Maternity care is in
crisis throughout Europe, yet maternity policy rarely forms part of national
or international health agendas. Some
countries, notably Ireland and France, have been experiencing a veritable
'baby boom'. In some maternity hospitals, standards of service provision
have been compromised to an unprecedented degree due to increasing demand, an
escalating shortage of scarce resources, and in particular, a growing shortage
of midwives. Such are the current
shortfalls in hospital care, both in Western and Eastern Europe, that the
physical and, indeed, mental health of women in childbirth, and their babies,
may be at risk.
Maternal
and infant mortality
Maternal mortality in
European hospitals continues to be a matter for concern. In Ireland, maternal
deaths accounted for 8 per cent of all maternal negligence claims taken
against obstetrician/gynaecologists from 1978-1998 (The
MDU Ireland, 1998). There is some
evidence that shortfalls in standards of service provision may result in
perinatal fatalities. In 1995,
the British Confidential Inquiry into Stillbirths and Deaths in Infancy
analysed the deaths of 873 normal term babies who died in labour: in over half
of these cases, it was estimated that better care would
reasonably have been expected to have made a difference to the outcome
(Department of Health, Britain, 1998).
Postnatal
health
Little is known about
the health of women after birth. For
many women, the transition to motherhood can be difficult. Although no
reliable national data exist, studies on postnatal depression give rates
varying from 8 to 25 per cent (O'Connor, 1995:186).
Postnatal depression is associated with the use of obstetric technology
in birth (Oakley, 1992:277-279). Although
the promotion of breastfeeding forms part of health care policy in many Member
States, breast-feeding rates continue to be low throughout much of Europe.
In Member States where the breast-feeding rates are lowest, such as
Ireland, community-based postnatal care does not form part of official health
care systems. Spiralling
health care costs have led to the introduction of cost-cutting measures in
hospital care, such as early
postnatal discharge, with mothers leaving hospital sometimes within hours of
giving birth. Such measures,
without the concomitant provision of midwifery services at community level,
result in significant deficits in postnatal care for new mothers and their
babies.
Centralisation,
rural women and induction
Maternity care is the
only sector in health care where, with the exception of The Netherlands, the
primary health care provider has been all but obliterated. Despite the fact
that as many as 80-85 per cent of women have uncomplicated pregnancies and
births, many European national health and insurance systems favour specialist
obstetric care for pregnant women.
The 'new' public
health, dating from the late 1970s, recognising the right of citizens to
autonomy in matters of health, and transforming the 1950s curative,
hospital-based approach into a strategy of prevention and promotion at
community level, has yet to be fully implemented in most Member States.
In some countries, official health care policies compel healthy,
pregnant women to place themselves under specialist, obstetric supervision.
Such policies require the centralisation of the birth services.
There is some evidence to suggest that centralisation may be
increasing. In France, for
example, maternity hospitals with as many as 1,500 births
annually are now being closed (Les Dossiers de l'Obstetrique/Espaces
Naissances, 2000).
National health
policies centralising maternity services discriminate against childbearing
women in rural areas. They deny
women access to safe, appropriate maternity care.
Centralising birth results in unplanned out-of-hospital births. In
Ireland, for example, a national study shows that the rate of planned to
unplanned out-of-hospital birth is 1:1 (O'Connor, 1992:10-11).
Unplanned out-of-hospital births carry very high mortality rates.
Centralising birth also results in the targeting of rural women for
induction. Local obstetric protocols underpin national health policies: many
women in rural areas have their
labour induced for geographical rather than medical indications.
The recent EU
Directive, adopted in June 2000 (2000/34/EC), will reduce the working time of
doctors in training to 48 hours per week by 2009.
This Directive is widely expected to result in the closure of obstetric
units throughout Europe, thereby exacerbating the established trend towards
centralisation of maternity care throughout the Member States.
This will result in more and more babies being born in fewer and fewer
units, with more and more women travelling further and further to give birth.
