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• The figures on maternal and perinatal outcomes for New Zealand have been long awaited but it is important not to over-interpret crude statistics which are unadjusted for the population. There are some pockets of very high-risk women giving birth in parts of NZ with particular and specific health risks.The comments by the Vice-President of RANZCOG are very pertinent and small numbers can easily be skewed. What is needed is detailed analysis of the factors behind each maternal and perinatal death to see if models of care are in any way possible contributors.Of course, it goes without saying that the recent changes in provison of maternity care in NZ may have contributed to an overall improvement in outcomes - these figures may have been worse without the changes,

  David Ellwood

  Professor of O&G,

  The Australian National University Medical School.

  Posted by Professor David Ellwood 18/03/2009 8:32:32 PM

• In 1983 when I arrived in Dunedin New Zealand as the country’s first Professor of General Practice, two thirds of all births in the Queen Mary Maternity Hospital were supervised by GP Obstetricians. Now there are no GP obstetricians in the whole of the country. It seems to me that there are three main messages from that for Australia

  1. The real cause of that disappearance was not the independence of midwives but the very poor funding of GP Obstetricians – in 1999-2000 my practice in rural Southland provided obstetric care for an average of $NZ5 per hour. The report on higher maternal mortality obviously has everyone running for the exits but the plain truth is that if you pay for a professional who is only trained to look after the obstetric parts of a patient ie a midwive, then there may be more risk from those other conditions that can kill mothers. The lesson might be not that midwives are more dangerous than GPs but that independence of any health professional is always a mistake. Feminist politicians in NZ had a field day in the 1980s against wicked male doctors and this was oine of the results.

  2. Australia has a real opportunity in New Zealand to observe the effects not only of this particular issue, but of health reform in general. The New Zealand Primary Health Care Strategy was put into place because a small minority of general practitioners –the so called ‘third sector’ physicians, combined with politicians and academics to force on the public a form of capitated general practice administered by Primary Healthcare Organisations (PHOs.) It is a remarkable experiment which has no control group. Any doctor who wants to do other than work within the system has to do that unsubsidised. The current Australian Labour government is very fond of bulkbilling –does any one else remember their policy of flying in Primary Health Care teams to areas with low rates and sorting them out? In New Zealand everyone stood idly by as private general practice was deliberately starved of cash, in order that the Primary Health Care Strategy could solve the problem.

  3. At the same time as we embark on health care reform, the discipline of General Practice in Australia is suffering a crisis of confidence, largely because we do not realise what is our main selling point-being someone’s own doctor. Deprived or divested of emergency care and obstetric care we are now ripe for the picking from the competition (eg nurse practitioners, midwives, paramedics, patient educators, physicians assistants) unless we emphasise the personal nature of our calling . I hope in 2035, if I am still alive, I am not recalling that in 2002, when I arrived in Kalgoorlie, 90% of all the primary care was done (very well) by general practitioners.

  Campbell Murdoch

  Winthrop Professor of Rural and Remote Medicine

  Rural Clinical School of Western Australia

  Edith Cowan University

  Bunbury WA 6230

  Posted by Professor Campbell Murdoch 18/03/2009 8:36:02 PM

• Ms Roxon obviously has a 'bee in her bonnet' against doctors - perhaps

  she has a friend/relative who is a midwife and has got into her ear? As

  someone who sees a lot of obstetrics close up, I would never let any of

  my loved ones be under the supervision of a midwife alone. I work in a

  tertiary/quaternary metropolitan obstetric centre and I am regularly

  confronted with supposedly "low risk" pregnancies that turn into full-on

  emergencies in seconds. Despite the high level of medical supervision

  and care, there is still a significant enough risk for parturients.

  Taking away appropriate medical supervision and letting midwives, (who

  are often anti-obstetrician and anti-anaesthetist) conduct the process

  as they see fit will only invite disaster. We have an enviable safety

  record in Australia just the way it is and for good reason. Ms Roxon's

  ignorance and narrow-mindedness are unfortunate, but she has a preferred

  outcome. It is a bit like alternative medicine - come up with the

  desired position and ignore all evidence to the contrary.

