Sunday, November 13, 2005

The Ideology Behind Our Maternity Policy

Over the last week or so there has been a lot of media attention directed at New Zealand's provision of Maternity care. There has been some criticism of midwives, and comments pointing out how few doctors are now available to do maternity care.

David Farrar wrote a post about the current midwife situation and he filed it under political correctness. The problem is the dominant ideology in the provision of maternity care isn't 'political correctness' (whatever the fuck that means), but neo-liberal economics.

In the mid-1990s the National Government introduced a new payment scheme for childbirth. Under this scheme each woman had to nominate a Lead Maternity Carer and there was a fixed sum available for each birth (there was more money for more complicated pregnancies). If the Lead Maternity Carer wanted to work with another professional, than this professionl's fees had to be paid out of the fixed sum available for the birth.

My sister was born at home in the late 1980s, before this system came in. My Mum had a midwife present all the time, and her doctor was there for a much shorter period of time (I don't know how they divied up the pre and post natal care). The doctor also ran a weekday practice, and my sister was born at 2.30 in the morning - so I'm not quite sure how GPs who did maternity care balanced all that out then.

This explains why most GPs no longer do maternity care. If a similar situation was going to happen now the doctor would have to pay for the midwife out of the fixed sum of money available for the birth. The new system meant that it was no longer worth it for GPs to do maternity care. They weren't driven out by anything but cost saving economics.

Government subsidies at a fixed price is part of the neo-liberal plan for our health system (and other areas of public services as well). On one level it is simply a cost-saving plan, as it fixes the costs the government will be liable per birth. But it also part of a larger trend towards commodification and privatisation of the health service. Firstly this plan created a gap, care by a doctor during maternity that could be filled by private health providers. Secondly a fixed price, rather than meeting the costs, the state began the process of turning maternity care into a commodity, as opposed to a service.

It is true that the change in the funding structure happend at the same time as the status of midwives changed, but that wasn't a necessary connection.


  1. The PC categorisation was referring to the statement about Maori women and tapu parts.

    Try not to be shocked but I actually agree that the funding formula is a major part of the problem.

    I'd be interested in what you would propose as a substitute, bearing in mind health expenditure is always limited and Governments like stability in costs.

  2. Presumably Governments also like minimisation in costs. Paying whatever turns out to be necessary for a decent service may not be stable, but it should substantially reduce overall costs through preventing avoidable complications and fatalities.

  3. Hi David

    Sorry I didn't respond earlier, I wanted to talk with some people who had actually give birth before I made suggestions.

    I think if you paid on an hourly basis, rather than a per-birth basis then it would clear up a lot of these problems. There could be guidelines about what a reasonable number of hours would be in different situations (for a first child, for a second child, in a rural area, etc) This would allow different sorts of care to be provided to the same woman, if that was what she wished.

    For instance one of the problems with supervision of new midwives is that there's no funding for it. With teaching a school with a new teacher gets extra top-up funds so that (among other things) another teacher can be released from their classes to supervise the new teacher. If every birth that a new midwife did came with a certain number of hours for an experienced midwife to supervise it would enable a more formal sort of supervision.

    In some cases it'd probably cost less. In cases where it costs more we can start by raiding the money they pay to maintain the stupid pretence that we don't have abortion on demand in New Zealand.