Home or hospital? The politics of birth
The High Court will rule on Friday in a landmark case against the HSE and its strict criteria for home births
Louisa Crowley, with her daughters Fia and Keeva, at home in Drumcondra, Dublin. Photograph: Dara Mac Dónaill
Aja Teehan with her husband, Charles Brand, and their supporters outside the Four Courts before her High Court action against the HSE. Photograph: Collins Courts
Is home birth safe? It depends on who you ask.Women who have had their babies at home are often evangelical about the experience. For the HSE, which has a long list of criteria under which it won’t support the practice, there is much emphasis on the risks.
The ESRI says there were 168 planned home births attended by a midwife in 2011, representing 0.2 per cent of all births. By contrast, 2.5 per cent of all births in the UK take place at home, and 20 per cent of all births in the Netherlands are home births. A study of Dutch births published in the British Medical Journal in June found that planned home births there were less risky than planned hospital births.
The study found that among “low-risk mothers”, the risk of severe complications was one in 1,000 for home births and 2.3 in 1,000 for hospital births.
The risk of being admitted to intensive care or needing a large blood transfusion was small and similar among first-time mothers giving birth at home and in hospital. In women who had given birth before, however, severe complications were found to be less common during planned home births.
Ireland’s Nurses and Midwives’ Bill (2010) is unlikely to lead to an increase in Irish rates of home birth. This made law that the State Claims Agency would not indemnify self-employed community midwives assisting home births for women who fall outside the HSE’s criteria for risk.
Citing everything from asthma to having had a previous Caesarean section, the HSE’s National Homebirth Service says such factors render a woman at too great a risk for inclusion in the State’s home-birth service. In two further lists, which include factors such as being over 40 and having fibroids, a woman can be included in a homebirth service only after assessment by a consultant obstetrician.
Meanwhile, the number of home births in Ireland is falling. The ESRI figures show the number of planned home births attended by a midwife has fallen by 41.7 per cent over the past decade while the decrease since 2010 is estimated at 5.1 per cent.
“I think the culture around home birth here is certainly one of fear on the part of health professionals,” says Declan Devane, professor of midwifery at NUI Galway. “We haven’t had a very strong history of supporting different models of maternity care in Ireland.”
Is the State exercising due caution or does it have a severe case of risk aversion? The High Court will answer that question on Friday, when it delivers its verdict in the case of Kilkenny woman Aja Teehan, whose second child is due in October.
Teehan has taken a case against the HSE arguing that a previous Caesarean section should not preclude her from having a home birth. She alleges that their refusal to cover the birth of her baby at home breaches her rights. Physically fit, a yoga practitioner and a runner, she doesn’t view the risks in the same way as the HSE.
Devane says that while some might perceive it unsafe for a woman who previously had a Caesarean section to have a home birth, it depends on how those risks are interpreted. He says the biggest risk to such a woman is uterine rupture.
“The risk of that on average would be somewhere around 50 per 10,000, but it’s all about how you present the data. It’s the same as saying one in 200 will rupture; or 99.5 per cent or 199 out of 200 women will not have a rupture.”
While some women may be comfortable with this level of risk, the HSE is not, and it will not insure a community midwife to attend their home births.
Figures from bump2babe.ie, a site supported by the Cuidiú, the Irish Childbirth Trust, show that hospital births in Ireland are not all plain sailing. In a survey sent to Ireland’s 22 maternity units, hospitals were asked to share information on their rates of induction, Caesarean births, episiotomies and other details, during 2009.