To the Editor: Pesce’s criticism of midwifery practice at Mareeba District Hospital1 requires rebuttal. His implication that the service is inefficient or pandering to “the powerful sway of maternity care politics” is incorrect and insults those who struggle to provide woman-centred care in a system focused on doctors.

A private obstetrician in Sydney cannot understand midwifery workloads in a rural hospital without knowing the local environment and other impacts on the way clinicians work. The small group of midwives in Mareeba provide a highly valued service in their community, with few of the ancillary services taken for granted in metropolitan areas.

In routine antenatal care, Dr Pesce presumably orders blood tests and then reviews the results filed in the chart or placed on his desk. A Mareeba midwife providing the same service will also perform the venepuncture, prepare a slide and spin the blood, arrange transport to the laboratory, make the next appointment, and file the results in the chart.

A Mareeba midwife’s workload includes, among other things:

• Comprehensive perinatal care of inpatient midwifery clients;

• Postnatal and neonatal transfers from Cairns Base Hospital (CBH) (eg, to establish breastfeeding for low birthweight babies);

• 35–40 paediatric admissions per month;

• Emergency stabilisation and transfer of high-risk presentations (eg, a woman planning delivery with a private obstetrician in Cairns will nevertheless present to Mareeba when in labour at 32 weeks);

• Follow-up of high-risk or disadvantaged women who should attend CBH, but won’t for various social reasons;

• Lactation and parenting support for Mareeba women, regardless of where their deliveries occur;

• Pap smears and vaccinations; and

• Indirect care, including policy development, data collection, compilation of reports, professional development, inservice training and education.

Pesce also criticised the low level of epidural use at Mareeba, which he says reflects a lack of access. However, models that provide one-to-one care in labour and promote continuity of care have been shown to decrease all interventions and increase maternal satisfaction.2,3 Perhaps the high use of epidurals and other interventions in modern tertiary units reflects a lack of access to such beneficial, woman-centred models of care.

In reply: I am surprised that Hawksworth feels my editorial1 was critical of the Mareeba birth unit. There is no criticism of midwifery practice at Mareeba contained in the editorial.

Several midwives have commended me for my support of the need for rural maternity units to evolve sustainable models of care based on the local workforce and infrastructure. Conversely, I received a few snide remarks from some obstetricians who felt that I had been too supportive. I have usually felt that when one is criticised by both sides in a controversial debate, one’s view is likely to be reasonable.

I stand by my comments that the resourcing of the unit, based on staff–patient ratios and the availability of a nearby alternative service, would be the envy of many rural medical, surgical or community health teams.

I also stand by my comments that a 1% rate of epidural use is more likely to reflect lack of access to an epidural service, rather than true patient preference. Reviews by a well known midwife of birth centre care and continuity of care confirm that these models of care decrease the use of epidural anaesthesia but are still associated with a 15% epidural rate.2,3 I am certain that if an epidural service were available, at least some of the Mareeba women would be grateful to have access to it.