Monday, 7 September 2009

Choice, that don't feel like no stinkin' choice

After finally making the decision to go through with plan 'b,' all of sudden a whole lot of decisions had to make quite quickly about where I'd have a baby and who I would like to deliver it.

Over the last decade or so the word 'choice' has been bandied about a lot in relation to maternity care, but actually I didn't feel like I got much of it so far in relationship to my care. The where was easy. I'm all for better living through pharmacology, so I would definitely be heading to hospital where there are lots of drugs on hand and people very happy to administer them. The who part was more problematic, I needed to find a Lead Maternity Carer.

The person I would have liked to deliver my baby was my GP as I have a great relationship with her. There are not many places in Auckland where they'll ring you up the next day to make sure you are fine after presenting with a routine albeit rather severe UTI. But apparently you've got a better chance of striking big Wednesday than finding a GP who still does deliveries and is willing to take a new patient on. So I was cast off into the world of maternity care by my lovely GP with a few names and numbers to call.

The Suit would have liked to go the private obstetrician route but with all the outgoings in our household it didn't make sense to add another $4k to our bills with a baby on the way. Which left us with one option really, a midwife. And again I didn't feel like I got much choice in the matter. I tried to contact several that simply didn't bother returning calls and the others that I did manage to get a hold of were unimpressed that I dared call them at the late stage of 9 weeks pregnant. Apparently in Auckland you should be booking your midwife the minute those two lines on your piss stick turn up.

At this point I was getting a bit desperate. I needed someone, anyone really, to deliver my baby and do their darnedest effort to make sure the both of us make it through the process in as good as shape as possible. Then I suddenly remembered that one of my friends was pregnant and dropped her name into the conversation with her midwife before we got along to the dreaded due date question. Thus my lead maternity carer was chosen on the basis that said midwife is 'not a hippy' and I was officially signed on at almost 11 weeks knocked up.

The midwife in question turned out to be a highly practical no-nonsense sort and shares my general philosophy on birth: that there is no point in setting yourself up for failure by trying to have the 'prefect birth' when a good birth would do myself and my baby just fine.

Although my pregnancy had a unhappy ending, my midwife made the ordeal a whole lot better than it could of been. Within minutes of my unhappy text she had made the arrangements for me to have my D&C done a few days after I arrived back home and also kept in contact with me throughout the day as I waited for my flight. There was something deeply reassuring about having a healthcare professional so concerned about you, that she insists on the midnight phone call to make sure you arrived in the country ok. Something I don't think the expensive obstetrician or in fact my own GP would have done.

But looking back on my initial journey through pregnancy, I couldn't help but wonder if I wouldn't have felt so at sea if my local GP practice had midwifes as part of their clinical staff. Judging by the number of pregnancy packs being left at the front desk, there would clearly be some demand. I hated that my relationship with my GP has effectively been severed even though she was effectively my LMC for almost the entirety of my first trimester. Perhaps the midwives themselves might benefit from having some administrative support which a practice would have. Of course I'm sure people will come up with plenty of reasons why this is a bad idea, cost is likely to be a big factor and maybe most midwives would hate the idea of joining a practice.

Nevertheless new thinking is needed in the much-reported doctor versus midwife debate. Maybe it isn't the end of the world if GPs are no longer involved in routine childbirth, as for me at least I really appreciated having someone there even in the middle of the night to make sure I was doing ok. However it does seem odd that maternity care is so far removed from most women's main port of call for health matters. I know I would feel a lot more confident about my care arrangements if there was a good chance that the GP and midwife might actually talk to each other as the pregnancy progresses. It might have been good for my GP to know that a) I had miscarried and b) had a D&C when I presented with complications a week after the event.


Alison said...

The big problem with having midwives associated with doctors' practices is that if you're signed to a PHO, as many women are, you'd have absolutely NO choice of midwife, unless you were willing to change doctors. That's pretty problematic.

I think having midwives associated with doctors is really an ambulance at the bottom of the cliff for the actual problem, which is a drastic shortage of midwives. Until we have a government that is really serious about increasing midwife numbers, that's going to be a problem.

Anonymous said...

When women were given the choice, they choose to have a midwife AND a GP involved in their maternity care. The govt put a stop to this because of the budget blow-out.

Having to choose leads to silliness such as this: when I became prgnant and engaged a self- employed midwife as my LMC, she requested that I not see my GP for anything remotely pregnancy-related without checking with her first. Why? Because if the pregnancy was discussed as part of the consultation with the GP, then the GP would rack up the visit as "maternity", which would be paid out of the fund of money available to my midwife for my antenatal care. I could see it from my midwife's perspective - the pay is crap which is why doctors, by and large, aren't interested - so why deny her any further payment? Especially if it was a matter she could deal with.