In Britain, for example, plans for the closure of almost 200 obstetric
units are well advanced. Despite
the anticipated closures, however, maternity care policies in the vast
majority of countries are still being framed within the traditional
specialised medical, hospital care
model.
The
Caesarean epidemic
As health care budgets
career out of control, the economic and social costs of this centralised model
of maternity care for physiological birth are becoming increasingly
unsustainable. Nonetheless, the provision of maternity care at primary level
by midwives is uncommon, except in The Netherlands.
Within the specialised, hospital or tertiary care model which is
in force elsewhere, birth
is treated as a medical problem. This
has led to huge amounts of unnecessary and costly medical intervention.
Rapidly rising Caesarean section and instrumental delivery rates have
become the norm throughout Europe. Since
1980, national Caesarean rates in some countries have doubled, and in some
hospitals, they have gone up four-fold. France
currently has a national Caesarean rate of 30 per cent (Lonzac, 2000), while
the combined operative and instrumental delivery rate in Spain is 40 per cent
(Wagner, 2000).
A call for the
surveillance of operative births was made by WHO as far back as 1985 (WHO,
1985:21). Despite the
considerable variation in local and national Caesarean rates, neither local
nor national surveillance systems have been implemented in Europe. Moreover,
in many Member States, the collection and publication of data on operative and
instrumental deliveries, both in publicly funded and privately owned
hospitals, is discretionary.
The continuous use of
electronic fetal monitoring (EFM) in labour is still commonplace in many
countries, despite substantial
evidence and national guidelines contraindicating its routine use (RCOG/NCT,
1993). EFM is used on 90 per cent of all women in labour in Spain (Wagner,
2000). In Ireland, the routine
use of EFM on admission to the labour ward (Cuidiu, 1999:12) has increased.
Electronic fetal monitoring has been identified by British obstetrician/gynaecologists
as one of the main factors in the growth of Caesarean rates, second only to
fear of litigation (Francombe and Savage, 1993). The variation in individual
obstetric Caesarean rates has been estimated at 0-50 per cent (Sakala, 1993).
Active
management of women in labour
Although high rates
can no longer be regarded as good practice, the induction of labour continues
to be common, as does the practice of acceleration.
There is some evidence to suggest that these practices are becoming
more widespread. In France, for
example, recent years have seen a doubling of national induction rates, from
10 per cent in 1981 to 21 per cent in 1995 (Desbouvrie-Bertaud, 1999).
Both induction and
acceleration in hospital are accomplished by means of the same drugs and/or
interventions. Amniotomy, for
example, is used both to induce and to accelerate labour.
Amniotomy involves puncturing the protective waters surrounding the
baby in the womb with an instrument resembling a crochet hook.
While women's views on the management of their bodies in labour are
rarely sought, some studies show that women find this procedure repugnant.
The acceleration of
labour is a cornerstone of the 'active' or aggressive management of women in
labour so prevalent in many Member States.
Active management is a set of obstetric protocols
standardising the medicalisation of first
births. It comprises early amniotomy, high-dose oxytocin (Frigoletto,
1995) and one-to-one 'nursing', the term it uses to denote midwifery.
At the National Maternity Hospital, a leading Dublin hospital dedicated
to active management, 50 per cent of all first-time mothers (Cuidiu,
1999:35) have their labours artificially accelerated for 'failure to
progress'.
Oxytocin is a central
element both in the acceleration and induction of labour.
Oxytocin, Kieran O'Driscoll - the inventor of active management -
admits, causes painful contractions whether or not a woman is in labour (O'Driscoll
et al, 1993:176).
Oxytocin can therefore be seen to increase the
demand for epidural anaesthesia, as women under active management strive
to make labour more tolerable. Epidural
anaesthesia, however, is estimated to multiply by four a low-risk woman's chances of having a Caesarean section (Frigoletto,
1994). This form of
anaesthesia is often accompanied by continuous electronic fetal monitoring,
thereby compounding the risk of Caesarean section in uncomplicated labour.
