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Thursday, 20 Feb 2003

Vol. 1 No. 3

Midwifery Birth Alliance: Presentation.

I welcome Ms Marie O'Connor from the Midwifery Birth Alliance, Ms Monica O'Connor from La Leche League, Ms Kitty Ross from the Midwives Association of Ireland, Maria Dowd, a mother, Philomena Canning, who is a midwife and Colm Macgheehin, the legal adviser to the alliance. I ask Mr. Macgheehin to commence the presentation. I remind him that the norm is that contributions are confined to ten minutes.

Mr. Colm Macgheehin

I assure the Chairman I intend to speak for much less than ten minutes. Following my introduction, there will be two further speakers, both of whom intend to keep their submissions short. All five of the witnesses are eager to answer any questions members of the committee may have.

We have found that the most productive approach to considering an issue is to have a ten minute presentation followed by a questions and answers session. I draw attention to the fact that while members of the committee have absolute privilege, this same privilege does not apply to witnesses. Members are also reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make that official identifiable.

Mr. Macgheehin

I will briefly reintroduce the line-up. As some members will be aware, Marie O'Connor is a sociologist who undertook probably the most extensive study of birth ever carried out in Ireland on behalf on the Department of Health and Children and the Coombe Hospital. She is the author of Birth Tides and is a prolific contributor to journals, broadcast media etc. She will set out the broad case as a brief introduction.

Monica O'Connor is a mother and consumer of the service. Following her experiences with the birth of her first child, she became heavily involved in birth organisations and like other mothers who had bad hospital experiences, she joined the Home Birth Association. She is also in La Leche League which takes a broad interest in maternity services.

Philomena Canning is currently a self-employed midwife. She qualified in 1983 and obtained a master's degree in public health from Australia where she studied. She worked in hospitals here on her return, but has been independently employed for the past three years. She will explain in detail the reason she took this radical step of working on her own.

Kitty Ross is a midwife of long standing who also did a master's degree on birth in the early 1990s. She worked in the service from which she is currently on secondment. Maria Dowd is an airline pilot by profession. She is also a consumer of the service in so far as she had one birth inside it. She will tell the committee how consumer friendly she found it and the degree to which birth plans are adhered to. In any event, her experiences have motivated her to get involved in the Midwifery Birth Alliance.

For the past six or seven years, I have been acting for many expectant parents and midwives in my capacity as a solicitor. Despite working in a very adversarial system, I found hard to believe the levels of hostility shown to anyone who tries to exercise choice outside the system or, as in the case of self-employed midwives, tries to work independently in his or her profession.

In dealings with midwives, one of the first things that struck me was their description of expectant mothers not as patients, which is the case with doctors, but as clients. The reason is obvious. As Professor Bonnar, the former chairman of the Institute of Obstetricians and Gynecologists, has said, more than 90% of pregnant women are perfectly healthy and have no illness of any kind, which is also the case with the children to whom they are giving birth.

Midwives' expertise lies in caring for people who have or ought to have normal births, which is how they differ from doctors. They are also skilled in detecting a pathology, in other words any form of illness or medical condition, which they are quite capable of referring to doctors. This is how the system works in other countries. Here, however, we still have an approach known as the consultant led service. Our principal argument is that this is a medically based system in which midwives have a subordinate role and exercise very little influence or power.

The same applies to consumers. Neither midwives nor consumers impact in any way on the continuing drift towards larger and larger maternity units. We all saw the crisis in Monaghan and Dundalk recently where maternity units have been closed down. These moves form part of a larger plan about which the consumers of the services in Counties Monaghan and Louth were not consulted. Clearly, midwives had no input into these decisions. It was mooted, even in the obstetrics and gynaecology professions, that midwife led units could be set up in Monaghan and Dundalk. It is possible, however, that any such unit would still have to adhere to the policy that all services must be consultant led.