Consequence: I had a serious does of flu when 6 months pregnant. Normally I never go to the doctor with flu but since I was pregnant and so sick (and lost 4kgs) I was really really really tempted to visit my GP. But I didn't out of concern for my midwife's bottom-line. How silly is that.

I'm sure there are plenty of other distortions arising from being forced to choose just one provider.

(My midwife, BTW, was fantastic and did a great job; she demonstrated a commitment to me that I doubt any GP would have. It is the need to choose between the two that I object to.)

Azlemed said...

making the choice of who to have as your LMC is difficult, my first one I liked she was no nonsense etc and i was happy with that, but at 12 weeks with number 3 she dropped the bomb that she was no longer lmc'ing and I was given to another midwife.... i didint click with her and due to other issues was lmcless till 20 weeks when I shifted towns and just got who I was given, wich turned out to be great.

This time I was really fussy and ave got a fab midwife wo responds to texts, and texts the next day if things havent been great.

I personally wouldnt like going to my gp's clinic for my pregnancy care, I arent sick and like the friendliness of the rooms where my midwife operates out of.

As for choice its pretty hard to find a midwife after 12 weeks, private Ob/gyn isnt possible in all places, there are none in palmy so you have only the choice of mw or the one gp that still lmc's here, for secondary care you just get who is on at the hospital.

am glad that your mw was able to help you. D

Snotty Otter said...

I work for an area of the Ministry of Health that deals with maternity care and the funding thereof. Alison is right - there's a shortage of LMCs across the nation. Some areas are better than others, but overall there just aren't enough to go around.

It's hardly ideal for pregnant women who have built up a trusting relationship with their doctors to have to find a different LMC, but it's also difficult for a GP to take on the LMC role while still maintaining their own everyday practice. You can basically be one, but not the other. Midwives/LMCs are able to commit to a level of care that's simply not possible for a GP, as general practitioners do not provide specialized care, which is what LMCs do.

Most of the midwives (and misc other maternity specialists) I'm in contact with professionally seem like lovely, committed people who genuinely care for the women they look after. It's just a pity there aren't enough of them for everyone to have a choice.

There will always be those haven't fully familiarized themselves with the funding policy and processes, though. And that may sometimes unfortunately lead to the sort of situation Anonymous describes, where she did not see a doctor at a time she needed it out of fear her midwife would not get paid her full entitlement. If you're sick and pregnant, by all means seek medical care! Your health is more important than your LMC's paperwork.

Alison said...

Yeah, unfortunately Anonymous' case sounds like a misunderstanding; going to the doctor for a non-pregnancy illness like flu has no bearing on the midwife's payment. However, it's quite correct that pregnancy-related illness should be discussed with the LMC first, and that applies whether the LMC is a midwife, GP or obstetrician (and why wouldn't you? If it is pregnancy-related, the care will be free, so it pays to find out if it is pregnancy-related).

Disappointingly, in the middle of such a massive shortage of midwives, the Midwifery Council is preventing Massey University and AUT from taking any intake of midwifery students next year; the MC have requested an overhaul of the country's courses which is not acceptable within a university environment (they want 3 year, full-time 48 week-per-year courses, rather than the 4 year course, with the same material, proposed by Massey). As a result, our two biggest midwifery training organisations won't have intakes in 2010. We really should be getting exercised about it, given the massive number of midwives coming up to retirement in the next 5-10 years.

katy said...

That there is no communication between your GP and your surgeon is a worry. I had a gynaecological surgery recently and after the procedure I happened to see my GP before the specialist so she was the one who advised me of the outcome and because she is much more accessible than the specialist (obviously) I see her role as really important in the whole palaver because I see her more often. I agree, it is very sucky if there is a disconnect there between your GP and the surgeons and specialists when it comes to maternity care.

Alison said...

Katy, if midwives or an LMC GP refer to a specialist, they will collaborate with that specialist just the way a GP would for any non-maternity referral. There are pretty strict guidelines for when referral should be made in maternity care, and what level of referral.

Midwives and non-LMC GPs are a bit different though, because they're both primary healthcare providers. They don't collaborate unless there's an issue like an pre-existing condition that might be aggravated by pregnancy. In that case it's still the GP's job to monitor that condition, while the midwife covers maternity-specific care, but there might be some negotiation of treatments and so on.

Azlemed said...

my midwife does my pregnancy health and my gp does my other health, I went to ob.gyn clinic as a referal last week, but for straight forward pregnancies ob's dont need to be involved,

I have been seen by Ob/gyn when up in delivery suite but that has been at the request of my midwife and she has still been the one in charge of my care, she has just consulted with them

Trouble said...

