Community midwives have healthy childbirth record

 

Midwifery scheme helps to reduce Caesarean section rate, but there is resistance to the scheme being extended, writes SARAH CAREY.

IT’S HARD to say which of the community midwives in the National Maternity Hospital in Holles Street I love the most. There’s Caroline who talked me down when I came in wailing like a banshee and generally making a show of myself during my first labour. There’s Niamh, who never left my side in the hours after that baby was born when I couldn’t stop vomiting and was so weak I couldn’t raise my head off the pillow.

Then there’s Clodagh who burst in the doors of our apartment in Blackrock two minutes after my heroic husband had delivered our second baby after a super-fast labour. Thanks to the Community Midwifery Scheme, instead of me delivering in a car on the side of the road, she got into hers and sorted me out in no time at home.

There’s Roisín, Kate, Sinéad and Theresa – all confident and careful super-women – and Margaret Hanahoe, their boss, into whose hands I gladly place my life and the lives of my sons. I could be accused of being over the top, but the scheme is 10-years-old this month and I’m not its only fan.

The idea of community midwifery is that healthy mothers and babies are in the care of a dedicated team of a midwives. Pre-natal care, labour, delivery and post-natal care are conducted by the same women, unless there is some medical indicator that necessitates intervention by an obstetrician.

This shocks some people who can’t understand how a baby can enter the world without the presence of masked doctors with sinister metal instruments.

The midwives deliver babies in hospital or at home. The politics of childbirth are polarising and women end up caught between fear of the labour ward management system on one side, and the medical isolation of independent midwifery on the other.

Hospital-based community midwifery provides all the hugs and aromatherapy you want, but also the hardcore drugs if you can’t hack it. They also have the full back-up of those doctors whose interventions one might spurn in theory, but whose skill you’ll never forget if mother or baby runs into trouble.

Thanks largely due to championing by former National Maternity Hospital master Declan Keane, Holles Street has led the way in delivering this enormously popular scheme. The only tragedy is that the service is limited to south Dublin and Wicklow. Since the team reaches capacity at 550 births per year, many more mothers would avail of it if they could. To its credit, the Rotunda is slowly ramping up a similar scheme, but does not yet provide home births and isn’t as seamless in its care.

Leaving aside the touchy-feely non-tangibles, what is the advantage in taking midwives out of the hospital and into the community? There are several. First, it gets mothers out of the hospitals quicker. Together with the early transfer home scheme, Holles Street midwives cared for 1,500 post-natal mothers at home last year. This frees up badly-needed beds in a system that often approaches, but miraculously never quite reaches, breaking point.

More importantly, they help to drive down the Caesarean section rate in a country that defies international recommendations. The World Health Organisation recommends that 15 per cent of births be delivered by section. Ireland’s rate hovers around a lamentable 23 per cent, up from 13 per cent in 1993.

Criticism of that rate is often simplistic. Norway’s national rate of 11 per cent looks amazing beside the Irish rate. But those Vikings are a homogenous group of strong, healthy women – unlike our mixed demographic profile here. Neither is it fair to compare Holles Street with the Rotunda.

Holles Street’s rate of 19 per cent looks good beside the Rotunda’s 24 per cent. There are differences in how labour is managed in each site, but the Rotunda has a higher proportion of disadvantaged patients who being poor, young and unhealthy, are less likely to deliver normally. Even in Holles Street, that 19 per cent looks bad beside the community midwifery rate of 7.3 per cent, but the midwives don’t take twins, breech births or mothers who are overweight or have diabetes. It’s natural that their low-risk clients would have a lower section rate.

The master of the National Maternity Hospital, Michael Robson, devised a system whereby mothers who have sections can be categorised into specific groups that allow for fair comparison. For example, his first group are first-time mothers, who reach 37 weeks, with the baby’s head down and who spontaneously went into labour themselves. In 2007, 6.8 per cent of these mothers in the normal labour management system at the National Maternity Hospital had a section.

The same group in the same hospital but cared for by midwives had a rate of 4.7 per cent. It’s not a dramatic difference, but is going in the right direction. With a clear trend like this, you’d think midwives would win support for expanding the scheme and allowing more mothers to enjoy this care.

Unfortunately, there is resistance and unless mothers book within six weeks, they must be turned away. The midwives are hosting a conference in Dublin on Saturday, February 21st, where some of these issues will be debated. They need friends in high places: interested professionals can book a place by e-mailing: commw@nmh.ie