Yesterday was the International Day of the Midwife. Irish midwives, however, feel there is little to celebrate, writes Marie O'Connor
Irish midwifery is in a state of crisis. Many midwives are suffering from burn-out, frustrated in their attempts to provide continuous, personal attention in labour to the women in their care. Today, in the big Dublin hospitals, each registered midwife is responsible for an average of 520 births a year. That's two to three babies being born on every shift. In most units, tea-breaks are a thing of the past and lunch is a luxury.
Only four per cent of registered midwives, some 640, are known to be in practice. From 1999 to 2000, the demand for midwifery training places fell by up to 45 per cent. Nationally, the turnover in midwives in the past two years has been running at one in three.
Despite the crippling problems of recruitment and retention faced by the profession, no reliable statistics exist on midwives in the workforce, as both the Nursing Board and the Department of Health and Children treat midwifery as a branch of nursing. Midwives, however, are unanimous that midwifery is a separate profession.
Midwives in the Republic are governed by a nursing board, represented by a nursing union and report to nursing management in hospitals, health boards, universities and government departments. Nursing dominance, they say, is one of the biggest barriers to the development of their profession.
Moreover, national healthcare policies ensure that hospital midwives lack control over their work. Maternity care policy, placing all women in childbirth under consultant supervision, means all hospital midwives are under consultant management. This policy has led to overcrowded, understaffed units and increasingly frustrated midwives.
Practising midwifery - a highly skilled, holistic approach to birth - in such units has become extremely difficult. The consequences for women are far-reaching. As high-tech, drug-based obstetric regimes proliferate, normal birth is declining. Although 80 to 90 per cent of women should have normal births, two out of every five mothers now give birth by Caesarean, forceps or vacuum extraction. Oxytocin is used to accelerate or induce labour in about 50 per cent of cases.
Midwives are the specialists in normal birth. Obstetricians, however, control the services. The birth market is a lucrative one, worth an estimated €30 million annually. In New Zealand, this market was opened to midwives in 1990. Here, the Maternity and Infant Care Scheme gives general practitioners a monopoly over antenatal care, a field in which midwives have much greater knowledge, expertise and training.
Our healthcare system gives women the choice of doctor but not the choice of midwife. This restricts options in maternity care. Booking into your local midwives' clinic or birth centre is impossible.
Less than three per cent of midwives are in community practice. Private health insurers, like the State, discriminate against midwives by refusing to recognise them as service providers. Hospital midwives are also discriminated against. They are paid about six per cent of what consultant obstetricians earn for what midwives say is more than equal work in normal birth. Midwives look after obstetricians' private patients in labour, with student midwives delivering their babies.
Medical input, particularly in the large hospitals, is virtually nil, unless surgery or instrumental delivery is required. The recent Nursing Alliance submission to the Benchmarking Commission, however, did not benchmark midwives against obstetricians. Instead, midwives were treated as nurses.
Many midwives are working for love rather than money. During a recent consultation process with Irish midwives, run by the European Institute of Midwifery, one experienced midwife reported that she was paid €63 for six hours work. On-call pay was described as "ridiculous". Midwives, with midwifery degrees, get paid the same as those with midwifery diplomas. Starting pay, students say, is "just a few hundred pounds above that of nurses". Yet qualified nurses do two years of further study to become midwives.
ALTHOUGH midwives are recognised as independent professionals in European law, they are denied prescribing powers and prohibited by the Nursing Board from "prescribing" over-the-counter medications. One hospital midwife observed that she had to get the signature of a junior hospital doctor before she could give out Panadol.
Midwives are seeking significant representation on hospital and health boards and on bodies such as the Health Research Board and the Women's Health Council. They want parity of representation with nurses on bodies such as the National Council for the Professional Development of Nursing and Midwifery. Parity of esteem, they say, means equality of representation with doctors and nurses at the table where decisions in maternity care are made. Midwifery will soon be the only health profession in Ireland without its own board, they point out.
A new nursing Bill, due in the autumn, is expected to give nurses a 6:1 majority over midwives on the new Nursing Board. Midwives say these proposals, would, if implemented, copperfasten the domination of midwifery by nursing and jeopardise the future of normal birth. Midwives in 2002 believe the time has come for them to govern themselves.
Marie O'Connor is a research sociologist and author.