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Midwifery Matters - Home sweet home birth

Home births by independent midwives and hospital-based outreach schemes demonstrate that the process is safe, writes Colm OBoyle

Home birth has not quite died out in Ireland, but the rate of planned home births has stayed below 0.5% for decades. There is a perceived wisdom that birth in hospital is better than home birth and although this has never been proven for low-risk healthy women and babies, home births have sharply declined in the last 60 years.

In 2003, the Supreme Court ruled that the HSE was not obliged to facilitate home births, but nevertheless there is resistance to the diminishing of women’s birth choices in Ireland. Home births assisted by independent midwives, and hospital-based home birth outreach schemes in Dublin, Waterford, and at one time Galway, each demonstrate that home birth is safe and practicable if there is a commitment to offering women a choice.

The number of women able to access the hospital-based schemes is miniscule and extremely restrictive geographically. The majority of the 200 or so home births annually in Ireland are attended by a staunch band of independent midwives.

Home births have sharply declined in the last 60 years

At one time ‘district’ midwifery was common. It was supported by grant payment to mothers and by PHNs and midwives with ample home birth experience. Now there are fewer than 20 independent or self-employed community midwives (SECMs) in practice, largely clustered around Cork, Galway and Dublin.

In 2007, the INMO (like the RCM in the UK before them) reported that because of the potential cost of damages claims associated with birth, their underwriters would no longer sanction indemnification of midwives for attendance at home birth. The HSE quickly convened the Domiciliary Birth Group to develop a State-sanctioned, indemnified home birth scheme.

In the report ‘Delivering Choice’, a memorandum of understanding between SECMs and the HSE was devised to enable a working relationship between them. Such was the urgency to provide for home birth and midwifery indemnification that the MOU was never wholly agreed by the multidisciplinary contributors.

The National Steering Committee on Home Birth (NSCHB) has modelled its recommendations for the home birth service on the highly successful, well-established Cork and Kerry scheme. Yet there are many aspects of the governance and home birth scheme that remain unclear and mechanisms for its implementation are underdeveloped. The designated midwifery officer positions, to support the scheme, have been recently filled.

Independent midwives have suffered from the belief that they are mavericks working ‘outside the system’. Women and midwives report an antagonism to home birth that is evident at booking and particularly, should it be necessary, at transfer to hospital. The MOU allows SECMs to demonstrate their continuing competence and gain the ‘respectability’ of a working relationship with the HSE. The reassurance of indemnification has been restored and some form of clinical governance has been reinstated.

The new Nurses and Midwives Act 2011 requires that midwifery attendance at birth is indemnified. However, indemnification for home birth is unavailable to midwives on the open insurance market. Despite efforts of the INMO on behalf of their SECM members, their underwriters have further advised they cannot provide indemnification for any aspect of a SECM’s practice.

This is a grave concern for the professional freedom of midwifery practice, as it means that an SECM cannot obtain indemnity insurance for home birth or for antenatal or postnatal care outside the MOU. It leaves community and home birth midwifery practice extremely vulnerable.

The HSE is not obliged to make home birth available to low-risk women, and in effect, has created a postcode lottery where demand for the service chronically exceeds the supply of midwives enabled to provide it. It is disingenuous for the health minister, the Department of Health or the HSE to suggest that Ireland ‘supports’ home birth in the absence of national provision to all eligible women and a lack of support for the relevant midwives.

In 2008 the Community Midwives Association (CMA) was formed to provide professional collegial support amongst SECMs. It provides professional support and continuing professional development by means of peer review. The CMA also devises study days for the maintenance of professional competence in the domiciliary setting. The Association is represented on the NSCHB, which is currently undertaking a revision of the MOU. It is hoped that the NSCHB will clarify governance structures and processes but also embed the home birth service within the HSE and enable its implementation, development and expansion nationally.

The statutory recognition of midwifery in An Bord Altranais agus Cnaimhseachais (Nursing and Midwifery Board of Ireland, NMBI) is welcome, but it remains to be seen whether midwifery and its issues can be fully represented, rather than eclipsed by the concerns of its larger, sister profession.

I urge all midwives to nourish professional collegiality. We must support each other in facing the particular challenges of our differing workplaces and work together to defend and expand community midwifery services and to better integrate them with hospital services.

Colm OBoyle is a lecturer in midwifery at the School of Nursing and Midwifery at Trinity College Dublin

Midwifery Matters - Home sweet home birth


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