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26 Comments

  1. 1
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    Jon Hunt

    Err…yes. I agree.

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  2. 2
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    Louise

    Good on you Simon. I think Doctors should be standing up for what they believe in rather than being bullied into submission by the AMA. If we are to improve our health care system we have to be honest in dealing with the issues at hand such as health workforce shortages.

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  3. 3
    Jennifer Doggett

    Jennifer Doggett

    The AMA as chief health policy advisor? Please tell me this was an April Fool’s joke!

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  4. 4
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    Gary Sauer-Thompson

    Another example of a social delusion

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  5. 5
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    Andrew Pesce

    I could ask Simon whether he can nominate another organisation which articulates as far as is possible the view of the medical profession. He seems torn between criticizing the AMA for representing doctors interests too well (ophthalmologists) and not representing doctors interests enough (junior doctors). For the record, AMA attempted to bring the ophthalmologists and govt together to negotiate an outcome. The government now understands that if it wants to review Medicare Benefits, it needs to enter into a proper process which analyses evidence and properly realigns benefits paid to value of services whist reflecting the true cost of providing those services. Dr van der Weyden’s views are his as the editor of the MJA, look to our media statements if you want our view. Our stance was to suggest that if the government wanted to make savings in ophthalmology, they should consult the doctors to obtain advice regarding how this can best be achieved, not unilaterally, without consultation announce significant cuts to patients rebates. I wonder if the government decided to half the number of senior training positions in the specialty to which Simon aspired which resulted in him losing his job, whether he might take a less sanguine approach to “equitable provision of healthcare in a world of limited resources” determined without consultation by someone in the department of health.
    The AMA is the only peak body which responded to the NHHRC report with a detailed Priority Investment Plan. The PM commended the AMA for its positive engagement in the health reform debate.
    The AMA publishes the indigenous health report card. The AMA runs committees in indigenous health, public health aged care, child and youth health to promote good health policy in these areas. These are not rivers of gold for doctors. The AMA Council for Doctors in Training focuses mainly on quality of medical training as well as safe work hours.
    It is easy to take pot shots at the only organisation which significantly resources policy development for the benefit of the health system. Perhaps Simon can check the information available on our website.
    Simon has to decide whether there should be an organisation representing the views of the profession or not. If not, so be it. If there should be, and in Simon’s view there is one which better represents those views than the AMA, he should join it. If there should be, and the AMA is it, then he should join and work towards combining representation and advocacy, which is always a difficult role for anyone who has tried it.

    Andrew Pesce
    Federal AMA President

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  6. 6
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    Simon Quilty

    Dear Dr. Pesce,

    Thank you for engaging with me in my concerns, I am flattered that you have taken the time to respond.

    I can nominate a professional organization that appeals to me much more than the AMA. The Public Health Association of Australia articulates more than just the view of the medical profession. This is an organization with a broad base of intellect in all areas and all meanings of that complex word “health”. The PHAA is not marred by conflict of interest and keeps it’s sights on the utilitarian delivery of all things that make people healthy, including but not solely doctors’ opinion.

    Perhaps I misunderstand but you appear to use the example of opthalmologists as a demonstration that you are trying to work out an equitable balance. So now that the opthalmologists have won, what is the AMA going to do to redress this situation that is so obvious to everyone in the know?

    And in response to your hypothetical question about the government cutting in half my training program, well it is hypothetical and will remain that way forever for most doctors, with or without the AMA.

    With due respect, let me ask you another hypothetical – what would happen if the AMA successfully lobbied the Royal Australian and New Zealand College of Opthalmologists to double their intake of trainees? There would be a lot of happy registrars, AMA membership would go up, the waiting lists that RANZCO are so concerned by would drop off over the years, and let’s not forget the poor old blind pensioner – sight-saving cataract surgery would remain at a competitive price.

    Dr. Pesce, I work at the coalface, and what I now understand deeply concerns me. Daily I witness over-servicing, over-prescribing, over-investigating, and so do my junior peers. The pharmaceutical industry has infiltrated every lunchtime meeting bringing gifts. These are real problems.

