When politics of birth comes before its purpose

25/02/2019

Why would government officials try to discredit a critical piece of research that raised concerns about maternity care and why wasn’t it followed up?

In the months leading up to the release of a study which asked how safe it is to give birth in New Zealand, health officials were busy.

As a courtesy, researchers from Otago University had advised the Ministry of Health well in advance the study looking into maternity care outcomes would be coming out. Closer to the date, they provided an advance copy to the department.

The study found evidence to suggest all babies were not being born equal. Those in midwife-led care were at risk of poorer outcomes than babies in doctor-led care. The authors, Diana Sarfati and Ellie Wernham, were careful to point out their support for a midwifery-led system.

However, their conclusions were clear: the current way maternity care is provided in New Zealand is not as good as it could be.

“It may well be that midwife-led care is optimal within the context of well-organized systems,” the authors wrote.

At the very least this should have led to more research, but what did the Ministry do?

In the months they knew about the study – and the nine weeks they had a copy of it – ministry officials did little to suggest they would take its findings seriously.

Instead, an investigation by Stuff has found the ministry actively worked to try and obscure the results. Communications in the months before the study’s release show staffers worked on how to avoid “fallout,” and in one case shared plans to discredit the study ahead of its release with industry body the College of Midwives.

The ministry this week rejected suggestions it underplayed the findings of the study.

But documents obtained under the Official Information Act show attempts to spin the results of the study and avoid the spotlight on the safety of the system, into which 60,000-odd babies are born each year. These were met with stiff resistance from Otago University. 

But documents obtained under the Official Information Act show attempts to spin the results of the study and avoid the spotlight on the safety of the system, into which 60,000-odd babies are born each year. These were met with stiff resistance from Otago University.

Ministry officials took the unusual step of meeting with Professor Peter Crampton, then the head of Otago University’s Medical School and the pro-vice chancellor of health sciences. In an interview with Stuff,Crampton said it was clear the ministry felt the study was flawed. He disagreed, backing the university’s research. . . 

The Ministry felt? Ministries shouldn’t act on feelings, they should act on fact based thoughts and research but:

No further research was commissioned.

The study fell from the headlines; Sarfati went back to cancer research, and former midwife Wernham is in her last year of training to be a doctor.

But Crampton, who has had oversight of hundreds of studies in more than four decades in academia, can’t forget.

“I’ve never seen anything quite like it. The extent to which [the researchers] felt beaten up and traumatised by the experience was way outside of the normal,” he says.

“There should have been more high quality research set up to explore the issues that were raised, and we should have been doing this from day one. The chilling effect of the response to the results basically means this hasn’t happened.

“In my view, this was more about the management of a contentious issue than a policy engagement with important findings.

“If this area is too hard to research, then this is a big problem.”

While all research was vulnerable to critique, the authors had been clear about the limitations of the research and to ignore the results was a mistake, he says.

“The [ministry’s] response implied a problematising of the research in a way I found very unusual and disquieting. They viewed the results as highly problematic, and my general sense was that there was a considerable effort to explain them away.” . . 

Why?

Birth is a highly politicised business.

Practices have quite rightly moved away from the old system where mothers-to-be lay back with their legs in stirrups, everyone did what doctors said and midwives were undervalued.

But the pendulum has swung too far to the opposite extreme where too often birth politics gets in the way of the safety of both mother and baby and those involved lose sight of the point of pregnancy – the safe delivery of a healthy baby.

Problems have been exacerbated by the exit of doctors from obstetrics and a shortage of midwives.

Problems with midwife shortages – particularly in rural and low-income areas – and an unsustainable working model for midwives which means long working hours, burnout, and insufficient pay have been long identified as issues.

Wernham and Sarfati’s study was the first ever to take an overarching look at the safety of babies within the current system. The differences she and Sarfati found were not small; across the five-year study of more than 244,000 babies, they found those in doctor-led care had lower chances of poor birth outcomes.

This included 55 per cent less chance of oxygen deprivation during delivery, 39 per cent lower odds of neonatal encephalopathy, and 48 per cent less chance of a low Apgar score, a measure of a baby’s wellbeing after delivery.

There was also a lower rate of stillbirth and newborn babies dying under medical-led care. This link was statistically weak due to the small number of baby deaths in the five years covered – 1.84 per 1000 births for midwife-led care (410 total deaths, from 20 weeks gestation to the first 27 days of life) and 1.31 per 1000 births for doctor-led care (27 total deaths) – but it was there.

Of course, comparing women with midwives as their lead maternity carer to those who have doctors is not necessarily fair.

After all, doctors – counting GPs and obstetricians – look after less than ten per cent of mums. It is very possible the types of mothers they see are different – mums who smoke might be more likely to see a midwife, while healthier mums might pay for a private obstetrician, for example.

The researchers knew these things could effect the results. So they used a mathematical model to account for factors like smoking, age, ethnicity, deprivation, and weight. “Women are not comparable, but the design adjusted for that,” says Otago University epidemiologist and emeritus professor Charlotte Paul, who has reviewed the research. “The authors restricted their population to women who were having single births and term births to make them more alike. Then they collected information on characteristics that differed between the groups and statistically adjusted for them. The results remained.” . . 

But the results didn’t fit the prevailing ideology and raising questions as this research did led to defensiveness rather than answers.

Independent policy analyst and researcher Dr Jess Berentson-Shaw co-directs think-tank The Workshop and is the author of A Matter of Fact: Talking truth in a post-truth world.

She says the midwifery-led maternity model was a major policy change which, like many in New Zealand, was never evaluated.

“We should always be exploring what models of care are working best for the people they are supposed to serve – mothers, babies, families – and that includes midwives themselves. We can’t shy away from it, shut it down, or pretend it doesn’t exist,” Berentson-Shaw says.

In maternity, with its historic power dynamics of a women-led profession fighting for autonomy, questions about the system were often not considered objectively. “There’s this feeling that you can’t critique maternity care without critiquing midwives. How has it got so unconstructive? How has this happened to the point that we cannot have a conversation about standards of care?

That the Ministry and College of Midwives appear unready to even have the conversation is a big part of the problem. The only bias either body should have is towards the health of both mothers and babies.

Sarfati doesn’t know what she could have done differently. “It was so draining and exhausting and seemed to have so little effect, and it was so stressful personally. It had a big impact on Ellie and me for quite a long time, and despite all our efforts it had no impact at all.

“All we were trying to do was evaluate this major policy change that had happened. We have a really unique system in New Zealand, and the research they use to support it is based on systems completely different to ours. It was an attempt to look at that.

“It suggested there were problems, which isn’t to say the entire system should be thrown away, but you need to address them like any professional group should.”

David Farrar calls this disgraceful behaviour by the MoH.

Stephen Franks gives due credit to the journalist in Great Michelle Duff journalism on MOH surrender to witchcraft

The latter isn’t a criticism of all midwives but it is a criticism of the system which has put the politics of birth before its purpose.


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