Maternity options are well overdue


A new survey shows that Irish women want more options and more input into how they give birth, writes SHEILA WAYMAN

WOMEN’S UNHAPPINESS at the lack of choice in the type of maternity care offered in Ireland is clearly signalled in a recent survey of mothers who have given birth here over the past five years.

Three-quarters of respondents said they wanted an option of midwifery-led care which was not available to them. Even where midwifery care was available, the research, conducted by the Association for Improvements in the Maternity Services (Aims) Ireland, found that women felt they were very easily excluded from it. The self-selecting, online survey was completed by 367 mothers.

In many parts of the country women have very polarised choices, says the spokeswoman for Aims Ireland, Krysia Lynch. “It is either home birth or consultant-led care and most women don’t want either – they want something in the middle.”

Anybody who ventures into a discussion of choices in maternity care knows just how divisive it can be. You only have to look at the forums on parenting websites to see ample evidence of that.

Giving birth is so personal and emotionally charged that, once experienced, it is hard to be neutral about it. It bemuses me how strongly some mothers challenge opposing views, based on their own experience.

A recent thread on discussing the attitude, “Your baby is healthy and that’s all that really matters”, very quickly developed into a stereotypical debate “between the delusional hippies who do hypnobirthing home births and the naive trusting sheep in over-medicalised hospitals”, as one contributor put it.

Equally, some will see our maternity care system validated by Ireland’s rating as the sixth safest country in the world in which to give birth, at 5.7 maternal deaths per 100,000 live births, in a report published by the Lancet medical journal last week. Others will question the data on which those figures are based and argue that simply surviving the process is not what good maternity care is about.

Lynch feels strongly that mothers-to-be don’t have adequate information to make an informed choice about maternity care.

The number one recommendation from Aims Ireland, arising from its survey, is that the HSE should fund the creation of a maternity care information pack detailing all models of antenatal care available by region.

In the absence of such neutral information, women currently have to rely on the “very loaded information from your GP”, she says, who has a vested interest in combined care, or from friends. And getting information about birth choices from friends is “very dodgy”.

“They are definitely not neutral. Mums tend to either want other mums to do what they’ve done, to validate their choice, or they definitely don’t want something too far away from what they’ve done as it might make them feel bad,” says Lynch.

The move towards an increased range of choice in maternity care is discernible but very slow. It has been hampered by conflicting professional interests, over-stretched maternity hospitals and a strong public culture of “doctor knows best”.

Meanwhile, the merits and dangers of both “natural birth” and “medicalised birth” are thrashed out on all sides.

Even midwives are divided among themselves about birthing issues, says the director of midwifery services at the Coombe Women and Infants University Hospital, Patricia Hughes.

“It is sad. There is room for everybody here. It is not about obstetric care being better or worse than midwifery, and neither is it about midwifery being worse or better.”

She sums up the issue succinctly, as being a question of “the right care being delivered to the right people at the right time by the right professionals”.

When the Coombe hospital eventually relocates to new premises in co-location with Tallaght hospital, it is envisaged that it will have capacity for 10,000 births annually, of which 2,000 will be in a midwifery-led unit. In the meantime, the hospital is taking small steps towards increasing access to midwifery care, with antenatal clinics in the community.

A multidisciplinary forum within the hospital recently agreed on “fairly significant proposals of change in how we deliver care”, explains Hughes, which it hopes to implement next month.

These measures include allowing mothers to drink fluids and even eat a snack during labour; midwives doing discharges of low-risk women and midwives administering the prostaglandin (used to induce natural labour) to “the uncomplicated labourer who is post-term”, says Hughes.

The argument for more midwifery-led care was strongly bolstered by the publication earlier this year of the evaluation of a pilot scheme in the HSE’s north eastern region.

The Republic’s first midwifery-led units were established alongside consultant-led units at Our Lady of Lourdes Hospital in Drogheda and at Cavan General Hospital in 2004.

The report on the randomised controlled trial of women attending these pilot programmes, compiled by the School of Nursing and Midwifery at Trinity College Dublin, concluded that the midwifery-led care practised there “is as safe as consultant-led care, results in less intervention, is viewed by women with greater satisfaction in some aspects of care and is more cost effective”.

