Birth wars rage in your delivery room

For further information about birth or private midwifery, contact Melissa Maimann at Essential Birth Consulting. Link

YOU'RE in the dentist's chair with a painful tooth, feeling fragile.

"That tooth has to come out,'' says the dentist.

"I'll give you an anaesthetic and extract it.''

You're surprised - you had hoped the tooth would be all right - but you nod and say something like "Ungh-hnghm'' through a mouthful of cotton wool and dentist fingers. After all, he's the expert.

The dentist turns to prepare the needle, when a dental technician leans over and whispers in your ear: "You know you don't have to do what he says.

"He doesn't know what he's talking about. What about root canal? Or homoeopathic remedies? And anyway, you don't need an anaesthetic.

"There's a dentist next door who does acupuncture and hypnosis for pain relief. It's much safer. Oh, and did you know fluoride is toxic?''

The dentist snaps at her to stop: "Ignore her - she's pushing her own agenda.''

Tense, stressed and utterly confused, you lie back, open your mouth and look up at two medicos glaring at one another.

Who is in charge here? What's the real truth? And why didn't anyone tell you there was some sort of power struggle going on?

Of course, this doesn't happen in dental surgeries. Open hostility between clinicians would be madness, serving only to baffle patients and undermine the whole purpose of creating healthy smiles.

But this is exactly what happens in maternity care, every day, in birth centres, hospitals and homes. Hostility, suspicion, mistrust, abuse and vitriol abound in relationships between obstetricians and midwives, clinicians, academics and activists.

Many readers already will have decided that this article is biased because I chose to use a dentistry metaphor - they'll say a diseased tooth is utterly incomparable to the natural process of childbirth.

Or ... they might say it's unfair to choose a dentist and a technician to represent the opposing forces, because it implies one is more expert than the other - or that it's wrong to mention homoeopathy or acupuncture because they have unfair implications of hippiedom.

Welcome to the birth wars. Everything that is published, posted or broadcast about the topic of pregnancy, birth and parenthood is contentious.

Some midwives and obstetricians are moderate and co-operative - but many are entirely opposed to the idea of working together, or sharing expertise ...

There seems to be no middle ground. And that's the problem, according to author Mary-Rose MacColl, a journalist ... who spent years investigating maternity care. Her new book, "The Birth Wars" ... is an exploration and denunciation of "the conflict putting Australian women and babies at risk''.

... MacColl uncovers a battleground that she believes Australians need to understand. It's a fight between ``organics'' and ``mechanics'' for control and influence.

In MacColl's parlance, the ``organics'' are mainly midwives who believe birth is a natural process that has become overly medicalised, with the consequence that many women are traumatised by cold, clinical births, unnecessary caesareans and excessive medication.

The ``mechanics'' include many obstetricians and hospital clinicians, who believe birth is a risky, delicate process that must be carefully monitored to ensure women and babies are safe.

Between the two sides, virtually nothing is agreed. Can a breech baby be delivered vaginally? Can a caesarean birth be followed by a vaginal birth? Should women be given synthetic hormones to help deliver placentas quickly after birth? Should home birth be encouraged, or even allowed?

... Beneath those practical questions are deeper, theoretical fights that rage with equal vehemence: what is an acceptable level of risk? What does ``safety'' mean? Is it essential that women have continuous care from a single, trusted practitioner?

Do we even have a right to expect that all births will result in live, healthy mothers and babies - or have we deluded ourselves about what to expect?

... The biggest problem ... is not home births nor caesareans nor any of a hundred other contentious issues: the biggest problem is the destructive birth wars themselves.

"They need to talk to each other and they need to work out their differences, so that women get a coherent view about maternity care from the maternity care profession. I think that's a reasonable thing for women to expect,'' she says. ... if there is no consensus between practitioners, how are expectant parents supposed to make decisions?

... Lillienne's story is told in The Birth Wars, but the short version is that her mother ... was labouring in the midwife-run Birth Centre ... After many ... hours she was transferred to the hospital's surgical Birth Suite. The baby's heart rate dropped dramatically during labour, she was deprived of oxygen for some time and was eventually born by c-section.

Reviews found numerous problems: Debra's high blood pressure was not interpreted as a warning sign at an early stage; confusion reigned over who was in charge; obstetricians were not welcome in the Birth Centre, where midwives were in charge.

... MacColl says there are many birth centres within hospitals, where doctors and midwives oversee completely separate domains ....

... the federal Government proposes to overhaul maternity by subsidising insurance costs for midwives, helping them to operate in private practice. Home births will not be covered.

... The proposal has sparked a furious debate, with home-birth advocates warning that women will have secret, underground home births without expert care.

