Normal birth: a thing of the past or the new future for primary health care?

Abstract

This paper will explore the similarities and contrasts between the United Kingdom, Netherlands and Australian systems of maternity service delivery, focusing on the status of midwives as primary care providers. Increasingly, women in western industrialized nations are subject to medical models of maternity care. These medical models stem from the field of obstetrics, which has an increasing influence in determining service provision in all three countries. The World Health Organization has stated that midwives are the most appropriate primary carers for women during pregnancy and childbirth. Yet the rise of obstetrics as a dominant model of care has displaced midwives as primary carers, giving greater privilege to an obstetric construction of pregnancy and childbirth. While midwives are educated to understand and support normal physiological birth and assess and respond to deviations (wellness model), by contrast, obstetricians are educated to assess risk and address concerns through active clinical management (illness model). It will be argued that the fundamental difference between midwifery and obstetric views of pregnancy and childbirth rest on the differing perceptions of wellness and illness; that the obstetric view has gained broad dominance as a result of unequal power relationships; and, that this in turn has altered service delivery to privilege medical models of care. While service delivery in the UK and Australia has tended to follow a similar pattern of dislodging midwives as primary carers, the Netherlands system of maternity care, while broadly resisting the displacement of midwives as primary carers, is nonetheless provided within a medicalized framework. By contrast, in the UK and Australia there is an increasing awareness of the need to reconfigure maternity services to give greater autonomy to midwifery practitioners, a situation that is not as relevant in the Netherlands. The conclusion highlights the need to develop core principles to strengthen maternity care systems in order to ensure that midwives are not further alienated from service provision, and that strong midwifery workforces can be sustained. The discussion is based on research undertaken during a study tour of the United Kingdom and Netherlands by the author.