Iatrogenic
damage
In any specialty,
medical intervention inevitably leads to a proportion of iatrogenic damage.
Episiotomy, an incision enlarging the vaginal opening, provides one
such example. The obstetric
belief was that episiotomy prevented tearing, and a surgical incision was
considered by obstetricians to be preferable to a naturally occurring
laceration, however minor. The midwifery view of episiotomy was that it was
'comparable with the wound of a second degree tear' (Myles, 1975:562).
(Second degree lacerations involve muscle as well as skin.) The
obstetric view prevailed, and episiotomy duly became a standard intervention
in birth. Its adverse physical
and sexual consequences have been known for many years.
Over the past two decades, evidence
as to its futility in preventing perineal lacerations has been widely
accepted. Nevertheless,
episiotomy continues as an obstetric routine. The national episiotomy
rate in Spain, for example, is 89 per cent (Wagner, 2000)
Since the beginning of
the last century, infection, pulmonary embolism, anaesthesia accidents, and
haemorrhage have been the principal causes of maternal death in Caesarean
section (Shearer, 1993:1226-1227). National
surveys on maternal deaths in the United Kingdom (Hall and Bewley, 1999) show
that while the mortality rate for all Caesareans is six times that of vaginal
birth, the fatality rate in elective
Caesareans is three times that of spontaneous or unassisted birth. The
principal risks posed by Caesarean
to the baby are iatrogenic prematurity and respiratory distress syndrome.
National rates for Caesarean babies admitted to neonatal intensive care
are unavailable.
The absence of
outcome-oriented research in maternity care means that national data
quantifying morbidity, whether iatrogenic or otherwise, are often
unavailable. The
existence, if not the scale, of iatrogenic damage can be gleaned from
individual research studies, where these exist,
and from malpractice insurance reports, as obstetric accidents, or
'adverse events' as they are known, occasionally lead to litigation.
Almost two-thirds of maternal negligence claims in Ireland are brought
on the grounds of psychological injury, with, additionally, one woman in
twelve claiming against obstetrician/gynaecologists for brain damage (The MDU
Ireland, 1998).
Widely used both to
accelerate and to induce labour, oxytocin features strongly in obstetric
negligence claims (The MDU Ireland, 1998). Oxytocin has been identified as a
salient factor in infant brain damage (Taylor, 1998:7) and in intrapartum
fetal deaths (Department of Health, Britain, 1995:36-37). Maternal deaths have
also been reported in connection with its use (Parke-Davis, 1993:1813).
The response to oxytocin is highly idiosyncratic. Its American
manufacturers, Parke-Davis, observe that the response depends on the
sensitivity of the individual woman: they recommend fetal scalp electrode
monitoring lest contractions
become too powerful or too prolonged either for the baby or for the mother.
At the National
Maternity Hospital, where active management was developed, more than one
newborn baby in six - nearly two-thirds
of whom are term - is admitted to intensive care following birth (National
Maternity Hospital, 1993:48)ospitalHH. Clinical data show that respiratory distress syndrome,
transient tachypnoea of the newborn, and sepsis are the principal indications
for admission (National Maternity Hospital, 1993:48). Staff at the hospital are indemnified against 'cephalopelvic
disproportion, rupture of uterus and injury to the child' (O'Driscoll et al,
1993:55-56).
The
waltz of obstetrics with litigation
Within the spiral of
intervention, with its pain-epidural-monitoring- Caesarean dynamic, the waltz
of obstetrics with litigation goes on: the more obstetrician/gynaecologists
intervene in birth, the more birth injuries occur: the more obstetricians get
sued, the more actively they manage women's bodies in labour.
Litigation anxiety, as we have already seen, has been identified by
obstetricians themselves as the main factor in the escalation of Caesarean
rates. Over 70 per cent of all
British and American obstetricians have been sued (Wagner, 1998).