    I see doctors who are making tens of thousands of dollars a week and adding very little value. Whilst most of my colleagues are ethical and hard-working, there are many who are motivated too much by money and not enough by their patient’s welfare. This is a much greater problem than the concerns raised by the AMA about Nurse Practitioners.

    The AMA doesn’t represent me, and it doesn’t represent the majority of my peers. Perhaps this is a glitch representing my workplace, but perhaps the AMA is losing its future membership base. Correct me, you know your membership stats.

    I am not embarrassed by my idealism, and nor are many of my colleagues. I will join the AMA when the chasm between its media releases and my understanding of these very complex issues is bridged. But tonight I’ve just done what I’ve been meaning to do for a while. The PHAA has another member.

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  7. 7
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    ST

    Not sure whether I feel more depressed that the AMA doctors’ organization is so deluded that it believes ‘health policy’ = ‘doctors views’; or that the government is so deluded it doesn’t see this powerful industrial union always putting its own vested interests first and foremost.

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  8. 8
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    Tania

    Couldn’t agree more re: Simon’s comments! I’ve had exactly the same type of experience with a certain allied health professional Assn which coincidentally i am now no longer a member of! I found them way too clinically focused with little attention paid to population health issues, plus the cost was staggering (especially considering the benefits…). It seems to be a familiar story though and one of the key issues with health orgs such as the AMA is the ‘old boys’ club culture (this is not unique to the AMA BTW). Its all about power though, especially in regards to doctors, and once people have power they don’t want to give it up. After all, doctors are the gatekeepers of the system and don’t you nurses or any of you other allied health professionals forget that!!

    I also agree that a social determinants of health approach is sorely needed. Need to stop spending all our time and money saving the people that have floated downstream and actually look upstream to see if we can prevent them from, or at least minimise the risk of, them falling in there in the 1st place. I mean just imagine if people actually had control over the determinants of their health…

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  9. 9
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    Andrew Pesce

    Congratulations Simon.

    I hope you become an active member of your preferred organisation and we all work towards improving the health system for all Australians. I am glad my contribution has brought about a positive outcome. Remember health advocacy is a difficult and sometimes tiresome task. Stick with it for the benefit of your patients. I can see you are genuine in your commitment, I can assure you so am I and the AMA.

    I also work at the coalface, and daily see the results of poor administrative decision making in the health system which a am determined to improve. It is the major reason I decided to become AMA Prsident, and double my workload whilst halving my income.

    For your information, the AMA has been at the forefront of lobbying governments to fund extra training accoss the broad range of specialties in medicine and surgery, and has welcomed the recent commitment by the fedral government to substantially increase training places. See http://ama.com.au/node/5404.

    Good Luck

    Andrew Pesce
    AMA President

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    OB FreeZone

    And what coal face what that be Dr Pesce? The spindoctoring to the media with statistics plucked from thin air about how dangerous homebirth is? My current favourite “statistics” you spouted was to The Australian last week; “Unfortunately a lot of women who do have risk factors continue to try [to] give birth at home. And that’s where you get babies dying, for example in the case of twins, where there is a one in eight chance during homebirth that one of them will die.” Where did you pull this one from Dr Pesce? I didnt realise you were a proctologist.

    I was speaking to my GP the other day about how you have helped destroy womens choices in this country but essentially making homebirth illegal. And he made of saying to me “Dr Pesce is not MY president”. He didnt see the point of being a member of such a pompous group of backslappers who didnt seem interested in anything but themselves.

    Seems he isnt the only one 😉

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  11. 11
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    Peter Sumich

    Simon
    You sound young and a bit angry and you remind me exactly of myself as I battled through the hospital system. After you do make it through training and gain a fulfilling career I suspect that you will want a strong body to represent your interests and those of your patients to a Government bureaucracy which can seem inpenetrable and autocratic.

    You would indeed be angrier if any Government acted unilaterally and without consultation with our profession in matters which they did not fully understand and which affected your patients adversely.

    Those of us who join the AMA choose to do so in order to have our concerns listened to at the highest levels of Government and a body which acts for the benefit of patients and their doctors. You would be surprised to realise how often these two groups have coinciding interests. You would also be surprised to realise what a broad church the AMA represents and how many competing and dissenting voices it contains.

