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The politics of pregnancy |
 A doula provides personal support to the labouring woman.
A woman does a pregnancy test with her GP and it is positive. She is overjoyed because it’s what she and her husband have been waiting for.
So the next step would be for the GP to give her a referral to an obstetrician. It’s the usual thing, because for many women any other direction would appear less safe and therefore not an option for those expectant mothers.
Another pregnant woman however has heard horror stories about personal disempowerment and the cascade of medical intervention in hospital. Yet another may have been unprepared for the shock of her first birth experience. So she seeks out a home birth midwife to escape from the possibility of a repeat episode.
To exemplify the opposing poles of birth models, a homebirth midwife’s bumper sticker reads: “The birth machine or the goddess - your choice.”
This is where we are at with practitioners from each camp distrustful of one another. The ferocity has settled a bit with recent talks on government supported homebirth now in progress as government sees a looming shortage of obstetricians.
So what are the alternatives available? One way for a woman to access more balanced pregnancy care is a blend involving her own GP, possibly a midwife and a specialist obstetrician - the sharecare model.
Sharecare
GPs for pregnancy care
Looking after pregnant women may not be every doctor’s preference. Those who find birth baffling or scary are under no obligation to pass on their own insecurities. Pregnant women can be emotionally vulnerable and a word in the wrong place about dangers and difficulties can be profoundly undermining.
On the other hand, many GPs enjoy looking after pregnant women because it is a nice contrast from the needs of the sick to deal with the optimism and good health of these patients. Except in rural areas, not many GPs attend birth, therefore the patient at some stage or other has to be passed on. When and to whom? And who is the one responsible for ordering the appropriate tests at the right times: the GP or the specialist? At what stage should each step be taken?
Sharecare disciplines
As well as the warm fuzzies that go with pregnancy care, there are definite windows of timing that need attention. For example, the most important ultrasound scan is ordered within 18-22 weeks. Done earlier or later means that the gestation cannot be so accurately assessed and the patient may be not eligible for a Medicare rebate.
Or, a woman first pregnant with Rh-negative blood is now offered anti-d twice during the gestation. If the doctor or midwife responsible did not attend to this detail and antibodies developed, then an expensive lawsuit would not be impossible, and that’s even before labour and its legal minefield has to be negotiated.
There is a great need for integrated care with good communication between all carers. Just doing a scan here and there and a blood test now and again falls below the mark. Yet this random approach to pregnancy care is widespread. Any obstetrician will affirm that seeing the pregnant woman first in late pregnancy often finds the previous care to have been unbalanced, with either over or under investigation having been conducted at the wrong times.
The old gold standard for records in NSW is ‘the yellow card’, which the pregnant woman carries and that hopefully gets filled in at each visit. There are problems. Pregnancy can be associated with memory and concentration lapses, so it can get left at home. The accepted etiquette is one line per visit. Some doctors write copious notes and fill in half the card, so it runs out of room. This must sound really petty, but as we all know our records can be our lifeboat when conditions get rough.
Pen and paper records are fading with the growth of practice computer programs, but it’s a tricky time. As the AGPAL assessor said to me at my recent practice re-accreditation visit: “You have the worst of both worlds with pregnancy records. Half paper and half computer.”
These issues have caused the sharecare model to be discussed at the NRAHS maternity services committee meetings. Reforms could be a useful to protect not just patients but also providers.
Other models
Some hospitals in the city have a midwife run birth centre for women seeking birth with low intervention. Most of these are attached to a major hospital for safety. These birth centres are very popular and get booked well ahead.
In many rural areas GPs look after a particular pregnancy in their rooms and book the birth for the local hospital with the assistance of nurse midwives. Women express satisfaction at this continuity of care. Sadly, this service seems to be drying up. Confusion around GP obstetrician succession planning ensures the domino effect. Rural birth units cannot manage solely with midwives and so in the Northern Rivers alone, Kyogle, Ballina, MacLean and Byron Bay hospitals have all closed their birth units (Byron being the most recent closure in the last couple of months). If one of the two remaining doctors should leave obstetrics in Casino, that service would also be jeopardised.
It’s true that rural doctors’ representatives have provoked good government incentives to assist those who are left, but to me it seems like repairing an old leaky boat rather than building a fleet of new ones. Why not introduce some measures to encourage younger doctors into GP obstetrics? Many registrar-training jobs seem little short of serfdom in a sausage factory in a system seemingly designed to destroy enthusiasm. It’s an unfortunate fact that most doctors with a diploma of obstetrics decide not to pursue a career attending birth.
One country hospital
The Mullumbimby birth unit has remained open with three (older) GPs and a recent recruit, the sole survivor from Byron Bay, who jumped on board when that birth unit sank.
The Mullumbimby centre is somewhat unusual because of the prominence of homebirth culture in this area and so the hospital pulls out all stops to provide a viable alternative to homebirth. For example, there is an accredited protocol that allows for waterbirth. This initiative was highly commended for the NSW Health Baxter awards last year. Mullumbimby includes no facility for monitoring, epidural or Caesarian section and women need to understand clearly the implications. One patient told me: “That’s the reason I’m here. I know I won’t be forced into anything because you haven’t got it.”
Birth support
So in preparation for the kind of birth where the woman would like to be responsible for her own labour, who does she call on for help? Or is it just up to the woman to go in and hope for the best?
The benefits of detailed attention to pregnancy support are far-reaching. Evidence shows personal skilled support cuts down the need for intervention and pain relief during birth for many women. It follows that good birth planning can lead to a saving in costs for the health system.
Most specialist obstetricians and hospital antenatal clinics are far too busy during pregnancy visits to have the time to work through all the fears and foibles of the woman’s journey. The routines of blood pressure recording, weight measurement and ordering the standard investigations simply may not be enough for her, but the woman may feel too rushed to express herself.
In a busy clinic what are the alternatives? One way for private clinics is to employ a midwife to allow time and space for the pregnant woman to deal with fears and issues outside the doctor’s office.
Personal support
Ever since attending births in this region both at home and in hospital, I have observed the custom of a woman bringing in her own special support woman who may be a friend or a relative. There is also an organisation of privately employed professionals known as doulas (lit. a birth slave who attends to the personal needs of the labouring woman but has no clinical input).
The success of this arrangement has become so self-evident that when a woman says that she only wants her husband and no-one else as support, experience says it might be wise for her to reconsider. Especially for a first baby when the labour may continue through several midwife shifts, an inexperienced partner may become completely overwhelmed or exhausted by the demands of his wife’s labour.
When two becomes three
The need for support goes beyond the birth. The visits during pregnancy care offer an opportunity for teaching and preparation in the realities of looking after a new baby.
The father may have unmet needs. Explanation and warning about the way his sexy lover may change into the apparition of a sleep-deprived milk bar may save the day later on.
The urban myth that a new baby is a good remedy to make marriage stronger, rather than being a challenge to the marriage, is one angle that could be explored in pregnancy. In the experience of the author, the first two years of life are a time of great risk to the parents.
Let’s go back to the beginning and use the time to provide tools for the best chance of a good life for each new person, through attention to detail in pregnancy care.
David Miller is a GP obstetrician who practices in Brunswick Heads. He would be interested in your feedback on this article and would be happy to answer questions and respond to comments in the next edition. Please email comments to media@nrdgp.org.au or fax to 6622 3185.
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