The Rise and Fall of National Women’s Hospital
Auckland University Press
Many readers will be familiar with the furore which arose when Linda Bryder‘s A History of the ‘Unfortunate Experiment’ at National Women’s Hospital (2009) concluded that Herb Green’s management of pre-cancerous lesions of the cervix was not an experiment and that Dame Sylvia Cartwright was in error. Bryder’s view was that Green’s non-interventional management of such cervical abnormalities was in line with that of other academic units overseas and, as the patients were not randomised, but treated on a case-by-case basis, the treatment was not experimental. This continues to be an area of vigorous debate (see letters in the New Zealand Listener for 19 and 26 April 2014). The Cartwright Enquiry book was a diversion from the research and construction of this comprehensive history of National Women’s Hospital for which Bryder received a Marsden Fund grant in 2003.
The hospital began in the former army hospital at Cornwall Park, but by 1964 had its own purpose-built, 11-storey building near Greenlane hospital. The astonishing energy and commitment of Stratford GP Doris Gordon in chivvying authorities and generating enthusiasm for raising funds, particularly with influential women’s groups, is a story in itself. The hospital’s mission was the “tripod” of patient care, research and teaching, an imported philosophy from University College, London, which translated into the setting of a new National Postgraduate School. Harvey Carey, who was appointed Professor in 1955, seems to have shared the same massive energy that drove Gordon. He not only set up teaching and research within the hospital, but maintained alert and cordial receptivity to many interest groups in the community. It is unfortunate that such a progressive dynamo felt driven out of Auckland shortly after the devolution of hospital control from the academic staff to the new position of medical superintendent, a move which Professor Bryder sees as the origin of the disempowerment and later demise of the postgraduate school.
Among other medical personalities, the achievements of Dennis Bonham, Ross Howie, Herb Green and Mont Liggins are very well explained, and the mana that accrued internationally because of their endeavours is appropriately celebrated. The recognition that the foetus is not a passive passenger, but an agent in its own right, is largely due to their work. The specialty of neonatology in part derives from their efforts. However, it is the in-hospital and the local conflicts over patient management which arouse a great deal of interest. The main issues in the last 50 years have been pain relief versus natural childbirth, home versus in-hospital birthing, midwives or doctors providing maternity services, abortion services, the management of cervical pre-cancerous lesions and the development of a strong consumer voice.
The major concern over whether doctors or midwives should supervise antenatal care and delivery was the subject of heated debate, without much resolution, until Helen Clark introduced the Nurses Amendment Act in 1990. This Act “made midwives equal to doctors in maternity care”. Clark stated that the bill had attracted 96 submissions and said of those which expressed reservations about safety: “While these concerns would merit serious attention if they were well based, it is my judgement that they are not.” This issue remains debatable today. The effect of the legislation was that maternity care became unworkable for GPs so that virtually all GPs had abandoned maternity care by 2005, while numbers of midwives had increased from three before the legislation to 600 in 1997.
A similar debate about the wisdom or otherwise of home births again resulted in fiery words and extravagant language. As perceived by Joan Donley, a pioneering midwife, forceful midwives’ leader and experienced practitioner, the real issues were “a power struggle between obstetricians-hospital boards, with their huge investment in architecture and technology aggravated by a falling birth rate and women who are trying to regain control over their own bodies.” She described obstetricians as “generals in the war against normal childbirth”. Such an approach left little room for reasoned debate, but did result in the provision of more friendly birthing suites and a less authoritative attitude by hospital staff. Surprisingly, even a GP argued that, in high-risk mothers, stillbirths and neonatal deaths were “a form of natural selection and (she) felt mothers were philosophical about this”. It would be interesting to know what proportion of midwives and what proportion of doctors now choose homebirth, since, if things go wrong, they do so mighty quickly, and the consequences for the infant can be lifelong and the consequences to the mother devastating.
Ultrasound technology entered the debating arena in 1970, to a cautious welcome from Professor Bonham, who warned that “the place of ultrasound in the diagnosis of twins, placenta praevia and foetal health growth is not yet certain”. However, by 1983 ultrasound was becoming standard practice. Yet again there was polarising debate, with some doctors resisting the practice of performing scans done “principally on social grounds”, while others came to accept the rationale of scans performed twice in pregnancy. It is clear that the procedure was introduced before it had been scientifically validated, which led to some consumer reaction, with some women asserting that such technology was part of an effort to disempower women and “undermine women’s confidence in, and knowledge of, their own bodies”. It is hard to know from the facts as presented how much of the hostility evident in some assessments of attitudes and practice at National Women’s Hospital were based on reasonable assessment and how much on a political agenda.
Certainly, the 1988 National Women’s Hospital enquiry caused a comprehensive reassessment of research practices throughout medicine in general and National Women’s in particular. It gave rise to greater patient advocacy, greater public scrutiny, and to national screening. It also had a major effect on staff morale which was compounded by a 1999 enquiry into “cupping’’, which is a form of chest physiotherapy which resulted in brain damage in some newborn babies. Although the enquiry found that the hospital was not to blame, it added to a lack of public confidence.
All this took place in an organisation which already experienced a frequently toxic climate of dissension between hospital and domiciliary midwives, between midwives and obstetricians and between those of conservative (often religiously based) and more liberal attitudes on the medical staff. Many of the positions adopted seem oppositional by reflex, rather than thoughtful and considered. This is particularly evident in the conflict concerning the provision of abortion services, which was a painful source of distress to neonatologists such as Professor Liley. Neither the hospital nor the wider community have been able to resolve the moral and practical issues involved.
The reading and research underlying the writing has been enormous. (There are 80 pages of notes and references.) While the stellar research achievements of those such as Liley and Liggins are well described and the evolution of patient care is highlighted, there is little about the third leg of the tripod: the institution’s teaching function. It was set up as the Postgraduate School of Obstetrics and Gynaecology and trained GPs to diploma level, trainee specialists to College Membership standard, and medical students. In his co-authored book On Being A Doctor (2013), Hamish Wilson writes:
Perhaps my worst (training) experience was in the early 1980s in Auckland, at National Women’s Hospital … . The hospital was run on a “bully system” initiated from the professors at the top. While many staff were individually good to work with, the prevalent culture was one of poor teamwork and criticism of others. Paediatric and obstetric staff seemed at times to be at loggerheads in their approach to shared care of mothers and babies, while the hierarchical structure meant that junior staff and nurses were not treated respectfully. On arriving each day at the hospital gates I developed abdominal pain ….
This experience was not his alone. It would have been interesting to learn about the experience of others who were taught at National Women’s to get some idea of how well it performed in the third axis of its “tripod”.
In 2004, National Women’s Hospital closed on the Greenlane site and was integrated into the new Auckland City Hospital building. Whether that shift was wise and will give rise to a new and better kind of training, research and patient care tripod, has yet to be seen. Certainly Professor Bryder’s clear, readable, comprehensive and thought-provoking history should be required reading for all those taking part in obstetric and gynaecological care.
Rae Varcoe is a poet and reviewer who lives in Nelson.