Clear guidelines on home births are needed because women who are medically unsuitable are being allowed to give birth at home, according to the master of the Rotunda maternity hospital, Dr Michael Geary.
At an inquest last week into the death of a still-born baby, the Dublin city coroner said he would write to the Health Service Executive (HSE) and the Department of Health calling for national guidelines allowing independent midwives to access services such as scans and blood tests at maternity hospitals.
At the inquest, independent midwife Kate Spillane said she had "felt inhibited" from raising issues with the Rotunda hospital regarding the woman's pregnancy. Since 2003, independent midwives have been unable to access blood tests or scans at the hospital and women have to book such tests themselves. At the inquest, Dr Geary pointed out that the issue of vicarious liability existed and he pointed out to the coroner the need for guidelines.
Speaking yesterday, Dr Geary stressed he was "not knocking home births", saying he accepted a number of women wanted to have their babies at home and it "has a place". He said there were a number of "wonderful independent midwives who do a fantastic job" but there had also been cases where women had been accepted by independent midwives when hospitals "wouldn't have dreamt of letting them deliver at home".
"The current arrangements are unsatisfactory. None of us - obstetricians, independent midwives and hospital staff - are comfortable with the situation," Dr Geary said.
What was needed, he said, was a clinical governance framework that would set out clear guidelines, agreed by all interested parties, concerning all aspects of home birth, including criteria regarding who was suitable. This framework would also include a system linking independent midwives to hospitals, clarifying lines of responsibility and accountability.
The care women receive could be audited and the results published, he said. "We should all have to follow an agreed set of rules in respect of patient safety," Dr Geary said.
While the need for such guidelines had already been raised with the Department of Health and the HSE, he believed there was now a need to "move on swiftly".
Independent midwife Christina Engel, who lectures in midwifery at NUI Galway, said she supported the coroner's call and that it was "very unsatisfactory" independent midwives did not have direct access to scanning and lab testing. She said the other major problem was that it did not provide for direct communication between independent midwives and consultants.
In some areas, consultants were happy to talk to independent midwives about patients, in others they were not. She believed Cork maternity hospital was the only one to allow independent midwives to book scans and blood tests for patients and to access results.
Some 20 independent midwives work in the State. Legally, they are obliged to hand over care of a patient to an obstetrician if problems arise and Ms Engel said she believed none of them would hesitate to do so.
She said she would like "less animosity towards independent midwives" and she felt there was sometimes "a lack of professional respect".
The master of the National Maternity Hospital in Holles Street, Dr Michael Robson, said there was a need for "a clinical governance umbrella" covering home births. This would ensure clear lines of accountability, mechanisms to guarantee quality of service and guidelines on management of risk. A HSE spokesman said an implementation group was currently examining the issue.