Call the midwife: Ireland’s 1950s childbirth model needs to change

Women are seemingly to blame for Ireland’s poorly performing maternity services, including a fourfold increase in Caesarean section (C-section) rates in 30 years. New research from the Economic and Social Research Institute (ESRI) found that women “have a worsening risk profile”.

They are too old at first pregnancy, too fat and have health problems such as diabetes and high blood pressure. Almost one-third of all babies born in Ireland’s 19 maternity units/hospitals are now delivered by C-section, more than twice the rate recommended by the World Health Organisation.

The main policy implication is “that funding and staffing levels in maternity services have not kept pace with either the number of births or risk profile”.

Obstetricians interviewed on RTÉ Radio about the findings said they had been calling for more obstetricians for years and this research proved they were right. Prof Michael Turner said, "Although many of the obstetric trends are challenging, Irish maternity units continue to deliver results which are among the best in the world."

Well no, they do not. Ireland ranks 22nd out of 179 countries in the Complete Mothers’ Index 2015 ,which measures, among other things, maternal and infant mortality rates. More obstetricians are not needed. Irish hospitals have about the same number (15.5) per 100,000 women as the Netherlands (15.4), Canada (14.4), and New Zealand (14.4) – countries with excellent maternity services. In fact, the Netherlands has a C-section rate half that of Ireland.

The ESRI research also found that “after adjusting for the risk profile of mothers, significant differences remain in the likelihood of a woman experiencing CS across maternity units in Ireland”. The obstetricians interviewed by RTÉ about the study did not address this problem. Neither did they address the fact that private patients are significantly more likely to have C-sections, nor the relationship between induction of labour and C-sections. What is going on in Ireland’s maternity services?

The truth is that Ireland’s childbirth model is bad for women’s health. The obstetric-led, interventionist model, introduced in the 1950s, does not deliver the best outcomes for women or babies. It generates fear and an illness culture.

Childbirth is the only health condition where consultants are provided whether women need them or not. This is not because policymakers and health experts think women are important but because obstetricians want to have absolute power over all aspects of pregnancy and birth.

The old adage “ when all you have is a hammer all you can see are nails” applies to childbirth Irish-style. Doctors are trained in diagnostics and medical solutions so it is inevitable that they are more likely to see pregnancy and labour as problems to be fixed instead of natural processes.

Instead of letting women get on with labour in their own time, many women are induced unnecessarily. Induction of labour (IOL) rates vary between maternity units and hospitals with rates as low as 14 per cent and as high as 46 per cent in first pregnancies. This variation remains after adjusting for sociodemographic and clinical variables and, according to another ESRI study, “possibly due to hospital-specific policies on IOL”. Unbelievably, giving birth on a weekday makes IOL more likely.

Unfortunately, the new national maternity strategy – Creating a Better Future Together: National Maternity Strategy 2016-2026 – will not make childbirth a better experience for women. Despite overwhelming evidence that midwife-led births are safer, Irish maternity units cling to the old-fashioned medical model. Best practice means all women should have access to alongside, (co-located with an acute hospital), midwife-led units. England, Scotland, Wales, Northern Ireland and other developed countries all provide midwife-led units. The strategy for Northern Ireland says "A culture of normalisation of pregnancy and birth will be promoted."

Ireland’s strategy says women will be provided with “alongside birth centres”, which will not necessarily be midwife-led. Women’s choices will be facilitated only “insofar as it is safe to do so”. In fact, Ireland is not going to have a fit-for-purpose maternity service until women achieve full equality. One of the goals of the National Women’s Council’s Strategic Plan 2016 to 2026 is for women to “realise their right to health and bodily integrity, including reproductive rights”.

If society wants women to give birth at a younger age, then policymakers need to offer longer, paid maternity leave and state-funded free childcare. That would change the risk profile of first-time mothers faster than recruiting hundreds of new obstetricians and midwives.

Unfortunately, this is unlikely to happen any time soon.

Jacky Jones is a former Health Service Executive regional manager of health promotion and is a member of the Healthy Ireland Council.

drjackyjones@gmail.com