One Midwife, One Woman, One Birth

national | rights, freedoms and repression | opinion/analysis Wednesday January 19, 2011 15:50 by AIMS Ireland - Association for Improvements in the Maternity Services Ireland chair at aimsireland dot com

One midwife, one woman, one birth

Childbirth groups and midwives’ associations across the country are united in their opposition to Sections 24 and 40 of this Bill. Deputy Caoimhghin O Caolain's amendments to these Sections are our amendments: they must be supported. Other amendments that have been proposed are a distraction.

This Bill as it stands is a threat to public safety, as well as a denial of human rights. It also denies midwives their rights as service providers.

Midwives must be given the power to regulate their own profession, if it is to survive. Midwifery is a separate profession from nursing: only midwives are in a position to determine the needs of midwifery.

Section 24 of the Bill still provides for a toothless committee that can be dissolved at a moment’s notice. We want an end to the subjugation of midwifery to nursing. This is a 1950s model that is not fit for purpose in 2011.

Midwives need a powerful Midwives Committee NOW. Midwifery is in crisis: this is impacting on public safety. The shortage of midwives in the main Dublin maternity hospitals is running at around 30 per cent. Midwives are delivering nearly double the number of babies that they ought to be. The risk of serious adverse events has increased significantly.

Highly experienced midwives are exiting the services, partly because they lack control over their work. Empowering midwives by amending Section 24 would be a first step in retaining those midwives.

If the Minister’s latest Section 24 amendment is passed, then midwives will be the only regulated health care professionals in Ireland without the ability to govern themselves. (The Health and Social Care Professionals Act 2005 gave twelve professions the power to rule themselves.)

While a stand alone Midwives Board would be logical, our Section 24 amendments achieve the same result much more cost effectively, using infrastructure of a single Board to enable two professions to govern themselves.

These amendments reflect modern midwifery legislation in New Zealand and Canada. This has led to safer, more accessible services; that are more in line with what women want; and that offer the state better value for money.

Enabling midwives to develop their profession would promote safer care. Midwives promote normal birth––using a low drug, low tech approach–– by helping women to give birth without epidurals that lead to more forceps and vacuum deliveries that lead to more trauma for babies.

Our current (interventionist) system of care is leading to poor outcomes––and more claims for brain damage. Ireland has high death rates around the time of birth. Only some of the former Eastern European bloc countries (Bulgaria, Latvia and Romania) have much higher perinatal death rates.

Lowering the intervention rates would lead to fewer claims against the state, as many awards for brain damage are linked to the use of oxytocin, a (synthetic) hormone that is routinely used to accelerate labour.

Non-interventionist, one to one care, as provided by midwives, rarely leads to litigation. In 30 years, fewer than five awards have been made against self-employed midwives, and these awards amounted to less than half a millon between them. Contrast this with a bill of €400 million in past claims incurred by obstetricians.

Midwifery care is also more cost effective. Any birth involving medical intervention costs more, with no benefit to normal healthy mothers and babies. One baby in every four is born by Caesarean: Caesarean is less safe than normal birth. And it costs three times more.

A study of midwife-led units in the northeast showed midwife-1ed care resulted in better health outcomes, and was economically more cost-effective than standard consultant-led care.

Mothers need a Bill that promotes the development of community midwifery services. Smaller maternity units are set to lose their inpatient services. These closures will leave thousands of mothers without ready access to care during labour, at risk of roadside births, without midwifery assistance. Women need locally accessible midwifery care. Amending Sections 24 and 40 are a first step.

Section 40, as is, effectively denies midwives their economic rights. This Section will be challenged in the courts unless amended. Making indemnity mandatory when midwives have NO ACCESS TO INSURANCE AS OF RIGHT is wrong and strips them of their capacity to provide services in the community, freely.

Section 40, as is, will make it unlawful to exercise the right to private practice, a right afforded to all other health care professionals in the state. The Section contravenes European law (Directive 2005/36/EC) which guarantees midwives the right to offer services independently. These services include family planning, childbirth education and advice with breastfeeding.

We need midwives to provide antenatal and postnatal care in the community. Antenatal care in hospitals has shrunk, due to staff shortages, while postnatal care is the community is non-existent. These shortfalls in care mean women are getting a service that is less safe and of lower quality.

Mandatory insurance MUST to be dropped. It belongs in service contracts, not statute. Criminalizing uninsured practice when midwives have no access to indemnity as of right is totally unjust.

Newly qualified graduates in midwifery face unemployment and are emigrating. Easing the restrictions on self-employment would help to stop the brain drain. Mandatory insurance is a barrier to self- employment.

Section 40 effectively criminalises clinical decision-making, makes private practice unlawful and will leave vulnerable women and their babies without care.

The Section is discriminatory in that it makes insurance compulsory for midwives but not for nurses (or medical practitioners). It also copperfastens an indemnity scheme that is in itself discriminatory.

In restricting the practice of self-employed midwives, Section 40, in effect, violates women’s human rights. The terms under which midwives are legally required to work are also the conditions under which women are obliged to give birth. Choice in childbirth has just been recognised as a human right by the European Court of Human Rights (the right to respect for private life: Article 8 of the European Convention on Human Rights). Again, the Section faces legal challenges on this front.

The Section is (invisibly) tied to a state indemnity scheme that is embedded in a restrictive HSE contract that significantly limits the range of services that can be provided independently by midwives in the community.

Self-employed midwives who feel ethically bound to continue to assist a home birth mother whose labour does not conform to insurance rules, for example, now face jail. This is unjust, unprecedented and unwarranted.

The vast majority of home births in Ireland are attended by self-employed midwives. Mothers who do not fit the state’s terms and conditions are already opting to give birth at home unattended. From a safety and human rights perspective, they should be enabled to access professional help, as in England.

Under the HSE contract, the midwife’s indemnity lapses as soon as her client exhibits some change in her condition that disqualifies her for home birth. If this happens during labour, the midwife is expected to withdraw care from the mother and notify ‘relevant stakeholders’, such as the Gardaí. As well as placing the midwife in an appalling dilemma­­­­, this will violate mothers’ human rights.

The European Court of Human Rights ruled before Christmas that the circumstances of giving birth incontestably form part of one's private life and that prospective mothers have the right to choose those circumstances.

Finally, EU Directive 2005/36/EC recognises midwifery as a liberal profession, which it defines as one that is ‘practiced on the basis of relevant professional qualifications, in a personal, responsible and professionally independent capacity’. This Bill totally undermines that recognition.

The Bill will provide the foundation for maternity care in Ireland for the next quarter of a century: how the services are organized depends on what midwives are legally entitled to do. Deputy Caoimhghin O Caolain's amendments to these Sections MUST be supported.