Home births midwife is facing suspension

It may be more difficult for women to have their babies at home if a case against one of the few domiciliary midwives practising…

It may be more difficult for women to have their babies at home if a case against one of the few domiciliary midwives practising in Dublin ends in her permanent suspension.

An Bord Altranais, the regulatory body for nurses, has already obtained an interim injunction against the midwife, which prevents her from practising pending a hearing by its Fitness to Practise committee. The High Court will hear an application for an interlocutory injunction when the courts resume sittings.

The action arose as a result of a complaint made by a doctor against the midwife. For legal reasons the details of the complaint or the midwife's response cannot be reported, but they will bring into the Irish courts a debate that has been raging elsewhere about the safety and availability of home, as against hospital, births.

The demand for home births has been rising in recent years. It goes hand-in-hand with the growing demand from women for more control over what happens during labour, and a wish to involve their partners and families in the births of their children. The health boards now pay £400 towards the cost of a home birth, which runs to about £900. The VHI and BUPA also give grants towards deliveries at home. Because both options still leave a bill to be paid, home births are still largely a middle-class phenomenon.

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There is some resistance to this development from sections of the medical profession, who maintain that the safest place for a woman to have her baby is in a hospital. A prominent Dublin obstetrician has been quoted as saying: "Home births are like riding a motorbike without a helmet. You get away with it for so long."

A home birth is attended by a midwife, not a doctor. She (there are only a few male midwives) will have qualified as a nurse and done an additional qualification in midwifery. Doctors who specialise in this area do obstetrics and gynaecology. Proponents of home births point out that pregnancy is not a disease, a woman giving birth is not sick, and most births are normal, natural occurrences, requiring assistance rather than medical intervention. They say that the training of obstetricians leaves them with a distorted concept of risk.

Of course, things can and do go wrong during childbirth, leading to, at worst, the death of the child and/or the mother. Modern medicine allows for the monitoring of a pregnancy and labour and the anticipation of some, if not all, the problems which can arise. Most women still opt for hospital births, feeling more secure that all the necessary help is available if something does go wrong.

Midwives assisting at home births take the woman to hospital if there is a problem with the pregnancy, labour or after-care. But there is still disagreement about what constitutes a problem. For example, a baby in a breech position is seen as a problem birth by a hospital, but not necessarily so by all midwives. A long labour is seen as abnormal, but, depending on its severity, may be regarded as normal by a midwife at a home birth.

Given such different interpretations of a normal birth, there is room for complaints against midwives assisting at home births, especially as their philosophy is based on abiding by the wishes of the woman. If a woman with a baby in a breech position insists of giving birth at home and the midwife goes along with that, is she culpable if a problem develops and she brings the woman to hospital at an advanced stage of the labour?

Prof Sheila Kitzinger has campaigned against excessive medical intervention during childbirth for decades and is the author of a number of influential books on the subject. She is in no doubt about what is at stake here. Forcing midwives involved in home births out of practice is, she said, "to deny women choice and any control over how they give birth."

She denies that home births pose a greater risk to mothers and children than do hospital births. She quoted a Scottish study by Prof Tricia Murphy-Black, professor of midwifery at the University of Stirling, which showed that women who have home births have fewer complications in labour, need fewer drugs for pain relief, are less likely to suffer damage to the perineum and have an episiotomy rate only a quarter of that of a matched group in hospital.

Other studies bear out these findings, she said, referring to a study of all home births in England and Wales by the National Perinatal and Epidemiological Unit in Oxford. "It concludes that there is no evidence to support the claim that the safest policy is for a woman to give birth in hospital," she told The Irish Times, "and that there was some evidence, though not conclusive, that morbidity for mothers and babies was higher in an institutional setting.

"Countries in which midwifery is respected, and where midwives, not doctors, are the usual birth attendants, have lower perinatal mortality rates than those which have done away with midwives," she said.

There is a growing recognition in some places of the importance of midwives in delivering care to women during childbirth. Three months ago the first midwife-led care unit in Northern Ireland was launched in Altnagelvin hospital in Derry, and women may now opt to have their babies without the involvement of obstetricians unless there is an emergency.

This unit is based in the hospital. However, a spokeswoman for the hospital told The Irish Times: "If a mother requests a home confinement it can be carried out within the unit. The choice is there."

But if the current court action discourages domiciliary midwives from practising, the choice may not be here. No one was available at An Bord Altranais yesterday to comment on the case.