    Some principles of decency and medicopolitics are however mandatory and consultation with stakeholders is one of these.

    The Cataract rebate decision to which you refer was grossly unfair to my pensioners who have no realistic access to Westmead Hospital within a a timeframe of years. The Government did not consult any group prior and did not listen to any reasonable discussion on the issue.

    We are not living in a totalitarian state where this is acceptable and certainly not with a major policy decision such as this.

    The AMA became involved when the ALP started running a dishonest and factually inaccurate attack campaign to denigrate doctors and rebrand us all as self interested. Up until that point the AMA had simply urged the two groups to engage meaningfully and highlighted to effects on gap payments and public hospital waiting lists.

    And to address the trainee issue, the limitation on training positions is due to the finite and limited volume of public hospital surgery which can be done. You cannot train more surgeons if you do not have the theatre time and cases to do it. Those who gain a training post need a certain minimum surgical exposure to make them safe enough to be let loose in the system.

    Sincerely
    Dr Peter Sumich
    Chairman, Independent Ophthalmologists Network

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  12. 12
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    Andrew Pesce

    Dear OB free zone

    4 out 31 twins born at home for home birth in UK database 2002-05 did not survive compared to matched cohort of 1 death out of 303 twins born in NHS maternity units.
    Published in BMJ online 22 June 2009.

    Best Wishes

    Andrew Pesce

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  13. 13
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    Gavin Mooney

    Dear Dr Pesce

    Sitting here in Cape Town, I am writing to you as the self-appointed Chief Health policy advisor to all political parties. Yesterday I attended a community meeting in Khayelitsha just outside Cape Town and, after Soweto, the largest township in South Africa.

    It is a place that knows quite devastating sickness and premature death on scales that are truly horrendous especially in the wake of the AIDS epidemic but also becasue of the grinding poverty and inequality in this country. That inequality is now worse than in 1994.

    The public health services here make one weep – many dedicated caring professional but so severely overstretched. A refugee from Zim, Tinashe, living in Khayelitsha whom my wife and I have befriended, has TB – as do so many of the poor in this country. But getting treatment is very difficult and it is made so much more difficult because the political parties to whom you are chief advisor continue to steal doctors from this country. The last time I looked I could see not one AMA media release speaking out against this depleting of the grossly overstretched medical staff here.

    If, as you claim, you are this “Chief Health Policy Advisor”, how about advising these politicians to stop or discourage this stealing of doctors or as a minimum to offer the South African people reparations? As starters however you might get your own organisation showing some compassion beyond Australian shores.

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  14. 14
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    Andrew Pesce

    Nice to hear from you Gavin.
    I worked at Baragwanath Hospital and am familiar with the spectaular health problems of the Soweto community, although it was before the AIDS era so things are undoubtably worse now in South Africa.
    At risk of being labelled a self interested old boys club AMA president,I believe that all goverments of the developed world should commit to supplying their own medical workforce and not import doctors from overseas except as a last resort. In the event that is necessary (and I am afraid governments will always make decisions in the interests of their electorate) I believe they should pay the cost of replacing the doctor they have recruited to the government of the imported doctors country of origin. This would a) provide some financial assistance to those countires to train more of their own doctors and b) provide a cost disincentive to what is essentially poaching a fully trained doctor for free at the expense of other countries. Even if we “poach” a UK doctor, they poach a New Zealand one, who poach a South African one, who get one from Zimbabwe, and God help the country at the bottom of the food chain.
    I once mentioned this idea to a previous President of the BMA, and was astounded at the violent reaction. I have mentioned it to politicians of both sides of politics here, who I am afraid see no gain in the proposal.

    So between doctors training issues, global health, opthalmology rebates and home birth the AMA does involve itself in many issues. Some involve doctors incomes, most don’t
    By the way, the fish brai in Kalk bay is still open, it’s well worth a visit for a sunset dinner.