It is heartening, says Hughes, to have this strong data from Ireland – “although I am sure there are people who still want to question it” – rather than having to point to the experience in other countries such as the Netherlands. It should pave the way for more midwifery -led units here.

When talking about midwifery-led care, it is always necessary to stress that this is for women identified as low risk. Women with complications, or indications of potential complications, are referred to consultants.

Pat Kinder, chairman of the Maternity Services Task Force which oversaw establishment of the two midwifery-led units, says it is a question of using a professional group to their maximum level of professionalism.

Midwives should be allowed to do what they do safely, leaving consultants more time to use their particular skills where needed – that is what makes it more economic, he points out.

“It would be wrong to see this as for the midwives and against doctors,” he stresses. “It is about women and children – and trying to present them choice without risk.”

He continues: “You would be a fool if you didn’t realise you are influencing professional boundaries when you are dealing with this. But nobody owns a patient.”

A mother has a right to make choices, as long as she understands what the implications are, he adds.

Both Kinder and Hughes were speakers at a workshop for midwifery students, birth support groups and birth educators in Trinity College Dublin, last weekend, organised by the Birth Project Group.

A collaboration between women in the college’s School of Nursing and Midwifery and some of their counterparts in Edinburgh, the group aims to promote the sharing of experiences and ideas for improving ways of supporting birthing women.

Birth Project Group member Jo Murphy-Lawless, a sociologist who lectures in Trinity’s School of Nursing and Midwifery, outlines measures she believes “can transform what at present is deeply medicalised care”.

These include: continuity of carer, so that each woman has the same midwife or the same pair of midwives from her first antenatal appointment to after her baby is born; moving midwifery into the community with midwifery-led units; and also making evidence-based information on birth options and birth interventions more readily available.

If we also had national care standards that were evidence-based, set and enforced by a body equivalent to the UK’s National Institute of Clinical Excellence, along with a national framework document for the development of maternity services, she adds, “we would have services to be proud of rather than the current pig in a poke which is being handed to women in Ireland”.

'It was the trust I had with the midwife that led to my natural birth'

Pregnancy and motherhood seemed an “extremely daunting task” to Carol McGowan the first time around, but a friend recommended the midwifery-led unit in Our Lady of Lourdes Hospital in Drogheda. She went for a booking appointment and was told she was an “ideal candidate” for the unit as she was perfectly healthy. From then on her antenatal visits were either at her GP’s surgery (where she mostly saw the practice nurse) or with the midwives. There was none of the usual waiting for hours in a crowded room of pregnant women, for a few minutes with a consultant.

“If you made an appointment for two o’clock in the midwifery-led unit, you would be seen at two o’clock,” says McGowan, a lecturer in social care at Dundalk Institute of Technology. “In my mind, birth is a normal healthy process and I didn’t need doctors. I was really hoping I would never see a consultant as I knew I would be moving to a risk category if I did.”

The midwives made her feel valued. “I felt really empowered as a woman. I built a relationship with the midwives and it was very likely I was going to have one of them assisting at the birth.” She could talk to them anytime if she had any worries about the pregnancy, and “normal ambivalence about motherhood was discussed in a way that was so empathetic and considered”, she says. “It was such a holistic service, and my husband Aidan felt so welcome there.”

Embarking on a journey of the unknown, did she worry that there would be no epidural available from the midwives? “Well, no – I knew it was on the next floor,” she points out. Women can be transferred to the consultant-led unit within minutes for medical reasons or if the pain becomes too much and they opt for an epidural.

When she went to the hospital in labour in the early hours of Friday, July 13th, 2007, she was the only patient in the midwifery-led unit. The birthing pool was “fantastic” for pain relief, she says. “The whole thing was really supportive of my natural birth, and I had a bit of gas and air near the end,” before delivering Aoibhín at 1.55pm.

Afterwards, McGowan was on a natural high “that went on for about five weeks. I felt amazing. It was the trust I had with the midwife that led to my natural birth,” she adds. “The birth happened within a relationship and that is what I think a lot of women are missing out on.”

Two years later she very happily did it all again – this time with an independent midwife at home – and gave birth to Moya, who is now six months old.

35%of women did not attend antenatal classes

3%rated their antenatal care as “poor” but

22%thought the care they received after birth was poor

Figures from What Matters to Yousurvey by the Association for Improvements in the Maternity Services, Ireland