Litigation increases the cost of professional indemnity or malpractice
insurance. In Britain, obstetric
claims cost the National Health Service over £150 million every year (Cumberlege,
2000).
In 1999, malpractice
insurance for obstetrician/gynaecologists in Ireland increased by 88 per cent
(Irish Medical Times, 1999:1), more
than seven times the percentage increase levied on other medical consultants
in the State. The Government's response
has been to propose no-fault compensation, aimed at infants brain-damaged at
or around the time of birth. This
scheme is designed to replace the concept of individual practitioner liability
with the concept of enterprise or
institutional liability underpinned by extensive risk management schemes.
If introduced, enterprise liability is widely expected to erode
even further the autonomy of midwives and of women in childbirth.
Whether or not the scheme would improve the quality of care at or
around birth is not known.
Public
costs and private profits
In the past, Caesarean
sections were estimated to cost three times more than vaginal births (WHO,
1986). Today, Dutch health
insurance data on the cost of birth shows that, in 1997 a Caesarean rate of
9.5 per cent accounted for 44 per cent of the total cost of maternity care in
Amsterdam, while home birth, at 26 per cent, made up only 5 per cent of the
total bill for birth in that city (Klinkert, 1999). British figures show that
an increase of 1 per cent in the Caesarean rate adds £5 million to maternity
care costs. This, as Baroness
Cumberlege has observed, is the equivalent of 167 midwives
(Cumberlege, 2000: 16). In
France, Jean-Marie Clement, Professor of Hospital and Medical Law at Paris
VIII University and former hospital administrator, estimates that birth in a
French hospital costs between FF2,000-5,000 per day, according to hospital
size: the larger the institution, the more expensive the birth
(Clement, 2000). In the
United States, it has been calculated that utilising midwifery care for 75 per
cent of births would result in an annual saving of 8.5 billion dollars
(Wagner, 1998).
Obstetrics can be a
lucrative business, as the Irish experience demonstrates.
Public and private care operates side by side, often on the same site.
Within this system, state-employed midwives care for obstetricians'
private patients. Midwives are
paid approximately 8 per cent of what obstetricians earn, but this may be an
over-estimation. The market for private maternity care (Republic only) is
worth approximately £20 million. This
is divided among 88 obstetricians, and is additional to their State salaries.
Private medical care is heavily subsidised by the state, and obstetricians
have unlimited access to the full range of public hospital facilities,
including midwifery time, without charge, for their private patients.
Obstetric incomes average £275,000 annually, but this may be an
under-estimation, as costings on surgical and operative deliveries are
unavailable. Caesarean section rates are known to be significantly higher
among private patients.
The
benefits of midwifery care
The recognition (ten
Hoope-Bender, 1997) that midwifery care can result in shorter labour, less
medication, and fewer interventions such as surgical or operative deliveries
is growing. In 1996, WHO
concluded that midwives are the most appropriate, and cost-effective
caregivers in normal pregnancy and birth (WHO, 1996).
Midwifery care
has been shown to be as safe, or safer, than care provided by doctors.
A recent American study of 4 million low-risk births (MacDorman and
Singh, 1998) showed that the outcomes of midwife-attended births were
significantly better than those of medically supervised deliveries.
The risk of having a neonatal death was 33 per cent lower with a certified nurse midwife than with a doctor, while the
risk of infant death was 19 per cent lower in midwifery births than it was in
physician deliveries.
Midwifery has also
been shown to have salient advantages in the area of preventive health.
Modern obstetrics has failed to reduce the number of low birthweight
babies being born. In Britain,
where the percentage of low birthweight babies is higher than it is in Albania
or Latvia (Cumberlege, 2000), Ann
Oakley has demonstrated that the provision of social support by midwives has a
markedly beneficial effect on the physical and emotional health of high- risk
mothers and on their babies' well-being: these effects are still measurable
one year after birth (Oakley, 1992: 277-79).