As I stated at the outset, there are no medical problems in more than 90% of cases. Midwives are the experts in normal birth. The principal argument of the presentation is that they, rather than doctors, should be in charge of the service. Midwives should refer women to doctors in the same way that a GP would refer a patient to a specialist. Obstetricians and gynaecologists are specialists and should practise their profession in specialist areas rather than largely controlling the entire birth process.

Before handing over to Ms O'Connor, I will make one final point. There are 13,000 nurses with midwifery qualifications in Ireland yet just 800 midwives are working in the profession. My guess for the reasons they are leaving in such huge numbers is that they earn about 6% to 8% of what consultants, the other profession in this area, earn, play a subordinate role and have none of the powers midwives in other countries enjoy.

Most of the people around this table probably believe or believed that Irish maternity care is the best in the world. That is simply untrue. We have a highly centralised system. I would go further than Mr. Macgheehin and describe it as a hyper-medically based system. Our caesarean rate is beginning to approach one in four births. We have arrived at a position in which half of mothers expecting their first children give birth by caesarean section, vacuum extraction or forceps delivery. This is a frightening statistic and a logical outgrowth of a hyper-medically based system which is bad for the health of women and babies.

We are seeing high rates of admission to neonatal intensive care. A new category called severe maternal morbidity has been included in the clinical report of Coombe Women's Hospital. Its incidence now stands at two per 1,000 births, which is a cause for extreme concern and a direct reflection of the increase in caesarean sections.

To return to our highly centralised system, this system discriminates against women. In view of the recent consultant proposals to close six of our maternity units, this whole question has taken on a new urgency. Part of our intention in coming before the committee today is to persuade committee members to take up maternity care as an issue and put it on their agenda for the working year. It is essential to begin to consider maternity care in depth. Despite the fact that the system is in crisis, it rarely receives attention in the media.

Centralisation discriminates most obviously against women who live outside urban areas, for example, women, who are having social inductions or need to have their labour augmented or accelerated when they go into hospital. There is a whole chain of intervention which may culminate in a caesarean section. We also have a category of baby here known as BBA - Born Before Arrival. This is a neat category because it encapsulates the difference between official health policy here and the actual experience of the service user. The trouble with BBAs is that when one examines the incidence of home birth here, one finds that for every home birth we have an unplanned emergency, out-of-hospital birth, which carry very high mortality rates of 68 per 1,000. This should not be considered a rural phenomenon, it is not. I noticed that the Coombe Hospital annual clinical report detailed 199 BBAs in 1999, over seven years, an extraordinary figure.

We have a very real problem. Centralisation results in women being subjected to the active medical management of their bodies in labour. This means that labour is accelerated by means of drugs and obstetric instruments. For women who want to have a physiological birth, the current approach directly undermines their rights in childbirth.

Women here have less choice in maternity care than in almost any other country in western Europe. There are no birth centres, midwifery led units or hospitals where women can choose, for example, to have water for pain relief, which is a much safer alternative than epidural anaesthesia. Facilities for home birth are also limited to non-existent.

What is the solution? In our view, it is to move towards midwifery based care and decentralisation. Unless we want birth to become an operation, as has been the case in Brazil where caesarean rates are 80%, we need to make this move soon.

Mr. Macgheehin

Monica O'Connor is a mother and very active in birth organisations. Perhaps she could address a few words to the committee.

My first point is around the issue of fully informed choice. In the interventions we describe, which are part of the Irish way of birth, mothers are not told before going into labour what each one will entail and the possible consequences.

We talk about a cascade of interventions. A mother goes into hospital. It is an unfamiliar environment. She is not with midwives she has seen at the ante-natal checks. Her labour naturally slows down. The Irish solution to that problem has been to artificially speed up her labour. What that means for women is that their waters are broken and they are given synthetic hormones to speed up their labour. It makes it much more painful - this is what pushes many women to ask for an epidural and to ask for pethidine as pain relief.

