Interview: Linda Bryder talks about The Best Country to Give Birth?
Linda Bryder has taught history at the University of Auckland since 1988 and in 2008 was appointed professor. She has an extensive publication list in the social history of health and medicine, including over one hundred peer-reviewed journal articles and book chapters, and significant monographs in the history of women and children’s health, including A Voice for Mothers: The Plunket Society and Infant Welfare, 1907–2000 .
In 2014, she was awarded an inaugural University of Auckland Research Excellence Award. From 2007 to 2023, she held an honorary chair at the London School of Hygiene & Tropical Medicine. She is a Fellow of the Royal Society of New Zealand Te Apārangi. A founding editor of the Oxford journal Social History of Medicine, Linda has served on the editorial board of several international medical history journals and co-edits the New Zealand Journal of History. She is currently President of the Australian and New Zealand Society of the History of Medicine. Linda talks to NZ Booklovers.
Tell us a little about The Best Country to Give Birth?
It was with great pride that the New Zealand College of Midwives, formed the previous year, celebrated the 1990 Nurses Amendment Act. This Act allowed midwives to practise autonomously in the community without oversight by, or reference to, any other health professional and to set up training schemes separate from nursing. The College claimed that midwives were thereby ‘liberated’ from the shackles of medicine and nursing, and could provide a truly women-centred maternity service. Not everyone agreed, however, voicing misgivings about the unpreparedness of newly trained midwives to deal with emergencies and their failure to prioritise safety over a commitment to natural childbirth. The College dismissed such arguments as scaremongering and anti-feminist. This book analyses the lead-up to the 1990 Act and the deep fractures within New Zealand’s maternity services that developed subsequently. It charts the concerns about the nature of the services expressed from a wide range of quarters, including coroners, health and disability commissioners, other health professionals and academic researchers, and above all by mothers and their families – the consumers. Divergent views on whether Aotearoa New Zealand was the best country in which to give birth emerged and persist to this day.
What inspired you to write this book?
I have had a longstanding interest in the history of infant and reproductive health since I published a book on the history of the Plunket Society twenty years ago. But I had not intended to write this most recent book. My original plan had been to write an academic article on the 1990 Nurses Amendment Act, which I had read ‘emancipated’ midwives. I set out to discover what exactly this meant. Reading the parliamentary debates, I found the focus was on homebirths, and that led me to investigate what the government was buying into when it supported this approach to childbirth. I discovered that homebirth was not just a choice about where to give birth but came with its own philosophy which was broadly anti-science. Having done that research, I was then intrigued to discover what happened after the 1990 Act, passed with the intention to promote homebirths, and, gathering this information, my academic article was clearly morphing into a book. While I initially intended to restrict the ‘aftermath’ to the 1990s, my curiosity drew me increasingly towards the present. I believe that this is an important story about the evolution of New Zealand’s maternity services over recent decades that needs to be told.
How did births happen in NZ pre-1990?
In 1970 most births took place in hospital. From 1939 all women were entitled to 14 days free maternity care, either in hospital or home – most chose the former. By the 1960s, hospital birth was almost universal; in 1971 there were only 24 recorded planned homebirths in New Zealand.
While most women chose to birth in hospital, they also worked to ‘humanise’ conditions in hospital, to make them less clinical than they had been in earlier decades when infections were a major source of maternal deaths (puerperal sepsis) and a sterile environment had to be a priority. From the 1960s, consumers wanted and achieved a more relaxed environment in hospital where there would be access to modern technology as required.
However, the 1980s also saw the rise of the homebirth movement, linked to the new Women’s Health Movement and second-wave feminism which questioned modern medicine and viewed the predominantly male medical profession as patriarchal and misogynist. Homebirths continued to be a very small minority, however, not more than 1% of all births prior to 1990, often linked to the counterculture and communal lifestyles.
Homebirths were conducted by midwives (paid by the Department of Health) and often a homebirth GP attended in a support role. This setup appeared to work well prior to 1990. In 1981, the Home Birth Association (formed in 1980) listed 105 homebirth GPs around the country who were willing to support the 17 practising homebirth midwives. There is much evidence from homebirth midwives of a collegial relationship developing between the two sectors at the time.
Where did the midwifery movement come from and why did they want change?
There was no `midwifery movement’ per se. Midwifery registration dates from 1904, and from 1937 there was a Midwifery and Obstetric Nurses Special Interest Section in the New Zealand Nurses’ Association. This Section was vehemently anti-homebirth in the 1970s and early 1980s. Around 1985 the Section was taken over by radical midwives, who argued that midwives had been ‘colonised’ by nurses and doctors and turned into doctors’ handmaidens, and that homebirth midwives were the only ‘real’ midwives left. Under the leadership of homebirth midwife Joan Donley, they persuaded midwives to disband the Section and form the New Zealand College of Midwives in 1989. The College celebrated being a feminist profession and working in partnership with women, although their consumer representatives came exclusively from the homebirth movement.