Totally right about the shortage and lack of choice and difficulty signing up with a midwife - that was exactly my experience. I don't think the answer is to get more GPs involved - there's no way a GP would spend a whole labour with someone as well as conduct their ordinary practice.

A few people I know have used the hospital midwives for their antenatal care where they couldn't find a standard LMC. Not so much continuity, but you aren't stuck with someone you don't like.

I made the effort to give a student midwife the chance to learn when I had my baby the other week - twice the examinations but it will benefit others when she's fully trained. And I can report that everyone from the midwives to the anaesthetist to the registrar and nurses worked well together and looked after us very well.

octopusgrrl said...

When those two lines came up on the pee-stick, I had absolutely no idea of how the maternity system in NZ works, and I'm sure I'm not alone. I went to my GP to "confirm" my pregnancy, which I assumed was what you did, but instead of the expected blood test, I got to pee on another stick (actually two, as the first came up negative but was from a "bad batch" apparently!) and my GP told me that she "doesn't do maternity work" but gave me the number of a good midwife. She ended up being my LMC (and was absolutely amazing) so I have no complaints there. But as you say, it's an illusion of choice: our midwife expected us to interview others before making a decision but we knew there was a shortage of midwives in Dunedin and really didn't know the right questions to ask, this being our first pregnancy and all. Our choices were: find a good midwife (luckily the majority of those available in Dunedin are highly recommended, but you have to choose early in your pregnancy); see an obstetrician (impossible on our budget); or go with the hospital team (they are well thought-of, but you're pretty much at the mercy of whoever happens to be on duty the day you give birth, which is something that I wasn't very comfortable with).

Principessa said...

I have a pre-existing medical condition that means when we decide to start our family we need to come up with a plan about how we will cope should I become unwell before, during and after pregnancy. And we need some advice about medications I'm on. It scares the bejesus out of me that I might become sick as a result of having our family and recently I've been trying to find someone I can talk to before even thinking about becoming pregnant. I'm not even pregnant yet and already I have discovered how hard it is for me to get the specialist advice I need. I do wish my GP could look after me as she is awesome. But I get the impression that tertiary services are overwhelmed and underfunded.

The ex-expat said...

Alison, I suppose my main beef is that there seems to be no communication. My GP was great about getting my into to my midwife, my midwife was great about getting my info into greenlane but then the communication stopped aside from one brief phone call one day post-op.

I also I felt that my 'choice' was very limited. Part of it was the unplanned nature of pregnancy. I was so spaced out by the thought of being pregnant the time I should have spent worrying about selecting a LMC was spent wondering what the hell to do with the pregnancy itself. Then I felt harried to find someone to take me!

Azlemed said...

hey principessa, give me a yell if you have lots of questions, I can help a wee bit, had some experience in that area. D

Azlemed said...

there is often no communication between your gp and your midwife, mine have nothing to do with each other at all.... its not personal its just how the system seems to be at the moment.

getting an lmc is quite hard and trying to do this within the first 12 weeks when you are totally confused isnt easy either. its a huge decision to make yet if you get it wrong its damn hard to change mw too... I couldnt get a mw at 16 wks in palmy which was ridiculous.

lenore said...

I have a different perspective and it is by no means to criticise others who feel the way they do. I personally am glad gps are no longer doing deliveries. When I had my oldest daughter i had to go through a gp. It was fine initially until i started thinking about how I wanted to labour and deliver my baby. When I told him I wanted a homebirth - he started threatening that I was going to kill my baby and then implied there was something wrong with her. Absolutely distressed i looked at an alternative and found a midwife. She was a great advocate for me and understood that it was the process that was just as important as the end result (gp thought that the ends justify the means - ie intervention etc)
I went into labour early and my midwife was there for me not my gp. He came 5 minutes after I had my baby despite it being a 24 hour labour. It was token on his part to collect his money from the government which was a lot more than my midwife.

I just feel unless a gp does a lot of deliveries, it isn't there speciality. Many gps never went the extra mile that a midwife did back then - ie I could call her anytime if I was concerned. They didn't always do great follow up care.

Our issues is that we do not have enough midwives, i don't think it is well paid and I have known young midwives who have left because we have such high expectations that nothing will go wrong with the birth, that if it does we point the finger at them.

I also think many gps got out of doing deliveries because they weren't going to be paid so much - ie the same as a midwife.

i was rapt not to have to have a gp with my other two children and my midwive gave me wonderful care before, during and after birth.

Also a lot of women still think that the pressure is on not to have drugs etc. I disagree, i think the pressure is still on to have it especially when you are in the middle of labour and they start pressuring partners etc that you need epidurals, drugs etc. Even before this, we are often only allowed to go so many days overdue before intervention is considered, despite the fact that a 40 week pregnancy is a bit of a myth and women are all different.