They are not told the consequences of those interventions, that their babies may end up with respiratory problems as a result of pethidine. There is much work done on post-epidural headache and backache for mothers themselves. One's chances of not being able to push the baby out oneself after an epidural are increased several fold. I do not want to blind the committee with statistics but there is a great deal of work done on this and if anyone wants to check any of the points with us afterwards or have us show them studies, we have no difficulty in doing so.

At the end of a typical epidural labour - about half first-time mothers in this country are having an epidural and the figure is as high as 70% in some of the hospitals - the mother may need a ventouse - vacuum - or forceps delivery of the baby and that will entail an episiotomy.

All of this means that getting over the birth will be much more difficult. The precious time around birth of meeting one's baby for the first time, that mother-infant bonding, is often completely disrupted. This would have happened at my first labour where my baby got pethidine very late. He got it 40 minutes before he was born, so he was taken away for 45 minutes and worked on. That was completely a result of what had happened earlier in the labour. That was iatrogenic. That was caused by the system in the hospital.

That means the precious time around birth, when one should get to know one's baby, get breast feeding established, is wiped out for many women. One can spend the weeks after the birth really mourning that period and wondering how one can to get back to that, blaming oneself for not being more assertive.

My second point is that ante-natal education, which is now called parent craft classes in many hospitals, seems more focused on getting women and their partners to accept these interventions, which have become the Irish way of birth, than on empowering women to make choices and saying that the chances of having a normal delivery - of pushing the baby out oneself - are so much more increased if one stays mobile, if one stays up. That means avoiding getting the waters broken, avoiding getting put on a drip. For women to avoid those kind of interventions in labour takes a great deal of assertiveness. When one goes into hospital in labour is really not a time to practise assertiveness skills. At that point a woman needs people around her whom she trusts, who listen to her, who respect her birth plans and wishes, who do not treat her as an infant. If one looks at the research, if one looks at women's stories about how they are treated and how they are spoken to when they are in labour, frankly it is quite disgusting the way the professionals will speak to women in labour.

If the Irish way of birth does not mean we are having a better experience for mothers, that babies and mothers are safer at the end of it, one has to ask whose needs are being served. We would say that it is the needs of large medical institutions and what we really need to do is get back to smaller units for giving birth where women can have a chance of knowing who will be with them in labour so that we can have continuity of care, one-to-one care of a known midwife. Other countries are able to have team midwifery where they can introduce a mother to all the people who she is likely to meet during labour and then one at least has a friendly face when one goes in there.

Mr. Macgheehin

To round off, I suggest we hear from a midwife, Philomena Canning, who has worked within the service and who is now self-employed.

Ms Philomena Canning

On the nature of midwifery, I came back to Ireland in 1994 and I was struck by how few people understood or knew what I meant when I told them that I work as a midwife. Invariably people would say, "Oh!, you are a nurse", and I would go on to explain to them that midwifery is quite different to nursing in that the focus of nursing is on curing people who are sick and restoring them to good health, while on the other hand the focus of midwifery is on the healthy woman and preventing disease and promoting her health. Likewise the difference between midwifery and obstetrics, the focus of obstetrics is on restoring the sick woman in child-birth to health again.

To give the committee some insight into the nature of my work on a daily basis, I will tell a story about a client I took on two years ago. I will refer to her as Christy. Christy was a young woman in her twenties. She was single. She had an unplanned pregnancy. She was renting accommodation in Fairview with two other young women and a young man, and she went to Holles Street to book in.

She went to the ante-natal classes and she found out about what lay ahead of her when she was going to come into labour, in other words, what Monica has talked about, the policy of active management. She had never been sick in her life before, she had never been in a hospital and she did not like the idea of needles, drips, etc., and she became quite frightened. She went to the community midwifery scheme in Holles Street to see if she could have a natural birth with them where she would not be subjected to all of the interventions and unfortunately she did not fit into their scheme because she lived in Fairview and the scheme did not extend north of the Liffey.

