Midge wrote
<<
Total deaths given as 268, directly or indirectly linkd to 
pregnancy, an increase of 40.

Is the triennial report on the web anywhere?  

Why should an increase of such a size be seen?>>

How about the increasing tendency to do sections?  Consider that worldwide
the rate ranges from aroung 2% (in the SFKW in Vienna) to as high as 50% in
some American centres. Such variation in the absence of obvious reasons is
indefensible. 
Then we have the deskilling of hospital midwives to the level of obstetric
nurses, the horrendous hours obstetricians work and the twisted
litigation-ridden atmosphere in UK obstetrics whereby doing *any* procedure
is a better defence than doing none. 
The closure of small units and cottage hospitals went at a great rate under
the Tories and it is surely obvious that any sane rational human being will
be at least a bit anxious going into a big hospital where he/she knows
no-one.  Animals crawl off to a dark quiet place to give birth; can anyone
think of a *less* appropriate place for delivery than a big busy labour
ward?  In Holland they used to have (and perhaps still have) an
anthropologist advising on some of the maternity committees, for the reason
given.  They also do sensible things like home births (without the pregnant
woman having to take the obstetrician hostage) and provide good domestic
support. 
In sum, a process which needs peace and quiet and good human support has
been institutionalised, chained to technology and stuck in the battle
ground between medicine and the law. It is no wonder that some parturients
are dying.

<<I am inclined to single out the midwifery establishment, who at 
least locally have acted unilaterally in changing arrangements, 
rotating midwives through practices who therefore remain part of a 
midwifery team but cannot integrate with the rest of the primary 
healthcare team, introducing a new and vastly inferior pateint >>

NOw that is bad but those who think a lot about maternity care (excluding
obstetricians who are not trained to think and besides have to guard their
empires) believe that good midwife care has a lot going for it. The best
ones I have known see continuity of care and low-tech approach as very
important.  Many of them prefer to be attached to a practice or patch so
that they can build up some continuity and I wonder who was behind the
changed arrangements in your area? Did it come from the coal-face? Or is it
possible that (as I have heard suggested before) the managers got so
worried about de-skilling of hospital midwives that they saw no alternative
but to rotate them through the community? 

<<Maternal care is a mess, and an unhappy mess, and the professional 
bodies which have successfully seized control of it would have been 
more ethically employed in getting on with their work.>>
I have been interested in this topic for years and I must say that the
biggest and baddest of them all for a long time was the RCOG. Obstetricians
spent their labour ward time in a frenzy of impatience and anxiety, fed by
the fears of litigation and the advice of the RCOG.  They expected things
to go wrong, they interfered far too much and they certainly did not want
*anyone* else coming in on the scene. It was only after Winterton that they
realised that their attitudes had to change, hence the rapprochement
between the RCOG, the RCM and the RCGP.  
Historically, the move to hospital delivery was fed by two factors; one was
the need to fill beds and the other was some questionable (to put it
mildly!) analysis of perinatal surveys back in the late 50s and early 60s. 
Read Marjorie Tew if you want to know more. 

Looking at the midwifery establishment UK-wide, I am inclined to see them
as possibly the best allies women and GPs could have.  At the presentation
of the NI version of Changing Childbirth in 1994 I spoke as  a GP and the
discussion afterwards was extremely good and positive.   It backed up my
own experience in practice, that the average community midwife round here
is bloody good at her job, cares a lot about the women and wants to keep
them well away from the labour ward until they are in established labour. I
always seconded that last piece of advice BTW----less time for junior
obstetricians to get worried! 
The decline and fall of GP obstetrics is sad. The enthusiasts seem to be
very good at it and I wonder if there is any way of sending GP registrars
who express some interest in community obs to go and train with those
enthusiasts?  I agree that the hospital training in obs is a national
disgrace for GP registrars and should have been sorted out long ago.  
Personally, if I were taking up GP obstetrics and/or planning to cover a
small rural unit I would have to re-train. A significant portion of my
re-training would be spent in midwife-led units like the Bournemouth one
and home birth independent midwifery  practices like one or two I know in
London. 

Declan


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