... "While ever they're fighting and it's `organics versus mechanics' we'll have no change in the hospital system. We'll keep establishing birth centres that draw lines in the linoleum and (say): `He's on that side, I'm on this side and he better not cross the line.

... How crazy is it that you can be in one of the largest tertiary hospitals in Australia and have a situation where doctors are not allowed in? And, at the same time, how can you not recognise that a woman in labour is going to need a quiet, dark, calm environment like a birth centre, instead of a stark hospital room?''

MacColl has two goals. The first is to raise awareness that the birth wars exist, in the hope that parents can think carefully about their choices before the contractions begin ...

I thought that was a fantastic article! I'm not sure that the solution is as simple as midwives and obstetricians sitting down and talking. For one thing, I don't necessarily agree that obstetricians have an agenda that is too dissimilar to midwives' agendas. I believe insurance is the key.

Currently, obstetricians have insurance and are far more likely than midwives, to be sued. Midwives essentially cannot be sued. For there to be a case, there needs to be solicitors and barristers on both sides. Private midwives are self-employed, and despite the view that women pay excessive amounts of money for their births, I can assure you we're not wealthy. Essentially, midwives do not have money to fund lengthy court cases. But obstetricians do. And so do hospitals. Hospital-employed midwives are covered by vicarious liability. So if there's going to be a court case, the woman or her baby are best suing the doctor or the hospital, rather than the private midwife.

No hospital or doctor wants to go through a court case. Even if they win, it's emotionally and mentally taxing, it takes much time, and costs money. So there's a strong incentive to avoid court cases and being sued. And the best way to do this is to practice defensively. Do a caesarean sooner rather than later. It's easier to sue for a caesarean that was not performed in time - clearly, if something went "wrong", a woman can argue that a caesarean should have been performed. Conversely, it's very hard to prove that a caesarean was unnecessary. You can always find a reason why it was necessary.

So we have created - via our legal system - a situation where caesareans and any other interventions are encouraged. You cannot be sued for intervening. Only for failing to intervene.

So our caesarean rate is amongst the highest in the world. Over 31%.

We induce many women.

We continuously monitor many babies in labour.

We do not encourage waterbirth (how can you get a woman out in time if there's an emergency??)

We encourage birth on the bed so that forceps or a vacuum can be easily applied if needed.

All births ought to take place in hospitals - or at worst, birth centres that are right next to the delivery suite and operating theatre. You just never know when they're going to be needed.

Can you see what's happening here? The fear of litigation prompts defensive practice, which leads to higher rates of intervention.

But I come back to my original statement: I don't believe that mdiwives' and obstetrician's agendas are too dissimilar. Both want the best for women and their babies. I do not believe that obstetricians are out there to perform as many caesareans as possible, and to induce all other women and extract their babies with forceps. Nor do I beieve that every midwife wants to birth women in the water, with no monitoring of the baby, letting the labour go on for as long as it takes.

But insurance is the key. People have a need for safety. That includes midwives and obstetricians. Noone goes to work with the intention of traumatising a woman with surgery - particularly unnecessary surgery - but this needs to be balanced with the needs of the professional to practice their profession safely, however they define it.

If it were up to me, I would call for two things:

1. Greater transparency of pratitioner's intervention rates, perhaps on a public register that is easily accessible, so that women are able to choose their health professionals with accurate information; and 2. Reform of our legal system, to a no-fault system such as the ACC Scheme in NZ.

Midiwves and obstetricians getting together and talking is a way away. It happens every day, but actually sorting out the differences will take time. There are many issues at the heart: competition, money, perceived superiority (from both sides!), the list goes on.

National guidelines on midwifery and obstetric care might help. Guidelines that state that within certain guidelines, women see a midwife. If they choose to see an obstetrician, they may fund this themself. And then, if a woman's condition deviates from normality, as defined by guidelines, the midwife and woman consults with an obstetrician, or refers the woman's care to an obstetrician. In this model, we see midwives caring for healthy pregnant and birthing women - doing what we do best, and obstetricians caring for women who need their services - doing what they do best. Such guidelines would optimise the care of pregnant women and eliminate the turf wars. These guidelines are in existence, and have been developed by the College of Midwives. Private midwives and employed midwives use them to guide the care they give to women.

The author of the article states, "obstetricians were not welcome in the Birth Centre, where midwives were in charge" - there is no issue with this. Midwives ought to be in charge of normal birth: it is our specialty. What is wrong is to fail to offer an obstetric consult to a woman when her condition deems it necessary. The GP provides most of the care to a family and refers members of the family to specialists when necessary: this is not perceived as a turf war. Why is midwifery and obstetrics any different?

Melissa Maimann, Essential Birth Consulting 0400 418 448