Christy called me. She worked as a waitress, she was a medical card holder and she told me that she had no other option but to consider giving birth to her baby at home where she could avoid medical intervention. I told Christy about the fees. At that time my fees were £1,200 and the health board would give Christy £600 towards the cost of it. There was no possible way that Christy could come up with the difference. Nevertheless I decided to take on her case. I recognised that she was quite a vulnerable young woman and by any of the standard criteria she was defined as an at risk woman.

I undertook her care. The first problem she had was she did not like the idea that she could not pay me so the first thing I did was refer her to a lawyer. I told him about her case, the difficulty she was in and asked was she or was she not entitled to give birth at home supported by the State, and out of that a legal action began. It meant quite a lot to Christy that she was at least doing something about trying to pay me for the service with which I was providing her.

The second thing I did was go to the social services, meet her social worker, get all of the forms together and get them all filled in so that all of this was ready and in place by the time her child was born. The third thing I did for her was go along to the lone parents' association. We got all of the leaflets and information from there. I sat down with Christy and we went through it all so that she could somehow or other understand what supports were there for her.

In late pregnancy, unfortunately her landlord got to know that she was pregnant. He did not like the idea of this woman coming home again from hospital with a new-born baby - little did he know that she actually had plans to give birth in the rented accommodation - and he decided that he wanted to evict her on the grounds that he did not want a new child living there.

At 38 or 39 weeks of pregnancy, when Christy had no transport and was relying on buses, etc., we started the process of trying to find her alternative accommodation. That required me on a Saturday morning to get into my car to go to meet Christy, putting her into my car, driving around Dublin to meet all the landlords and try to find her accommodation, which fortunately we did. She moved into her new place on a Friday morning and went into labour that night. I went along to her——

I hesitate to remind you about time because the case study is very impressive.

Ms Canning

The point I am making is that maternity care is a major public health issue. Three out of four women will give birth at some stage in their lives. Midwifery is consistent with the objectives and aims of public health, that is, disease prevention and health promotion. When one considers the population coverage that can be achieved by midwifery, it highlights the importance of midwifery to the promotion of public health. I will leave it at that.

Why did the group feel it should be accompanied by a legal representative? It is unusual.

We would see legislative reform as being essential to the reform of maternity services generally. The present system is underpinned by a raft of legislation which needs to be fundamentally reformed. That is the reason.

I welcome the witnesses. Some committee members may have met them before but it is useful to hear what they have to say. Their presentation was challenging and they rightly said we should explore this issue further. Perhaps we could extend this discussion further into the future and hear other views. The witnesses ranged widely over aspects of maternity care in Ireland.

The witnesses mentioned that, in comparison to other countries, there are many deficiencies in access to midwifery services, which are different from the centralised hospital model. I would like to hear more about that.

Have the witnesses been involved in the work of the national midwifery advisory forum established by the Department of Health and Children? It would be interesting to know what progress has been made in delivering a service that not only offers more choice for mothers but also protects standards of care.

There are three aspects on which I would like the group to comment, namely, sensitivity, safety and solicitors. Sensitivity relates to natural and normal birth. Some of us have undergone birth and I do not remember sensitivity being part of my experience. That said, I took great comfort in the fact that I was surrounded by technology. While I was fortunate enough to be one of the 90%, had I been one of the 10%, being surrounded by technology would have been of comfort to me.

This raises the issue of safety. Where all the indicators show that a woman is capable of having a normal healthy birth, the idea of maternity-based units is clearly the way to go. It appears to be the agreed way that this area should be developed. I am interested to hear the comments of the group on the pilot schemes in Holles Street. Safety is an issue that demands a response. Otherwise, people will have a constant nagging fear. Whatever about a mother's wishes, there is a baby and his or her chances of leading a good, full and healthy life must be central to the process.