    Andrew Pesce

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  15. 15
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    Fiona

    I have to say that I am horrified to see that the AMA thinks it should be the “chief health policy advisor” to all political parties. Just how exactly does this accurately reflect the importance of all disciplines in providing effective healthcare to all? How does this accurately reflect what the general public wants in the provision of health care? How exactly can the AMA justify it’s stance that only doctors are capable of influencing policy that affects other professionals who practice within their own regulated professional frameworks that are structured according to evidence based practice and specific laws and ethics?

    It appears from Dr Simon Quilty’s experience that the AMA does not accurately reflect the opinions of many Australian doctors and that in fact it struggles to represent the interests of Australian doctors, serving only to attempt to protect their interests; so how on earth could the government allow them to attempt to be the chief influence on health policy that then affects the population of an entire country?

    It is all well and good to aspire to and “work towards combining representation and advocacy, which is always a difficult role for anyone who has tried it” and I think this is an admirable and disarmingly honest view. However, if the president of the AMA finds it a challenge to both advocate for and represent a single profession when that is the main objective of that organisation, then surely attempting to advocate for and represent all other health care professions as well as the best interests of the public (which I believe is essential in the development of health policy and provision of effective health care) is well beyond the grasp of the AMA.

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    Tallulah

    How outrageous for the AMA to be proposing itself as “Chief Health Policy Advisor”! It should be putting its own house in order before it proposes to advise others, and bring the medical profession into the 21st Century. I come from a town where the Director of Obstetrics at the public hospital was caught assaulting women with the evidence being backed up by women and midwives, yet instead of having his registration removed, he is given a 6 figure pay out and is currently in private practice in the very same town. Similarly the Butcher of Bega, was well known by other doctors to be a mutilator but there were no consequences until women got together and forced action. http://www.dailytelegraph.com.au/news/sunday-telegraph/revealed-the-butcher-of-bega/story-e6frewt0-1111115628451 The same has occurred in Bundaberg with Dr Death, where the AMA and the rest of the medical profession couldn’t respond to dangerous incompetence in their own ranks. Consumers and nurses had to blow the whistle for years to get any response. http://www.theage.com.au/news/General/The-scandal-of-Dr-Death/2005/05/27/1117129900672.html Doctors are unaccountable and a law unto themselves only pretending to be regulated. To have the AMA proposing to represent the interests of the public is diabolical.

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  17. 17
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    Jonny Levy

    Dear Drs. Pesce & Mooney,

    I know we are straying “off topic” slightly – but the issue is important and goes to the heart of the AMAs raison d’etre – in the wider context.

    Australia does poach doctors from countries that can ill afford to train and then lose their medical workforce. It is natural that the Federal Government here would not wish to change that, as it provides a band-aid solution to rural and remote Australian medical workforce provision.

    The only way to change this status quo is to force legislative change.

    If s19AB and the 10 Year Moratorium were to be phased out and replaced by the requirement for all Australian medical graduates to serve some time “out bush”, there would be no need to poach doctors from third-world countries.

    I understand that mandatory rural work would not be popular with many, but foreknowledge of the policy may, with time, well attract a different type of person into medicine. It should be noted that the police and teachers embraced this years ago.

    It would also lead to a highly trained post-graduate workforce with additional skills gained from such placements – who would be able to contribute to to relieving some of the pressure on tertiary hospitals and EDs in the metropolitan arena.

    The current policy regarding overseas-born doctors in Australia is deeply wrong – on many levels. New Zealand recognised exactly this when it overturned its version of 19AB in the late 90s.

    I welcome the AMAs advocacy for policy change last year.

    Will the AMA now push to scrap s19AB (beyond just making a statement to this effect) and help to end Australia’s poaching of much needed developing-world doctors?

    Cheers,

    Jonny Levy.

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  18. 18
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    midwife

    Well done Simon.
    It takes a true professional to take a stand. I admire your strength for confidently putting aside the chest-beating-addiction of the AMA for an effective and preventative health system. A functional and effective Health System relies on a spirited team, combined skills and genuine caring and advising the government wisely across the broad spectrum of health professionals. In my opinion ‘Chief Pesce’ has done nothing to create professional unity and continues his attempts to control other health professions. He is an AMA living legend, in his attempts to destroy midwifery, homebirth and nurse practitioners and then blames ineffective administrators for doctors self interest and greed. Poor Andrew he “decided to become AMA President…double [his] my workload whilst halving [his] my income.” Interesting! The largest proportion of health professionals work longer hours, receive smaller incomes, provide equally important services for Australians and most enjoy their professional work on more cost effective incomes.

