Paul Hutchison: Our kids deserve a decent start in life

Paul Hutchison

The key objective of any maternity service must be to protect and enhance the health and wellbeing of babies and their mothers.

An optimal children's and maternity policy for New Zealand must recognise the overwhelming scientific evidence that pre, ante, and early post-natal life, are crucial in dictating whether our children have a good start in life.

No one health professional could be expected to understand all the complexities of this rapidly changing field and care should be characterised by shared intelligence.

That is why there is a strong case for the Labour Government to act on Coroner Garry Evans' call for an independent review of maternity services and a national audit of births. The reasons lie far wider than the two preventable tragedies the coroner reported on, and they are far more pertinent than the gender and patch issues that have prevailed for centuries around childbirth.

A much overlooked report was published in September 1999 by the National Health Committee (NHC) entitled Review of Maternity Services in New Zealand and chaired by Professor Mason Durie.

The report emphasised the key position that no health professional should work in isolation, and the committee recommends a change in emphasis towards explicit team work among professionals.

Professor Durie said, "Instead of the increasing separation between professional disciplines that has marked maternity services in recent years, many women want a return to willing co-operation between medical care and midwifery."

It is an indictment on Labour that it has taken six years in Government before they have refocused on maternity, and after a coroner's report Labour are still resisting an independent inquiry.

Huge efforts were made years ago by a number of health professionals and professional organisations, including myself, to convince Health Minister Annette King she should immediately reignite the Perinatal and Maternal Mortality committee which provides the evidence for health-outcome statistics.

It has taken Labour six years to restart the this committee. It provides detail that is necessary for accurate accountability and improvement and which was neglected during the distraction of Labour's restructuring.

It is ironic the Labour-appointed mortality committee has no formally trained epidemiologist, no anaesthetist, and all its members are women.

A colourful illustration of the influence of politics on childbirth is that of a 17th-century French King who used to get into repeated trouble with his Queen because the female midwives told the Queen of the results of her husband's frequent infidelity. The King responded by hiring a male midwife, who vowed not to tell of his master's exploits. However, the male midwife insisted on delivering all the King's illegitimate offspring on a bed, thus preventing normal physiological labour. The bed was known as the lit de misere or bed of misery.

The King told his cousins around Europe and soon male midwives became dominant.

Normal physiological labour had become perverted by a hierarchical system that was medicalised to the extent that at one North American teaching hospital, routine episiotomies (or surgical incisions) were carried out through the rectum as recently as the 1950s. In the United Kingdom, it was not until the 20th century that legislation outlawing female midwifery was changed.

However, courageous women, many of them outstanding midwives and a few men, fought for change. That change happened slowly in New Zealand from the 1950s, but rapidly by the 1980s, when choice of physiological birth, informed consent, the questioning of unnecessary medical interventions and the occurrence of 50 per cent of women medical graduates gathered momentum.

The changes to the Nurse Amendment Act in 1990 that equated midwives with general-practitioner obstetricians and the subsequent extraordinary payments of up to $140 an hour for monitoring normal labour, led to distortions in service delivery that would predictably never endure.

While it has been a triumph to at last acknowledge the vital part midwives play in maternity care, it has been a disaster to see the exodus of general practitioner obstetricians.

The enormous value of lifelong continuity of care that general practitioners provide must not be underestimated. Their participation in aspects of maternity and medical care during pregnancy, particularly when 50 per cent of medical graduates are now women, is of pivotal importance to developing excellent, maternity and child services in New Zealand.

College of Midwives head, Karen Guilliland, who has made a substantial contribution to the field, is reported to have said that in the 15 years midwives have been working independently, the infant death rate had dropped by more than a quarter and was continuing to fall. What Ms Guilliland failed to say is that infant mortality has been falling dramatically throughout the last century. Over the past six years infant mortality appears to have stalled in New Zealand, though this may be due to a difference in reporting.

While our infant mortality rates were amongst the top five of the world in the 1960s, by 2002 New Zealand was 17th in the OECD. Countries like Singapore surpassed New Zealand with an infant mortality rate that is less than half ours.

The determinants of outcomes in maternity and child health aremultiple and complex, and influenced by socio-economic factors.

The call by Coroner Evans for an independent review of maternity services and a national audit of births is timely. The overlooked 1999 Review of Maternity Services, and its key recommendation that no health professional should work in isolation and that there should be a change in emphasis towards explicit teamwork among professionals must be taken into account if we are to improve ourcurrent mediocre maternity and child health statistics. The basis for improvement should be made on clear evidence.

* Paul Hutchison MP is National Party spokesman for policy on children.