There is the issue of litigation which is a driving force in medical care, not just maternity services. We are fooling ourselves if we disregard that. It may not be fair to ask the solicitor to comment but someone must comment on it. We are talking pie in the sky unless there is some way of dealing with litigation in a serious way, because it is having such an influence on the health service that it is distorting possibilities, including the ones the group presented.

I thank the witnesses for their presentation. It was, as my colleague said, challenging. I was aware in a vague way that there was a debate about how childbirth should be managed and that there was something of a battle between the medical model and those who would prefer home births and use the midwife service. I was also aware that there was an unmet demand for using water births as a method of controlling pain.

What gobsmacked me about the presentation was the statistics, and I would like to explore this further. If there is any element of truth to them, they are disturbing. I may have picked it up incorrectly but did someone say that almost one in four births are caesarean and 50% have some form of intervention?

The other statistic, which I did not quite understand, was that there was a very high mortality rate for babies born before expected arrival.

It is 68 per 1,000.

These are staggering statistics. This area will have to be explored further to hear from other sides. Does the group know if the statistics for Ireland have changed over time and how they compare internationally? Do we have international statistics? This is the first time some of us have heard these figures. It is something we would want to examine further.

Obviously we would want to approach this issue on a factual basis because it is emotive. People feel strongly one way or the other and, more than anything else, the safety aspect drives mothers into hospital, quite apart from the litigation aspect. To make any argument stand up, we need statistics to make comparisons over time in Ireland and with other countries. Perhaps the group could come back on that.

It is only fair that I put my cards on the table by saying that I am very supportive of the group and have had many dealings with them. As a result of my experience of one of my children being born in hospital and the other at home, I would say the home birth was far superior. I am not trying to be too critical of maternity hospitals because I understand there are reasons. However, they have become birth factories where birth has become a medical intervention and a fairly brutal experience for some women and children.

Does the group agree that it is the pressure on hospitals to have women admitted and discharged quickly that has led to the fact that women are talked down to? I believe that to be a fact. While men are allowed to observe the birth, I formed the impression that we get in the way.

I wish to deal with the effects on a child of a medical intervention, be it a caesarean section, epidural or induction. From my experience it struck me that parents are in a vulnerable position. They are told that, if they do not allow the procedure to take place, something could go wrong, and basically they agree to everything. What are the possible after-effects on a child of these medical interventions? Do the witnesses agree that, in terms of after-care, this is an important moment for the woman and that one-to-one care is essential, particularly in regard to breastfeeding? In hospitals, a woman is dismissed quickly if she cannot get the hang of breastfeeding. A home birth situation is better because more patience is displayed by the midwife and the mother is coaxed to continue the effort. What direct measures do the witnesses suggest? What legislation is required and what can be done to make birth a more pleasant experience for everyone?

Mr. Macgeehin

Ms Ross, a midwife, will take the questions about induction.

I am speaking here on behalf of the Midwives Association of Ireland. We were set up in the mid-1980s and our main objective is the safety and welfare of mothers and babies. We have no other agenda. We are not undertaking a battle, as someone mentioned. It is not like that. We are all involved in the provision of maternity care because we genuinely believe that we are providing the best. If there is high intervention and a medical approach the people providing that believe that is the best way to do things.

Our argument this morning is that birth should be redefined. It should be redefined on the issue of safety. I have in the region of 20 years' experience in midwifery, I have four children and have gone through the birth process. I have studied midwifery at a senior level and have also taught it. From my research on papers covering the past 250 years, I have found that wherever the approach used was to let the mother birth on her own as much as possible the rate of normal delivery was 95%. Everywhere I looked, from 1750 to the present day, and the research work to substantiate what I say is in University College Cork, the same figures came up repeatedly.

