recognised as being a particularly stressful factor for ED doctors. The negatives associated with this practice have been linked to ill health and the well-being factors discussed above, as well as contributing factor in high rates of attrition of ED workers and difficulties in staffing ED departments (Howlett, Doody et al. 2015).
Indeed, the American College of Emergency Physicians state that “the effects of rotating shifts are cumulative, and represent the most important reason physicians leave the specialty” (ACEP 2003). Research by Shanafelt et al (2009) on burnout in American surgeons also found a strong association between the number of nights on call per week and burnout defined as “emotional exhaustion and depersonalization leading to decreased effectiveness at work” (p. 463). Of particular concern for ED doctors is the recognition that work outside of normal sleep hours has a clear impact on how well people can function, both in cognitive and physical terms. Frank and Ovens (2002) emphasise the impact of circadian desynchrony in terms of time on task and the time of day that the task is being undertaken. They acknowledge the considerable body of literature that suggests fatigue due to shift work-induced sleep deprivation is a key factor in the occurrence of adverse events. For example, disasters such as the Chernobyl and the space shuttle Challenger accident have been linked to human error while on night shift (Mitler, Carskadon et al. 1988). Burgess (2007) also cites research that found, on average, a 30% increase in human error incidents on night shift relative to morning shifts.
In the context of emergency medicine, Smith-Coggins, Rosekind et al. (1994) have documented the decline in physician performance as represented by speed of intubation and ability to correctly read charts as a consequence of working night shifts. Dula, Dula et al. (2001) similarly found in their research on the performance of emergency medicine residents that performance declined substantially over the course of the number of night shifts worked relative to physicians on day shifts. In the New Zealand context, Gander, Merry et al. (2000) reported a high level of recollection of fatigue-related errors amongst anaesthetists as a consequence of hours and time of work.
What is happening is that the safety net which is a multidisciplinary team was broken. This leads to increased risk, because there is no checking, no accountability: in part this is because the doctor — obstetrician in this case — will not accept that her or his judgement should be over ruled by a less trained midwife. (Especially as midwives no longer do a nursing training first).
Putting obstetricians on shift work won’t solve the problem. Reconstructing the team will. But that is not acceptable, for ideology. It needs to become so: all other physicians work with and lead teams. Because the consequences to mothers and babies are now shown.
But the midwits would rather patch up their failing system.
UPDATE 1.
When I am using the term Midwit I mean moderately intelligent. To quote someone quite bright:
The difference between the mid-wit and the genuinely intelligent is usually fairly easy to identify. The mid-witted individual tends to compare himself to those below the average and concludes that because he isn’t like them, he must be a genius. The genuinely intelligent individual compares himself to the great minds of the past – with which he is familiar, having experienced many of their works – and concludes that for all his intellectual superiority to the great mass of relative retards presently surrounding him – he is nothing particularly special. The tragedy of the mid-wit is that he lives in a world that simply doesn’t exist and is constructed flimsily out of his unimaginative imagination due to his failure to either observe the real world or think about it. His is is a very plain and simple world, and because he is not only comfortable in it, but important in it, he reacts with fear and hostility when he is forced, for one reason or another, to confront the fact that it does not exist.
Intelligence doesn’t concern name-checking authors nor does it consist of being literate or even well-read. And even if one has been granted unusual cognitive capacity by the grace of God or the roll of the genetic dice, it remains little more than potential until one proves that one can actually do something, preferably something worthwhile, with it.
The main quotes show this quite well.
UPDATE 2.
Ellen Goodwin, of the Otago Daily Times, is a good health reporter. She followed up yesterday’s post with a comment from a mother who has a disasterous birth that there should be a team involved in deliveries, and not just the “lead maternal carer”, who is usually a midwife. She concludes the article with the official response.
”What other self-employed person in New Zealand is in charge of a potentially life and death situation for at least two people at a time?”
Ms Bolton had two babies after Daryl-Ann with an obstetrician as lead maternity carer.
Ministry of Health principal adviser maternity, Bronwen Pelvin, said in a statement the study findings would be investigated.
”The Ministry of Health has referred the study to the national maternity monitoring group for advice on whether further research needs to be undertaken to help us better understand whether the findings reflect something about the way the study was done, differences in the maternity care provided by midwives and doctors, and whether there are things we can change to get better outcomes for women and their babies.
”The study looked at the lead maternity carer at the time of registration for maternity care, but it didn’t look at who else was involved in providing care.
”This seems particularly important when trying to account for the differences between the two groups being compared in the study,” Ms Pelvin said.
The question is if reality will intrude into the ideological model that has been constructed. I would think… unfortunately… not.