In the United States, MacDorman and Singh (1998) showed that the risk of
having a low birthweight baby was 31 per cent less with a certified
nurse-midwife than with a doctor. Small babies are associated with
significantly increased perinatal mortality rates.
Discrimination
against midwives
Whatever the benefits
of midwifery care, laws and regulations discriminating against midwives are
widespread throughout Europe. National health and insurance systems sustain
medical monopolies, even at primary health level, in areas of midwifery
expertise such as antenatal care. In
many countries, official health care policies prevent midwives - the
specialists in normal birth - from assuming responsibility from the care of
healthy women in childbirth.
Structural and legal
barriers to midwives' equality in the workplace are common.
Many midwives are forced to work as obstetric nurses, and births become
deliveries conducted according to obstetric protocols. In many Member States,
midwives are hindered from practising their profession to the full.
European Directives on midwifery, adopted 20 years ago, have yet to be
fully transposed into national law. In
some States, for example, midwives do not have prescribing rights, although
such rights are to be inferred from the Directive of the European Parliament
and of the Council of 21 January, 1980 (80/155/EC). In Ireland, where midwives are governed by nurses, midwives
are further prohibited by the Nursing Board from 'prescribing'
non-prescription or 'over-the-counter' medication to their clients (An Bord
Altranais, 1999:13). Midwives in
Ireland who work at primary care level lack the basic requisites to practise
their profession. They are
obliged to beg, borrow, or contrive to get essential drugs, and other
requisites necessary for the safe practice of their profession.
Most European midwives
do not have hospital 'privileges', that is, the right to admit a client to
hospital, to assume responsibility for her care, and to discharge her
thereafter. Many midwives
do not even have referral rights, that is, the right to refer a midwifery
client to another professional practitioner.
Nor are midwives commonly allowed to certify a woman's unfitness to
work in pregnancy, or after the birth of her baby.
While midwives are generally permitted to notify births, they are
usually precluded from signing
perinatal death certificates.
In some countries,
there is a growing midwifery shortage. In
Britain, for example, only 34 per cent of registered midwives are currently in
practice (Emerton, 2000:19). Working
conditions are poor for many midwives, and unequal pay structures persist in
many countries. National health
and insurance systems continue to discriminate against midwives - equal pay
with doctors for equal work, or for work of equal value, introduced in New
Zealand in the 1990s at primary health care level, is virtually unknown in
Europe. There is further evidence
to suggest that European midwifery is lagging behind midwifery in other parts
of the world. Most European
midwives, with the exception of The Netherlands, have yet to be given equal
powers and responsibilities with general medical practitioners in maternity
care. In Ontario, Canadian midwives were given such powers as far back as in
1994 (Shroff, 1997: 205-239).
Working
conditions in Europe
European midwifery, in
contrast, is distinguished by discriminatory short-term, temporary, and
part-time work contracts; non-recognition of years spent working in the home,
or abroad by public service superannuation schemes; lack of parity with other
health professionals in areas such as pension entitlements; lack of career
development and inequitable promotional opportunities. In England, in recent
years, the proportion of midwives working part-time has increased to 40 per
cent (Sandall, 1995). Pervasive
discrimination in the workplace is leading to increasing discontent.
Hospital midwives frequently complain of bullying in the work place
(Commission on Nursing, 1998:181), a command and obey model of management, a
preoccupation with hierarchy and bureaucracy, and a tendency towards
information control (ibid.:123-125), within
an overall culture which can no longer distinguish between midwifery and
nursing. All of this has led to
low morale among midwives, and high migration from the profession.
In 1999, in a break
with tradition, Dutch midwives, in an endeavour to secure better pay and
working conditions, marked the advent of the third millenium with a midnight
strike (de By, 2000). Overworked, and underpaid, midwives in The Netherlands
point out that there has been an increasing shortage of new midwives in recent
years. With an annual caseload of
155 clients (Klinkert, 1999), many are suffering from burnout.