Nature is complex. Mother nature knows more than any of us. I have hens and cows. I have watched hens and seen their ability to hatch and mother. Sometimes I moved the hens from one nest to the other with the genuine intention of keeping them away from a dog or fox. I wanted to do it for safety reasons, but I complicated things. The hen went from one nest to the other and could not get back. I complicated things so much that I ended up with no chickens. Talk to a farmer. A farmer once said to me that if the cow is moved into the houses from the field, with the intention of keeping a closer eye on her for safety, the birth process is prolonged. I looked twice at him but I asked more farmers about it afterwards and they told me the same thing. I was brought up on a farm, but it never occurred to me then that we were moving mothers when moving animals.

We often expect mothers to move long distances. I travelled from Longford to Dublin today. When I came out of Connolly Station I asked myself how I was going to get here because there was so much traffic and it was so busy. I thought of how it would be if I was in labour and trying to get to a hospital. It is bad enough trying to travel through traffic with one's normal senses and I would not even consider that a safety issue. I believe that keeping mothers in hospitals, where anaesthetics, hospital theatres and intensive care are available, is done with the best of intentions, but it is not producing the results. I do not know the reason for this. In our minds and with the best intentions we think we are doing what is best, but we are not. We are actually going backwards.

In regard to safety, I cannot produce figures to say that a medical approach to care, based on intervention, is better for mother and baby. Deputy Gormley spoke about babies who are subjected to pethidine and to a synthetic drug to speed up labour. I have seen babies' heartbeats slow down on monitors after use of that drug. I have seen the pattern change and the heartbeat decelerate and then come back up. The baby is not able to cope as well as in normal deliveries. The contractions are different.

With respect, pethidine is for pain. I appreciate what the witness is saying and enjoyed the presentation which is necessary and timely. This is a debate that has been going on for some time and there is much medical literature about it. As a general practitioner who has worked on the islands and in the obstetrics departments of hospitals, I have seen the situation. I have had BBAs in my house where the patients have not got to hospital in time because of the distance involved. I agree that over-civilisation is a big problem. We should try to find the balance if we can.

The Deputy's intervention is important, but there are questions banked and other people are in line to ask questions.

I also want to ask questions.

Of course and the Deputy is on the list, but could we first have succinct answers to the questions already put?

Ms Maria Dowd

I will address the questions put forward by Deputies McManus and Mitchell. Before I joined Aer Lingus as a pilot, I did a master's degree in clinical psychology. When I became pregnant I brought both my interest in psychology and my interest in safety with me and did a lot of research. The issues I want to deal with specifically are the sensitivity and the issue of home birth versus hospital birth. What I heard all around me about hospital births was that it was difficult to have a natural birth. As I read all the literature, it became apparent that the safest option for my baby and for me would be to try and have a natural birth because intervention techniques and drugs affect the outcome.

I decided the safest option for me would be to look for a doctor and hospital that would support natural birth as much as possible, but that I would give birth in a hospital. I got the names of various people and finally attended one of the Dublin hospitals. I got a wonderful service from that hospital during the eight and a half months I attended it. It gave wonderful back-up, yoga classes and nutritional advice. When it came to actually going in for the birth, matters changed radically. I had discussed well in advance - and with my husband with me on all occasions - with the obstetrician I was attending my request to have a natural birth. He was supportive and encouraged us to prepare a birth plan.

A birth plan just states what a person would like during the birth. I stated that I did not want electronic foetal monitoring. I wanted the baby monitored, but not electronically. He agreed and signed the birth plan. Obviously, if anything was to go wrong we would welcome intervention but if it was a normal labour I did not want anything. I went home and told a friend who had just been through the system that this was one of the things I had written down. She just laughed and said they would not allow that. On my next visit I told the doctor I had been told my plan would not be acceptable and I asked him to confirm that it would be all right not to have electronic foetal monitoring. He confirmed it and said the plan would be fine. I asked him to sign it off and he did so for the second time.