In their campaign for change, homebirth midwives falsely claimed they had to be supervised by doctors, referring to the 1971 Nurses Act. This Act stated that it was illegal to undertake obstetric nursing without a medical practitioner taking responsibility for the pregnant woman. In this, New Zealand followed the Dutch model of homebirth - if a woman wanted a homebirth she would see her GP who examined her and if she were deemed ‘low risk’ she would be passed on to a midwife who would manage the birth, and only call the doctor in an emergency. There was no legislated supervision. Overseen by the Health Department, midwives practised independently for births that proceeded without complications.
But some homebirth midwives wanted no involvement by doctors in homebirths. They also advocated for direct-entry midwifery training, i.e. no nurse training prior to midwifery training. They argued that under the current system midwives had to ‘unlearn’ what they had been taught as nurses, to enable them to treat birth as a normal life event. This proactive political group managed to persuade the government that women wanted midwifery-led homebirth, which was the focus of discussions as the 1990 bill made its way through parliament.
What changed with the 1990 legislation?
The legislation extended far beyond facilitating homebirth which was the primary focus of submissions to the parliamentary select committee. Rather, midwives were given equal status and equal rights to GP obstetricians under the Act. This included being able to prescribe medicines and order laboratory tests and the right to use hospital facilities to deliver babies if they chose.
The Act also introduced experimental direct-entry midwifery training programmes. The first courses started in 1992 and after their three years training, midwives could practise alone in the community with no hospital internship and no supervision. While it was assumed that midwives would restrict their practices to so-called normal pregnancies and births, there was nothing in the legislation which decreed this; rather this was based on trust.
What were plusses and minuses of the situation it created?
For the government, one minus was that cost-effective homebirths did not take off as anticipated. Immediately after the Act, women liked the fact that they could engage a midwife as well as their GP – both would be paid by the government’s maternity benefit. This was definitely a plus for women but it didn’t last. Paying midwives and doctors the same hourly rate under the maternity benefit caused a budget blowout for the government, as sometimes midwives stayed with the mother for many hours, whereas doctors had traditionally only done so in emergencies.
This resulted in a new funding system from 1996 – the Lead Maternity Carer (LMC) system. One provider was designated the budget-holder and could contract out part of the services to another provider. Doctors had never worked alone and much of their budget was absorbed in contracting midwives, whereas some midwives were happy to work alone – if not at home then in the growing number of midwifery-run primary birthing units.
GPs were squeezed out of the system. This was regarded as a minus for consumers; many women wanted the involvement of their family practitioner. Another minus under the new system was accessing an LMC; there were simply not enough to go round. Those coming from lower socio-economic areas and/or specific ethnic groups (Māori, Pasifika, Indian) were particularly disadvantaged, which was often reflected in poorer birth outcomes. Postnatal care in some rural communities also suffered. The onus was on women to contract an LMC.
Many commentators, including hospital midwives, in the post-1990 era saw the lack of a hospital internship following training as a minus, hindering the ability of so-called independent midwives to deal with or even recognise emergencies. However, the College of Midwives steadfastly claimed that a hospital internship would be ‘counter-productive’ as it would initiate midwives into the ‘medical model’ and hinder them in their role as guardians of normal birth.
What are plusses and minuses now?
It sounds idyllic to have a midwifery-led childbirth system in which the midwife partners the mother from early pregnancy, through birth, and six-weeks postnatally, but this system is not sustainable and has unresolved issues. These issues, which arose from the system that evolved from the 1990s fall under four categories: access, training, philosophy, and accountability. They are themes explored in the book and summarised in the concluding chapter in relation to the Health and Disability Commissioner’s 2022 report into a recent death of a baby in childbirth.
Unfortunately, I see many minuses and no plusses. The College of Midwives and the Midwifery Council (set up in 2004) needs to be more open to multi-disciplinary collaboration in practice and in training. Babies’ deaths and injuries continue to be regarded by some as collateral damage in a celebrated woman-centred maternity system. While most births proceed without mishap, when they don’t it is tragic for the whole family, and this is even more galling when the death or injury is deemed preventable. The Perinatal and Maternal Mortality Review Committee, which gathered statistics from 2007, constantly found about 20% perinatal deaths and one-third maternal deaths could be classified as ‘preventable’ owing to provider or systemic failures.
What research was involved in writing The Best Country to Give Birth?
My research encompassed a wide range of sources. I considered what midwives themselves wrote in order to understand their perspectives. Sources for this included the College of Midwives’ journal, newsletters and archival sources, books and midwives’ postgraduate theses and dissertations.
Official sources included parliamentary debates and legislation. I analysed multiple government reports and investigations, with a careful reading of the Perinatal and Maternal Mortality Review Committee’s reports. I read the reports by the Health and Disability Commissioners and the summaries of coroners’ reports. The printed media was useful to gain an understanding of the public’s perspectives over time.
The views expressed in the book are carefully documented and referenced, with the references and bibliography amounting to 93 pages of the book.
Auckland University Press