New document on British maternity services is fundamentally unethical

The folks at the Royal College of Obstetricians and Gynecologists should be profoundly ashamed of themselves. They have participated in the creation of new clinical guidance that is fundamentally unethical.

I'm referrering to Making sense of commissioning Maternity Services in England, produced in collaboration with the Royal College of Midwives and the National Childbirth Trust. It is fundamentally unethical because it focuses on process instead of outcome. It reads like a full employment plan for midwives and childbirth educators, since that is basically what it is.

The chief goal of any maternity service or any maternity provider is simple and straightforward. The chief goal is to deliver healthy babies to healthy mothers. PERIOD. Anything else is untterly inappopriate and smacks of self-interest, not concern with patients. Indeed, this document is an object lesson in the venality and self-absorption of contemporary advocates of natural childbirth. It is in their interest to increase their employment options, but increasing employment options for a particular group has no place in a document that purports to be about patient care.

To understand what I mean, try a thought experiment:

Imagine if a group of lawyers, paralegals and casket manufacturers called for replacing death row appeals with paralegal counseling on will preparation for the condemned man. And for good measure imagine that they recommended withholding legal services of many people who have been charged with murder entirely on the grounds that they are probably guilty anyway.

Sounds reprehensible, right? But it's no different than the document in which the RCOG participated.

• Both promote saving money above improving outcomes.
• Both promote responses that are based on cost rather than on efficacy.
• Both promote replacing more highly trained professionals with extenders who cost less and are capable of less.
• Both take no account of the needs, wishes and outcomes of the receivers of services.
• Both are transparent attempts to line the pockets of the extenders and others who benefit when the patient loses services.
• Both are fundamentally unethical because they replace the best interests of recipients of services with the economic interests of government, extenders and providers of ancillary services.

It would be one thing if the British maternity system was a shining beacon of best outcomes. Then, perhaps, it might be reasonable to consider ways to provide the same outstanding outcomes with less money. That's not the case in the UK. Mortality rates are average to high (London mortality rates in particular, are unacceptably high and rising) and multiple hospital systems are facing multiple massive lawsuits precipitated by deaths that occurred when midwives insisting on managing patients that should have been transferred to doctors.

Indeed, there is precisely zero evidence that the recommendations in the report will improve anything beside the economic well being of midwives and childbirth educators. There is no reason to suppose that an effort to reduce C-sections will improve mortality rates and every reason to suppose that they will result in preventable deaths. There is no reason to suppose that with holding epidurals will improve mortality rates and we know for a fact that it will definitely increase the pain and suffering of women who are denied pain relief.

The Hippocratic oath covers this type of situation:

Primum non nocere. First, do no harm.

The RCOG seems to have forgotten that Hippocrates was referring to the patients, not to the economic interests of midwives, childbirth educators, or the government.


Addendum: For more on this subject, check out Pauline Hull's press release.