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  19. 19
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    Free

    Another layer of bureaucracy delivered by the AMA to politics with a strong agenda. I find it rather frightening.

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    shell

    Dear Dr Pesce

    Thanks for the twin death rates Dr Pesce- although after your track record with interpreting statistics on homebirth to suit your own agenda I’m sorry but I won’t be taking your word for it. You seem to be willing to pull these statistics out of your hat to justify your agenda – what about the thousands of babies who die or are injured during childbirth in hospital every year? What are you doing about that?

    You have aggressively lobbied the Federal Government on maternity reform and as a result have left thousands of women around the country without any assurance as to whether they will be able to employ their care provider of choice – a private midwife.

    You might not agree with home birth Dr Pesce – but this is not just about what you and other obstetricians want or believe about birth. Have you even been to a home birth? The majority of families who are lucky enough to have one say it is one of the most amazing experiences of their lives – and you are taking that away to protect the interests of your profession.

    Once the women and babies start arriving at the doors of your hospitals from women who continued to assert their fundamental human right to choose their place of birth (home) and could no longer employ a skilled care provider to care for them during birth due to the legislative changes you have lobbied for – what will you do then?

    You have traded the rights of mothers and babies for financial and political gain. I’m glad to hear many Doctors don’t support you. Most Doctors I talk to are NOT members of the AMA – I hope that the power unbalance here will be addressed by the medical community as a whole in the greater interests of health and human rights for all Australians now and in the future.

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  21. 21
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    Gavin Mooney

    Dear Andrew

    You write: “I believe [the importing countries] should pay the cost of replacing the doctor they have recruited to the government of the imported doctors country of origin. This would a) provide some financial assistance to those countires to train more of their own doctors and b) provide a cost disincentive to what is essentially poaching a fully trained doctor for free at the expense of other countries.”

    This is wonderful and I thank you for that. I have crossed swords with a previous incumbent in your position and got a very different response – so this is delightful!

    So what to do to change things?

    Three suggestions:

    1. Draw Australian politicians’ attentions to the fact that a poor country – Cuba – is able to export doctors. So why can’t we?

    2. While your suggestion of paying the costs of training is excellent and certainly a good place to start, maybe what we need additionally is to estimate the ‘health costs’ of this poaching. For every South African doctor we poach, what is the benefit in terms of lives saved/ health gains for Australians? And at a cost of how many lives/health losses for South Africans?

    3. There are many South African doctors in Australia – there is a rumour that in Perth hospitals Grand Rounds are bi-lingual – in English and Afrikaans. What about the AMA setting up a fund to which these doctors (and other Australian based doctors) might contribute which might be used to help to fund a clinic in Khayelitsha or to provide food to the poor of that township?

    Even the AMA President in his role of Chief Health Policy Advisor has his limitations I am sure and while you continue to work on the pollies on this issue broadly could the AMA move on this fund quickly? Even if it came up with only say $5000, what a difference that could make!

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  22. 22
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    Michael Maw

