Medicine for the Rich, Medicine for the Poor

A private midwife service established at a public hospital is being seen as a threat to the country's health system.

A private, personal midwife and nursing service was recently installed in the maternity department of Sheba Medical Center. The new private service - like the private physicians service at Sheba - is operating without any authorization from the health, finance or justice ministries, despite the opposition of the health minister and his top officials, and despite the fact that private nursing and medical services contravene a whole list of laws and regulations.

The service (detailed here for the first time) is run by the "Sheba Maternity Club," which enables pregnant women to hire midwives from a list of 30 maternity nurses on the department staff. The list includes Ilit Mashiah - until six months ago the head maternity ward nurse, and the wife of Prof. Shlomo Mashiah, head of gynecology and obstetrics at Sheba. The cost of a private midwife is NIS 3,900. This covers the presence of a nurse during delivery, along with the regular medical staff. Sheba says private midwives attend 5-10 percent of the estimated 10,000 deliveries a year at the hospital.

This is the first private care-giver service in a public hospital in Israel. It was set up without any discussion in the Health Ministry, and despite the objections of Health Minister Nissim Dahan, who is "firmly opposed," say his aides. A month ago the ministry's legal adviser, Mira Hibner, asked the hospital not to introduce the service. The ministry's head nurse, Shoshana Riba, told the minister that the service is "illegal" and only the minister and the director-general may authorize a private medical service.

Five years ago, before the new private service was introduced, Sheba made a private doctor available - including one to perform Caeserean sections - through the research fund and the supplementary medical insurance funds. Ichilov, Assaf Harofe, and Rambam - all state hospitals - also allow a choice of private doctors, although none received legal authority to do so.

Private medical services have long been under discussion in the Attorney General's Office. In recent months, stormy arguments have raged among senior nurses in the state hospitals about the private care-giver service at Sheba. The argument began in August after the organization of midwives told maternity ward nurses about the service. The organization said it was working "in coordination with the care-givers department in the Health Ministry" and it had met with the ministry's head nurse, Riba. She says the care-givers service department, which she heads, "is in no way promoting the cause of personal midwives."

The midwives organization distributed to the maternity nurses a detailed proposal for offering private midwife services similar to those at Sheba. The proposal was written after head nurses in maternity wards held a series of meetings with Riba. Six nurses from Hadassah Hospital, Beilinson and Ichilov wrote the proposal. The maternity ward nurses and heads of care-giver services departments in the hospitals were asked to comment on the proposal.

The service is a response to growing demand by pregnant women for personal midwives, the proposal says, adding that it will increase revenues for the hospitals and the midwives. It also claims that the service "will improve maternity results" to the satisfaction of both the mothers and the midwives, and increase competition between the various staff members of the care-giving services.

According to the proposal, private midwife services are available only to pregnant women who are at low risk - healthy women who reach full term without complications and no previous surgery, and women whose baby will not weigh more than 4.5 kilograms at birth.

Private midwives, according to the proposal, chosen by the pregnant women, build a "birth program" with the woman and her spouse, holding meetings with them before and after the birth. Guidance on such issues as nursing is included. Telephone consultations are also part of the deal, and the couple signs a "birth contract" that includes the payment details and a 30 percent bonus if the birth takes place in the evening or night, or on a Saturday or holiday.

The proposal sparked fierce opposition from senior nurses in hospitals outside the Dan region. Tamar Avid, for example, head of care-giving services at Barzilai Hospital in Ashkelon, wrote to Riba in October that the proposals were written without consulting nurses from outside the center of the country, "and we don't regard that positively.'"

She wrote that she took a "grave" view of the process. "It's unthinkable that a few large hospitals will dictate policy for the entire country and that you - Shoshana Riba - will approve these processes ... the private birth program is a disgrace to the profession. We are lending a hand to creating medicine for the rich and medicine for the poor. I expect care-givers to be here to help the weak. We are not America. As a leader of care-givers, I expect that we should come out with a call for quality service, at the highest level, to all members of the population and not only the people with financial means. I hope that the proposal for private midwives is shelved."

Masha Hechtlinger, of Soroka Hospital in Be'er Sheva, which handles more births than any other hospital in the country, is also vehemently opposed to the proposal and announced she would try to foil it.

Only after the protests arose did the ministry wake up - even though the Sheba service has been operating for months. In early November, Gabi Bin-Nun, deputy director general at the ministry and one of the most stubborn opponents of private medical services in state-owned hospitals, wrote to the ministry director-general warning against "creeping privatization" in the hospitals. "We'll find ourselves on this slippery slope with a personal nurse, a personal anesthetist, a personal physiotherapist, personal X-ray technician - everyone costing extra."

A month ago, attorney Hibner proposed that the ministry issue "immediate" instructions to all hospitals to cease offering private medical services, including the maternity service. A week later, the ministry director-general told her to start drafting the instructions. According to the ministry, Hibner is "still working on the formulation" - even though Hibner was the one who noted the urgency of the need to distribute them through the system.

HMO chief calls for legal action

Prof. Dan Michaeli, chairman of the board of Kupat Holim Clalit, the largest HMO In the country, demanded earlier this week that Health Minister Nissim Dahan and Attorney General Elyakim Rubinstein take action to "protect public health services in Israel," and immediately cease "the corrupt phenomenon" of private midwives in the Maternity Ward in Sheba Hospital at Tel Hashomer. He called for them to take legal action against all those involved in establishing private medical services at the state hospital.

Michaeli, a former director general of the Health Ministry, wrote to Dahan and Rubinstein that "if anyone doubted the destructive results of the private medical services and their dangers to the existence of public health services, this is the proof. Right now it's 30 nurses at Sheba, and tomorrow it will expand to include all the midwives in the state hospitals, and the day after that, there will be private dialysis nurses, intensive care nurses, etc."