The findings were unexpected – so the Health Ministry tried to undermine a maternity study
their population to women who were having single births and term births to make them more alike. Then they collected information on characteristics that differed between the groups and statistically adjusted for them. The results remained.’’
Though maternity was not Sarfati’s usual area, she knew any research critical of the system was likely to be controversial. For this reason, she contacted the ministry well before the study had been accepted for publication in Plos Medicine, a high-ranked, peerreviewed medical journal.
She and Wernham met Tuohy and Pelvin and went through the results, in person and by email, describing their methods and how they had adjusted for bias.
‘‘In the end it didn’t seem to make much difference at all,’’ says Sarfati now. ‘‘They had nearly a year to consider their response, and in the end their response was largely to discredit the research.’’
THE BREAKDOWN
Initial contact between the ministry and Otago University researchers had been positive. In December 2015, Tuohy thanked Sarfati for her ‘‘ethical’’ approach, writing: ‘‘I think with careful handling it could be a catalyst for ongoing quality improvement in the maternity sector.’’
A meeting in June 2016 involved Tuohy, Pelvin, thenCollege of Midwives chief executive Karen Guilliland and adviser Lesley Dixon, and Sarfati and Wernham.
After this meeting, Sarfati and Wernham sent a joint email to attendees thanking them for the meeting, reiterating their support for a midwifery-led model of care and saying they were on board with avoiding media fallout and criticism of maternity care.
Shortly after this, the ministry’s communication staff contacted Otago University about ‘‘messaging’’. In the meantime, Pelvin and Guilliland were exchanging emails. ‘‘The ministry understands that there are NO plans for any press releases to be made regarding the publication of the paper but we, yourselves and the University of Otago will have statements ready in case anybody picks the paper up,’’ Pelvin wrote.
‘‘We are likely to take a systems approach and support the system NZ women have and point to other markers . . . my idea would be to raise questions about the women looked after by [obstetricians] compared to midwives and raise any other questions – eg, rurality or anything else they may not have standardised for.’’
As publication neared, the relationship began to break down. The ministry drafted a misleading media release that questioned the study’s findings and contained inaccuracies, including that the study had found no differences in the death rate for babies who had midwifeled or doctor-led care. Sarfati pushed back, telling the ministry the study had been through vigorous scrutiny.
In mid-September, Sarfati was sent an excerpt from the College of Midwives’ national committee minutes, criticising the yet-to-be-published research.
She emailed the ministry: ‘‘Obviously this is a major breach of confidentiality. But perhaps more importantly, and given all the communication there has been on this issue, it would be a real shame if this was the level of response . . .’’
In the days before publication, Guilliland made it clear where the college stood. ‘‘We have . . . done some investigation of the research and have found several issues with the analysis that makes many of the authors’ assumptions questionable and we will be vociferous in voicing these,’’ she wrote in an email.
She reiterated her views in a further email, also sent to ministry officials and several college staff. In it, she accused the authors of ‘‘scaremongering’’ and bias, saying the study had a ‘‘lack of credible analysis and discussion’’ and ignored the better resources available to private obstetricians.
When the study landed in September 2016, the College of Midwives said the comparison between care was unfair, as midwives would look after more young, sick, and rural women. The ministry speculated that contributing factors could include women under the care of midwives being more likely to be ‘‘younger, overweight, nonEuropean, to have higher deprivation and to smoke’’.
In the weeks after publication, Pelvin emailed a ministry colleague, dismissing the study and its data as ‘‘unreliable’’ and saying she had ‘‘no clue’’ how it obtained its results.
Tuohy sent a reassuring email to Guilliland, saying the study contained ‘‘major methodological flaws’’ and would ‘‘soon be consigned to the back pages’’.
THE AFTERMATH
Independent policy analyst and researcher Jess Berentson-Shaw co-directs think-tank The Workshop and is the author of A Matter of Fact: Talking truth in a post-truth world. She says the midwifery-led maternity model was a major policy change that, like many others in New Zealand, was never evaluated.
‘‘We should always be exploring what models of care are working best for the people they are supposed to serve – mothers, babies, families – and that includes midwives themselves. We can’t shy away from it, shut it down, or pretend it doesn’t exist.’’
In maternity, with its historic power dynamics of a women-led profession fighting for autonomy, questions about the system were often not considered objectively, she says. ‘‘There’s this feeling that you can’t critique maternity care without critiquing midwives.
‘‘How has it got so unconstructive? How has this happened to the point that we cannot have a conversation about standards of care?
‘‘If we do this well, everyone wins. The evidence shows us midwife-led care can be really safe care and, if this is not always happening, how can we make sure the outcomes we know are possible are happening?’’
Guilliland has retired from the College of Midwives. New chief executive Alison Eddy says the college entered discussions with researchers in good faith. ‘‘Given previous experience, we also expressed concerns that the media may misinterpret the paper to criticise midwives and maternity care, potentially creating unnecessary anxiety in women and their families. The college believes there is an inherent gender bias that characterises some media representations of midwifery and maternity services negatively.’’
It maintains the study used a ‘‘lower-level quality of evidence’’ with limitations because of its retrospective design.
However, Eddy agrees further research is necessary, to ‘‘more fully understand what is influencing the findings and unpick the reasons for these differences’’. The under-valuing of midwifery, lack of maternity funding, higher-risk pregnancies and poverty undoubtedly have an impact, she says.
While Eddy had not been party to correspondence about the study, she says the college had the right to constructively criticise and review research that was likely to mislead and cause unnecessary anxiety and distress.
Though Sarfati never spoke to the National Maternity Monitoring Group (NMMG), it considered the study and recommended the ministry develop a ‘‘co-ordinated maternity research programme that recognises the need for improvements within an already high-quality . . . system.’’
In February 2017, the ministry told the NMMG it was considering working with the Health Research Council (HRC) to commission research proposals in maternity, and had discussed research areas. It was forming a group to direct this work.
But two years later, in response to questions from Stuff, the ministry would not say if it had done any of this. Instead, it pointed to Lynn Sadler’s study, commissioned before the Wernham study by the last government, as covering off questions raised by the research.
‘‘We support the findings of Sadler . . . that is, that graduate midwives in New Zealand provide safe care when comparing their performance with more experienced midwives. The message is that pregnant women in New Zealand can have confidence in our midwives. When compared internationally, New Zealand women receive excellent care.’’
Its meetings with university staff were not unusual, it says. ‘‘We respect their work and value our relationships with them as with other tertiary institutions. Regular meetings are part of those relationships.’’
Sarfati doesn’t know what she could have done differently. ‘‘It was so draining and exhausting
. . . It had a big impact on Ellie and me for quite a long time, and despite all our efforts it had no impact at all.
‘‘All we were trying to do was evaluate this major policy change . . . It suggested there were problems, which isn’t to say the entire system should be thrown away, but you need to address them like any professional group should.’’