Second Opinion: Mindset prevails that women cannot be trusted in pregnancy
Suddenly, women no longer had the right to decide how, when and where to give birth. Photograph: Getty Images
Since the publication of the report into perinatal deaths at the Midland Regional Hospital, Portlaoise, various commentators, including Liam Doran, General Secretary of the Irish Nurses and Midwives Organisation (INMO), have spoken about the shortage of midwives.
The INMO claim that 550 extra midwives are needed to provide safe, high-quality care for women and babies. More midwives may indeed be needed but they will not make our maternity hospitals/
units safer or more women-centred unless the current birthing model, which is 60 years old, is abolished.
The Hiqa investigation into the death of Savita Halappanavar found that midwifery workforce planning needs “to take place after models of care for maternity services have been agreed by the HSE”.
The obstetrician-led Maternity and Infant Care Scheme (Mics), introduced in 1954, was not the best childbirth model then and it is even less so now. Ostensibly, Mics was brought in because of Ireland’s high maternal and infant mortality rates.
A report published by the CSO, That was then, this is now: change in Ireland 1949-1999 , shows that in the 1950s about 100 women died in childbirth each year and the infant mortality rate was 40 per 1,000 births.
The theory was that giving pregnant women free access to care would improve their health and that of their babies. In practice, the consultant-led model instantly led to the medicalisation of childbirth, downgraded the midwife’s role, and maximised the power of health professionals over women’s health.
Suddenly, women no longer had the right to decide how, when and where to give birth.
Interventionist model unjustified
The mortality rates did not justify the introduction of such a highly interventionist medical model of childbirth. Women were not dying in the 1950s because they had no access to obstetricians or hospital care, or because babies were born at home.
Most maternal and infant deaths at that time were caused by poverty. Women were poorly nourished and educated, and had terrible social and living conditions. Many women had 10 or more children they could not afford to feed, with each pregnancy less healthy than the last.
It is hard to escape the conclusion that Mics was primarily introduced as a means of controlling women’s lives and, in particular, their fertility.
It is no coincidence that the Catholic hierarchy, who vociferously objected to Noel Browne’s 1951 Mother and Child plan, accepted the 1954 consultant-led scheme with enthusiasm.
It ensured that obstetricians working in Catholic maternity hospitals/units could rigidly control contraception, sterilisation, abortion, fertility rates and, therefore, women’s lives generally.
The CSO report notes the reduction in maternal and perinatal mortality between 1949 and 1999 and attributes this to less poverty and better female education, not just maternity services.
In fact, maternal and infant death rates had already started to come down before the introduction of Mics.
Improvements in social and living conditions would have ensured further reductions in death rates and better health for women and children.
In addition, a woman-centred model of maternity care should have been put in place in 1954 which would have provided expert care to the 30 per cent of women who wanted home births; midwife-led units in hospitals for women who do not need surgical or instrumental interventions; and obstetrician-led care for the 15-20 per cent of pregnant women who do. This did not happen.
Instead a medical model of childbirth was imposed on all women. Caesarean section rates are now twice that recommended by the WHO.
A 2013 Cochrane Collaboration study found that midwife-led models of care are associated with benefits for women and babies and no adverse effects, compared with models of consultant-led care.
The authors concluded that “most women should be offered midwife-led continuity models of care” which have a strongly positive effect on length of labour, breastfeeding and women’s satisfaction levels.
Ireland’s breastfeeding rates are abysmally low and have been since the introduction of Mics.
Is there a connection? There probably is. Disempowered women are less likely to breastfeed because they have little faith in their own capabilities. Midwife-led models of care cost €400 less per birth, a saving of €22 million per annum in the Irish health context.
This would cover the cost of the extra midwives needed by the HSE. What’s not to like? What is stopping the introduction of midwife-led services into every maternity hospital/unit in the State? Why are women not encouraged to have home births?
The mind-set that women cannot be trusted with their own pregnancies, that’s what.
Dr Jacky Jones is a former HSE regional manager of health promotion