How the boys
Finally beat the girls
© Marie O’ Connor

The 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.

The 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.

Competition 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.

Today stake-burning has been replaced by more sophisticated and costly methods.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.

Last 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 Boylan’s former private patients had previously defected to Ms Kelly in mid-pregnancy.

The 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.

As 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 care.

Restrictions 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 midwives.

In 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.

The 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.

Irish 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.

In 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.

These 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.

Why 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 the money”.

The 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 simple.

In 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.

The 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.

Current 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.

These fees are what the patient pays. They represent what’s 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.

While 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

EUR2, 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.

As a midwife observed, it’s 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.

© Marie O’Connor
Northern Standard on 27 March 2003

© National Birth Alliance An Chomhghuallaiocht Naisiunta Breithe