    The AMA as the chief health policy advisor to all political parties.
    This is a novel concept for an organisation that, in my opinion has actively demonstrated its subterfuge and ignorance around chosen areas of health provision. As an example; The AMA policy statement on Nurse practitioners includes a blatant misinterpretation of what occurs in rural Australia. The AMA statement claims that “Nurses do not substitute for general practitioners” The same AMA position paper goes further to state that the role of a nurse in the primary care setting does not include formulating medical diagnosis or independent ordering of radiology amongst other descriptions. I have spent many years in rural and remote practice. Working at times over 700kms from any medically trained colleagues I can ensure Dr Pesce that this nurse has indeed formulated a medical diagnosis on many hundreds of occasions (Note also to the potential chief policy advisor to all parties: An accepted definition of a medical diagnosis for all of us is “identification of a disease from its symptoms”)
    If only Dr Pesce could have witnessed driving through the desert at night with a patient who had his fractured arm diagnosed by a nurse, Dr Pesce could have observed the same nurse order, take, then manually develop his radiographs plus interpret the dripping wet films independently prior to applying a plaster slab. Some of my wonderful friends who are GPs agree that this is indeed an example of a “nurse substituting for a general practitioner”!
    The AMA states “Australia already has chronic nursing workforce shortages and it makes little sense to seek to transfer more work from doctors to nurses in such an environment.” Thanks for the concern, but as an authorised Nurse Practitioner with over 20 years experience and formal post graduate qualifications in prescribing and immediate medical care from the royal college of surgeons I am happy to continue providing the best quality care I can manage for the people I am fortunate enough to treat in “such an environment”.
    I have been privileged to enjoy the camaraderie and support of working collaboratively with teams of enlightened passionate allied health staff, nurses and some health care providers like Dr Simon Quilty who was quoted above. I commend Dr Pesce and his AMA colleagues for the passion they also bring to the health care debate. I only wish they were better informed, transparent in intent, and remained strictly factual in policy areas where they seek to express opinion. If it comes to a vote I hope they understand that this nurse will not be recommending the AMA leader as my preferred chief health policy advisor.

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  23. 23
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    laural

    Dear Andrew Pesce,

    My response is in regards to your statement, “Unfortunately a lot of women who do have risk factors continue to try [to] give birth at home. And that’s where you get babies dying, for example in the case of twins, where there is a one in eight chance during homebirth that one of them will die.”
    I believe this statement to be a bit one sided. I have, in fact, read the study and yes the author did attribute breech birth and twin pregnancy to higher death rates. However you failed to mention that the author also found that for low risk women, giving birth at home is as safe as giving birth in hospital and that in fact clinical outcomes across a range of variables are much better for women using an independent midwife. In support of the above, a recent study carried out in Sweden found that the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries(Lindgren, H. a; R destad, I, Christensson, K, Hildingsson, 2008)

    I have no problem with you stating the latest literature, as long as you present the whole picture when doing so. This ‘picking and choosing’ what you are going to mention in the media is unethical.

    My belief is that if woman felt that the obstetrician was going to listen to them and respect their wishes, they would not feel the need to homebirth when pregnancy was high risk.

    As the study you mentioned states, “Health systems will need to cultivate models that foster open referral and consultation between professional groups and most importantly make genuine efforts to include women in decision making”.

    In our current health system this is not the case.

    If I wanted to be sensationalist I could pluck snippets from the research you mentioned as well. I could state that babies are at risk of prematurity and are more likely to be admitted to neonatal intensive care unit if they are born at hospital compared to homebirthed babies. This however would be fear mungering, but if I pick and choose what I want to highlight in the research, as you have done, I easily could have.

    Further research on the subject of twin births and homebirth obviously need to be done. But one study based on such a small number of births, is not enough to close the matter and label twin births at home dangerous.

    I see everyday first hand how our current maternity system leads to poorer physical and emotional health outcomes for woman.

    It sounds from your previous replies you are a rational and well meaning man. I ask that you reflect on your beliefs surrounding homebirth taking into account the other components the study mentioned. I also ask you to listen to the thousands of maternity consumers who are asking for change in our current maternity system. Woman need continuity of care THIS is clearly reflected in the literature. Let this be reflected in your policy making and your media statements.

    Laura

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    bigboysgirl83

    I wish there were more people like simon and the rest of you with like minds, the AMA says alot but what does it really do??. My twins died at the Bundaberg Base Hospital due to the fact that my doctor deemed that survival of a preemie was over 28 weeks and made a comment of the same to the HQCC, the reason my babies died was simply due to his opinion and therefore not coinciding with his opinion he decided that no treatment was required, I quote, “statistically,Lillee wasn’t worth saving”, this is his response when my husband and i asked why nothing had been done to try and prevent the death of my children, Dr Pesce, is this a response you would give a grieving mother?, would you endorse this?. This is what the public has to deal with everyday, whats being done about it?. (Readers please note that this comment has been edited for legal reasons).

    Reply

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