When my husband and I went into the labour ward in that hospital a few weeks later, the sister who greeted us refused to allow us to carry out that particular wish. We said that our obstetrician was the master of the hospital and he had signed twice to say it was all right. I said I welcomed her to listen with the sonic aid, but I did not want to be strapped down because research shows that the mother needs to move and to be comfortable to help labour progress. The conversation progressed. The research also shows that for a woman's labour to progress naturally, she has to feel safe. One of the hormones involved in the natural acceleration of labour is oxytocin. For the oxytocin to be secreted by the woman, she has to feel safe. At this point, I started to feel very threatened and this is why many women's labours arrest when they go into hospital because they no longer feel safe.

May I suggest that case histories are fine, but we will be here all day if we go through every case history. I ask you to get to the nub of the question and give us the answers.

Ms Dowd

I apologise for taking so long. What I am trying to say is that when a woman goes into any of the maternity hospitals in Dublin, whether she wants a natural birth or not, it is practically impossible to have one. She is subjected to the active management of labour so that even when she specifically goes through all the work and research and has a birth plan noted by the master of the hospital, natural birth is not available. The hospital wants her to go through its system quickly. This leads women to feeling highly vulnerable. I felt like a five year old child in there.

I want to be helpful to the delegation because I am very supportive of their work. Members have asked questions and I detect a certain frustration so perhaps our guests could just answer the questions.

We are getting case histories here. I just want answers to questions that have been asked.

Mr. Macgheehin

We are very conscious of the questions that are backed up. I want to touch briefly on the litigation issues that Deputy McManus raised. There are no helpful statistics that I can give in relation to them. I am conscious that obstetricians and gynaecologists make up less than 100 of all the consultants in the country. I think there are 1,500 consultants altogether. I and many other solicitors are struck by the fact that there seems to be a huge proportion of cases relating to obstetricians and gynaecologists, which is completely out of kilter with the other specialities. There is some speculation that it could be as high as 25% of cases.

I noted a vital point in the Drogheda cases in which I am involved. The Drogheda cases go back to 1979.

We cannot go into specific cases here.

Mr. Macgheehin

I am not going into specific cases.

I ask Mr. Macgeehin to desist.

Mr. Macgheehin

Okay. Perhaps a central issue is the fact that auditing of hospitals does not happen on an annual basis whereby people like politicians could analyse what is going on. Those figures should be published for every hospital in the country. I will ask Marie to deal with the remaining questions.

I will do a general round-up of questions. I will take the questions in no particular order. I will start with the "born before arrival" category.

The point about babies born before arrival is that these are babies who are born in a variety of circumstances and they are regarded as medical emergencies. When I was doing my research for the Department of Health and Children, I found that births took place in, for example, Garda barracks. A baby was born in a politician's clinic and I am sure none of the Deputies here would wish to be called upon to provide that service for their constituents. This is proof positive, if proof were needed, that a highly centralised system is not meeting the needs of all women in childbirth.

I already mentioned the mortality rates and these are taken from a national survey in England and Wales. I can give the committee a copy of the research paper if required.

Was there a percentage who were very premature?

That study did not cross-tab by prematurity.

It is important.

It is very important.

Another relevant point to be made is that these are, effectively, usually births which are not attended professionally. We have heard, for example, about taxi drivers delivering babies.

A very important point to make is that all this did not happen by accident. I have great sympathy with what our guests say, but it did not happen by accident. This system came about because of a litigation-conscious public. In the United States, nobody will become an obstetrician because the rates are so high. The malpractice insurance is very high for an obstetrician to practice in this country.

Our guests said that evidence shows that midwife-based care and birth is as safe and safer than care supplied by doctors. They also stated that the risk of neonatal death was 33% lower in midwifery births than in physician deliveries. The point is that the cases are cherry-picked. The cases to which they refer are those which obstetricians would say did not involve first-time births or mothers with a bad medical history. The reasons obstetricians exist is for the safety of patients and, clearly, that was not happening.

