Midwives, An Obstetrical Boutique

What would I do for material if the Calgary Herald didn’t expound on health care from time to time. In Monday’s Herald (Mar13/06) the editorial starts with: “If one of the key goals of Alberta’s “third way” in health care is to rein in escalating costs of the public system, then it makes no sense to refuse to fund a service that will save the system money” and ends “With a solid business case like that, there’s no reason to delay this increasing popular low cost to doctor-directed deliveries”.
Their entire position seems to be predicated on statements provided to them by the Alberta Association of Midwives. No outside analysis or independent analysis is quoted. Reference is made to other provinces paying midwives $70,000.oo to $72,000.oo per year or approximately $2,000.oo per delivery but I could not find any cost accounting by these provinces as to whether this was cost effective as compared to family doctors and obstetricians being paid less than $1,000.oo per delivery. Personally, if I was a family doctor or obstetrician practicing in a province that paid midwives twice as much as physicians, I would quit doing obstetrics.
Midwives say that they deliver a different service than a physician, and this is likely true. It is probably the “boutique” of obstetrics with special catering and individual service geared to patient’s likes and dislikes with more “public relations and hand holding” thrown in. But should I, as a tax payer, pay for this special service?
There is no question in my mind that other provinces have brought in coverage of midwives for political, not economic reasons. In the face of an ever decreasing obstetrical care work force it would be and is politically difficult, to turn down potential caregivers at any cost. Kudos to Health Minister Iris Evans and Alberta Health spokesman Howard May for making Alberta’s position clear, and I agree with that position. Adding a new service to the list of covered services at a time when the goal is to bring in more private services and review existing covered services would be unwise. Many points made in the Herald editorial are obviously taken directly from the Alberta Association of Midwives public relations people or persons. From my inquiries the issues of midwives delivering in the hospital setting are many and complex, and certainly do not point to any cost savings. Cost savings can certainly be realized with home deliveries and deliveries outside of a hospital setting. (birthing centers). This raises specific quality of care issues, and the monitoring and provision of safety in the home and birthing centre settings. If the government paid for the service, should there not be quality assurance and safety guarantees? Good medicine for me has been: “Always expect and be prepared for the unexpected”. The following experience in my professional life convinced me that I would never be involved in, or recommend, deliveries at home or in community birthing centers.
In my early years of family medicine I was delivering approximately fifty babies a year. On one occasion I was called to a delivery at the Holy Cross Hospital at approximately four A.M. to deliver the first baby of a twenty year old woman who had a totally normal prenatal period and would be termed “low risk”. As the baby delivered and I leaned forward to place the infant on mother’s chest she exclaimed “I don’t feel so well” and promptly became unconscious. At the same instant I experienced a gush of warm wetness over the entire front of my gown, and on looking down, saw a gush of blood one to two inches in diameter basically shooting out against the front of my gown. One would have to estimate the rate of flow at about one gallon per minute if it were to continue. Fortunately, there were two nurses in the room and within 15 seconds there were two more nurses present. The baby had to be taken to a safe place, the mother had to be tipped head down, intravenous medication had to be given, the blood pressure had to be monitored continuously, a second I.V. line was started, the laboratory had to be called for “stat” cross matching of blood, a specialist had to be called. Meanwhile, I had to do an immediate manual removal of the placenta and then apply immediate and considerable pressure on the uterus from above and from below per vagina until the I.V. medication controlled the bleeding and the uterine tone. My arms ached from the maintained pressure. Once the bleeding was controlled, the cervix and perineum were examined for lacerations. By the time the specialist arrived the mother was stable and awake with two I.V.’s running and blood on the way. The bleeding had stopped, the baby was fine.
Since that time whenever someone advocates home deliveries I think of that experience and on occasion have had nightmares of that scenario in a home environment. Other life threatening events can occur during obstetrical deliveries: prolapsed umbilical cord, uterine rupture, placental separation and precipitous fetal distress to name a few. Although the majority of deliveries need very little intervention from health professionals, our and the systems responsibility is to be prepared for the worst. And as one elderly wise obstetrician reminded me: “If you haven’t experienced this kind of unforeseen obstetrical emergency, you simply haven’t delivered enough babies yet”.