  Obstetric Anaesthetist - Melbourne

  FANZCA

  Posted by Obstetric Anaesthetist 18/03/2009 8:37:00 PM

• I hope in the next few years when we have a wave of new medical graduates the government will be forced to abandon the efforts of nurse practitioners, midwives to be pseudo-short cut doctors. I hope that the government will be smart enough to realise that they subsidise the cost of a very expensive education lets make better use of our best and brightest and not waste time with the med school rejects

  Posted by Dr K 19/03/2009 7:36:20 AM

• As someone from a medical/legal/insurance background I have to point out 2 realistic issues.

  1) Nurse practitioners, midwives, allied health will try very hard to get a foot into the GP/doctors domain but the reality is that insurance to cover them will be high. Insurance companies know that they have limited training and experience and that the college of nursing/midwifery or universities will not be able to back them up (from a comprehensive training point of view). This is a reality the government will have to face if considering covering them.

  2) In 5 years there will be an overflow of medical graduates (as mentioned in a earlier post). The cost of training these doctors will require them to serve our community. With an aging population we will need more nurses to do nursing jobs. It would seem inefficient to train nurses to try and do 'some' medical tasks when we don't have enough basic nursing. So why not focus on training doctors to do medical jobs, keeping nurses in the ward/community and promoting midwifery as part of a team approach rather then a solo/independent venture.

  3) At the end of the day minister roxon needs to wake up and face reality and understand the roles of doctors/nurses/midwives. The sad fact is that she will play the political game and the Australian population will be left with a broken/poor quality health system.

  Posted by Steven Hope 19/03/2009 4:42:47 PM

• We are very fortunate in Australia that many births are uncomplicated and mother and baby do well. Contrast that with many other countries where peri natal morbidity and mortality are at levels we would find unacceptable (1). Midwives, Obstetricians, Anaesthetists are all invaluable and necessary contributors to peri natal care. To date we have no clear cut way of predicting which mothers will require medical intervention to optimise the safety of themselves and their newborn. Until that time, the midwifery versus medical debate is null and void. Instead let’s continue the tradition of the best of both worlds we are privileged to have in Australia. The healthiest and happiest mothers and babies are those who get the particular care they need when they need it! For the majority of Australians we look forward to any birth in the happy expectation that mother and child will do well and go on to lead happy & healthy lives. A precious privilege indeed!

  Posted by Dr Michaela Baulderstone, Adelaide 19/03/2009 7:21:38 PM

• Let us make no bones about it. the reason why I and my GP colleagues gave up obstetrics was being driven out by midwives. Let me assure you that there is no more lonely experience than being on the other end of a pair of forceps at 2.00am with an exhausted mother and a distressed bady, a frightened father and a midwife who knows it all and who you know is going to mutter in the patients and the father's ear the next day that "the doctor should have done such and such" Let us once and for all stop this stupid, politically correct hypocrisy and call the problem exactly how it is. Midwives do not want GP's in maternity wards and they are determined to get rid of them.

  Lee Simes GP Nowra

  Posted by Lee Simes 22/03/2009 9:58:20 AM

• Can we please stop the politically correct hypocrisy. The reason why there will be no GP's in obstetrics is that they will, as my colleagues and I have been, driven out of maternity units by midwives. Believe me there is no lonelier feeling than being on the end of a pair of forceps at 2.00am with an exhausted mother, a distressed babe, a frightened father and a midwife who knows it all and who you know is going to mutter in the patient's ear the next day that "the doctor really should have done such and such". Hands up all country GP's who have had that experience. Now hands up all the midwives who have never done something like it.

  Lee Simes GP Nowra

  Posted by Lee Simes 22/03/2009 10:26:55 AM

• I apologize for repeating myself. I didn't think the first feedback went through.

  Posted by Lee Simes 22/03/2009 12:33:33 PM

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