The home birth rate in The Netherlands has fallen from 60 to 35 per
cent over the past 25 years (de By, 2000).
The
overshadowing of midwifery by nursing
WHO has recently
described midwives' lack of influence on national health care policies as an
'anomaly' to be corrected (WHO, 2000). Invisibility
is a major difficulty for midwives, and for midwifery. In many
countries, educational requirements underpin and reinforce the overshadowing
of midwifery by nursing. Despite
the fact that nursing and midwifery are two separate and distinct professions,
entry into midwifery is often restricted to qualified nurses. In some
countries, midwifery is officially classified as a medical profession. In Ireland, the term nurse
may legally refer to a midwife (Nurses' Act, 1985). Furthermore, Irish medical practitioners are legally deemed
providers of midwifery services (Spruyte and Wates v Southern Health Board,
1988). In Britain, legislative
change weakening the already fragile boundaries around midwifery, and leading
to the submergence of midwifery within nursing, has recently been proposed
(NHS Executive, 2000).
Gender
mainstreaming
In some States, the
adoption of 'gender mainstreaming' in the public service
requires the building in of a gender perspective into state policies,
services, and structures to make them 'gender sensitive'.
Gender mainstreaming, however, has yet to lead to equality of midwifery
representation in maternity care. Midwifery is often 'represented' by nursing,
and equality of representation with nursing and medical interests is rare.
In some countries, midwives lack both the regulatory and trade union
structures which would enable them to participate effectively in planning.
Throughout most of Europe, midwives are excluded from policy-making,
overshadowed by adjacent professions such as nursing, and obstetrics. This exclusion is evident in regulatory bodies, professional
associations, government ministries, maternity hospitals, university
faculties, and in health and other agencies.
The non-representation of midwifery in elected and appointed bodies at local,
national, and international levels has serious implications for the
development of woman-centred maternity care.
The
democratic deficit
Neither has gender
mainstreaming led to adequate consumer representation in maternity care.
The democratic deficit extends from service providers to service users
who are themselves female. Women,
-as 'patients' - are often denied choice and freedom in birth.
Midwifery is almost exclusively a female profession, while obstetrics is, in
the main, a male occupation. The adoption of
a gender perspective would suggest that, at this most female time of
their lives, women have the right to a choice of midwife as well as a choice
of doctor.
In some Member
States, both midwifery and consumer representation in maternity care policy
structures are virtually unknown. In
addition to the relative powerlessness of being a patient, many women face
additional barriers in childbirth because of poverty, ethnicity, language,
religion, sexual orientation, disability, migrant, or refugee status.
These barriers reinforce these women's fundamental exclusion as full
and equal participants with providers in maternity care.
Some women still lack control over the services they receive for birth,
finding themselves excluded from the decision-making process by midwives who
themselves are often powerless to offer alternatives to medical management.
This exclusion from decision-making of both service providers and
service users, reproduces, and is reproduced by, their joint exclusion at
higher levels, in a process of mutually reinforcing circles of powerlessness.
Gender equity, it appears, has yet to be brought into the birth
chamber.
ă
Marie O'Connor
Dublin, October 2000.
Written on behalf of Pegasus, the Academy
for the Further Education of Midwives, Aachen, Germany, The European Workgroup
of Independent Midwives, Epen, The
Netherlands, and the European
Institute of Midwifery, Dublin, Ireland.
Correspondence concerning this
article should be addressed to Marie O'Connor, Director, European Institute of
Midwifery, 42 Rathdown Road, Dublin 7, Ireland; emaruan@gofree.indigo.ie.
The author wishes to thank
Philomena Canning, Director, European Insititute of Midwifery, Dr Jo
Murphy-Lawless, Sociologist, Colm MacGeehin, Solicitor, and Dr Paul O'Connor
for their comments, suggestions and advice regarding the text.
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