The Birth Of The Future

Sydney Morning Herald

Wednesday August 17, 2005

Childbirth is political. Anyone who has been to a birth class knows that. As they learn about the physical process that awaits them, pregnant women are encouraged to be strong, to feel the pain but rise above it, to resist intervention as long as possible. They and their supporters are told to make the birth joyous, an empowering celebration of life, and if a doctor offers pain relief, not to listen - not to weaken or fail. Doctors, on the other hand, see birth as potentially fraught with danger, a natural process, yes, but one which has to be controlled at every stage. Professional experience has taught them caution, and malpractice suits have reinforced the message. The two approaches - one fundamentally optimistic, the other pessimistic - are a world apart. Those same two views of childbirth are engaged in another tussle, this one over the status of midwifery.

The Minister for Health, Tony Abbott, has said he will consider extending Medicare coverage to midwives offering services outside hospitals. The move would in effect give professional status to midwives, alongside other practitioners such as podiatrists. Midwives argue they could give better service to expectant mothers with low-risk pregnancies. At present almost all midwives are employed by hospitals, and are supervised by doctors. A woman may see a series of different midwives during her pregnancy. The change would offer valuable continuity: women whose doctors agree to refer them could choose the midwife who will follow the progress of their pregnancy, attend the birth, and offer postnatal care. It is true most babies are delivered by midwives. Many mothers consult a private obstetrician throughout a pregnancy, only to find he or she is unable to attend the birth, leaving the delivery to whichever midwife is rostered on. But why would this change if a private midwife is engaged instead of an obstetrician? Neither profession has a monopoly on dedication or selflessness.

Midwives also claim their different approach to birth encourages less medical intervention - fewer caesareans, fewer forceps births - and therefore lowers costs. They hint that doctors oppose their involvement as professionals because they are defending a lucrative monopoly. The word overservicing is murmured in hushed tones. Doctors, needless to say, reject the suggestion. This is an extension of the battle of the birth classes. In any case, both professions recognise, as they must, that there will always be difficult births where a doctor's attendance is essential.

New Zealand made a similar change in the 1990s, and now professional midwives handle seven births out of 10. (They manage fewer than one in 20 in Australia.) It may seem as if New Zealand's mothers have voted with their feet, but doctors claim the licensing of midwives simply had the effect of pricing general practitioners out of the market, and reducing choice. If it is found to increase women's ability to choose the style of birth they prefer, Mr Abbott's suggested move is worth supporting. But it must be implemented carefully to ensure choice is enhanced, not reduced - and monitored to see standards of care are maintained.