Finally beat the girls
Marie O’ Connor
Competition Authority has just published a report done for it
by Indecon, as part of its study into restrictive practices in
selected professions. Medicine was one of those studied.
Authority appears not to have read at least one of the submissions
made to it as part of this study. This submission examined how
the services for birth were delivered, and how the boys finally
beat the girls. Curiously enough, while Indecon spotted that veterinary
nurses, for example, were restricted in their practices by veterinary
surgeons, they failed to see that midwives were even more restricted
in their practice by obstetricians.
between doctors and midwives for the provision of services for
birth is as old as time. Women were doctors without degrees. They
were nurses, midwives, herbalists and healers. They were called
wise women or witches. And, in medieval times, they
were burnt at the stake.
stake-burning has been replaced by more sophisticated and costly
methods. Midwives trials are likely to be by court or by
fitness to practice tribunals. In America, for example, midwives
accused of practising medicine without a license - are
raided at gunpoint to safeguard a lucrative medical monopoly.
In Ireland, things are less dramatic.
September, self-employed midwife Ann Kelly finally won her marathon
five-year legal battle against the Nursing Board. Her case cost
the Board EUR2m. in legal costs. The action was initiated by consultant
obstetrician Peter Boylan, then Master of the National Maternity
Hospital. Dr Boylan complained Ms Kelly to the Board in respect
of a home birth, although neither mother nor baby had sustained
any injury. Several of Dr Boylans former private patients
had previously defected to Ms Kelly in mid-pregnancy.
only services for birth not controlled by obstetricians in Ireland
are those provided by self-employed midwives. Less than 3 per
cent of midwives work as independent contractors. This is hardly
surprising, as there are significant barriers to midwifery practice
in the community. Yet midwives today are highly skilled, highly
trained specialists in normal birth, who undergo six years' university
education to enter the profession.
consumer dissatisfation with obstetric services grows, demand
for community midwifery-based services is increasing. Only a fraction
of this demand is being met at the present time. Midwives market
share, to use the language of the Competition Authority,
is less than 0.4 per cent. Demand for their services has been
assessed by the Economic and Social Research Institute. According
to a 1997 survey carried out by the Institute, 14 per cent of
less well off women and 17 per cent of middle-class women said
they would like to have the choice of midwifery-based community
on midwives are many, however. These restrictions are rooted in
law, custom and behaviour, such as the recent refusal by the Master
of the National Maternity Hospital to supply blood testing and
ultrasound scanning facilities to the clients of self-employed
many countries, including The Netherlands, France, Germany and
New Zealand, midwives have the power to prescribe the drugs and
requisites necessary for the practice of their profession. Not
in Ireland. Here, the power to prescribe is limited by law to
medical practitioners, although midwives are recognised in European
law as independent professionals.
State makes it difficult for community midwives to access vital
drugs, such as ergometrine, and requisites such as oxygen. Even
the sterilisation of their equipment is made more difficult by
a State that seems bent on putting them out of business.
midwives, if they accompany a client to hospital, are generally
told to sit in waiting rooms full of anxious fathers. Dutch midwives,
in contrast, have hospital privileges, that is, the
power to admit and discharge clients to and from hospital. Once
in hospital, midwives continue to assume responsibility for their
care they are their clients.
Britain, midwives also have the right to admit and care for their
clients in hospital. Here in Ireland, doctors squabble over the
right to discharge patients, a power which they guard
jealously, and which, if shared, would free up more beds in a
dangerously overloaded system.
restrictions represent a perversion of the public interest. Many
see them as constituting an abuse of a dominant position, both
by the medical profession and by the State. Indeed, the State
appears to be acting as agents for the medical profession. Their
common purpose would appear to be nothing less than the maintenance
of medical monopoly in maternity care. And it is this monopoly
which has left Monaghan and Louth without a maternity service
over the past two years.
the implacable hostility of the medical establishment to independent
midwifery practice? As Deep Throat said to Woodward and Bernstein,
in the dark recesses of that sinister underground carpark: Follow
market for private maternity care in this country is estimated
to be worth in excess of EUR50m annually. This yields average
obstetric incomes of at least EUR500,000, every year, in addition
to private fees from gynaecological work obstetrics and
gynaecology are a twin specialty - on top of a basic State salary
of, give or take, EUR120,000, plus allowances. How have these
extraordinary figures been arrived at? While the number of noughts
gets a bit confusing, the calculations themselves are remarkably
2001, 57, 882 babies were born in the Republic. According. to
the Institute of Public Administration, 45 per cent of the population
have private health care insurance. It is reasonable to assume
that women avail of this cover as maternity patients.
If 45 per cent of 58,000 women avail of private maternity care,
this represents a market of 26, 100 consumers.
services for birth are almost entirely controlled by a relatively
small group of consultant obstetricians. According to figures
supplied by the Medical Manpower Forum, there were 89 consultant
obstetrician gynaecologists in permanent employment in the public
service in January, 2001. Allowing for a small number of consultants
practising solely in private hospitals, this brings the total
number of consultant obstetricians to approximately 100.
obstetric fees charged to patients in the Dublin maternity hospitals
are in the region of EUR2, 000. Some consultants even charge hello
money of EUR225 for appearing at the birth, on top of a basic
fee of EUR1,900. Non-appearance of consultant obstetricians is
common, as normal healthy women do not need medical attention.
The actual work of caring for women in labour is, as it has always
been, left to midwives, the normal birth specialists.
fees are what the patient pays. They represent whats termed
balance billing. In addition, private insurers such
as VHI and BUPA, make a contribution to professional fees of approximately
EUR200-380, or even more, depending on individual subscriber policies.
it can be argued that obstetric fees outside Dublin tend to be
lower than those in the capital, excluding VHI/BUPA contributions,
not to mention hello money, should offset any urban/rural
fee differential. Taking an average, then, of
000 per patient, and a pool of patients of 26, 100 patients, this
particular pot of gold appears to be worth well in excess of EUR52.2m,
and this is divided between approximately 100 consultant obstetricians.
a midwife observed, its like winning the Lotto every year.
Interestingly enough, the winners are nearly all men. Obstetrics,
like most areas of hospital medicine, is an overwhelmingly male
specialty. 84 per cent of consultant obstetricians are male. Midwifery
in contrast is an almost exclusively female profession. Midwives
get paid 8 per cent of what consultant obstetricians earn for
equal work in normal birth.
Northern Standard on 27 March 2003
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