Many years ago all deliveries were attended by GPs and there were problems. There was a certain satisfaction to the work, but there were major problems and the mortality rate was very high. I suggest to Mr. Macgeehin who is a solicitor, that his profession would be of more help to our guests than any other. I detect a certain battle here between the consultants and the midwives. I agree that nurses are midwives, but safety is the critical factor. I ask how we are going to guarantee patient safety if we go by our guests' figures, which I believe are cherry-picked and do not represent the true situation.

Perhaps Senator Henry wishes to——

May I finish what I was going to say because I have a number of other brief points in response to the questions which have been raised? The study, quoted by Deputy Cowley, of 4 million births involved births that were all low-risk. Those cases were specifically low-risk so that study refers exclusively to low-risk births.

Therefore, it could not be compared with the high-risk hospital cases?

I have known many of our guests for a long time and have been very supportive of the fact that women should be able to have home births. However, safety is an important issue.

Safety is a very important issue and births were centralised in this country in 1976 by Comhairle na nOspidéal. It is a policy which has never since been revisited and we hope it will be now. It was done without any evidence regarding the greater safety of obstetric care.

Our guests are putting forward several arguments and some of them are not doing their cause much good. There is the question as to whether we should have a midwife-led service. I presume some of them have visited the Liverpool Women's Hospital. I have been there and I have visited other midwife-led services in England and they are terrific. I have suggested that we introduce it in our maternity hospitals. In only about 20% of the births is there any involvement by an obstetrician.

The area of home births is where we are running into many problems. It is difficult to obtain any statistics about the safety of home births. The 1999 perinatal mortality figures show 274 births and one case of infant mortality. Anecdotal evidence says that there are other cases - planned home deliveries - where the woman is transferred very late in labour to a maternity hospital and the child dies. A coroner recently said that a child was 57 times more likely to die if born at home. This sounds bizarre to me. It is impossible to get any statistics on this subject. I am sure most of our guests would agree that women who have had previous Caesarean sections should not be delivered in the community, yet I have been told this happens. I do not think that is right.

Maria Dowd quite rightly talked about the indignity of being strapped down and a foetal monitor being attached, but Deputies Cowley and McManus raised the situation of litigation. Everyone will tell one that the figures are there to show that there is no lower incidence of cerebral palsy in infants who have been monitored than in infants who are not. If one goes to the courts, however, one needs to have plenty of paper as evidence that the infant was monitored. These are the facts to which we have to face up.

That would suggest that it is litigation rather than safety driven.

We have to face that.

We should hear Ms O'Connor's views because that is the problem.

I remember 30 women per year dying in this country with maternal mortality.

I will be brief. We are all coming from the same angle. At the end of pregnancy we want a healthy mother and a healthy baby, and we need to decide how we can deliver that. Rather than giving out about the hospitals we should look at why historically the hospitals came about. There was a very high incidence of infant and maternal mortality in the late 19th century and early 20th century. That has reduced substantially. Some 90% of all pregnancies are perfect and 10% go wrong to some extent.

Deputy Moloney took the Chair.

At a certain level I have no problem with a midwife-led service. However, if something goes wrong, as unfortunately happens with some pregnancies, who is responsible? I strongly favour home births or preferably births in a community-led hospital where they are controlled. For the small percentage of births that go wrong - and they tend to go wrong very quickly in those cases - there should be access to a consultant-led service very close by. Deputy McManus touched on the kernel of the problem in pointing out that the cost of medical insurance in obstetrics is the highest in the country and one of the highest in the world.

We cannot get obstetricians to work because the cost of insurance is so high. The same is true in the United States and it is because the litigation rate is so high.

Perhaps the Government should take over the payment of their insurance so that we can hold on to the few who are in the system.

I am glad to have had all my babies; I would not like to be starting again. I had four babies in hospital and I had a wonderful experience. I never felt I was being talked down to or talked at. I always felt I had normal and natural deliveries. However, I am now a little confused. What is the difference between a normal delivery and a natural delivery? There are three maternity hospitals in Dublin each delivering about 7,000 babies per year, which gives a total of 21,000 for the greater Dublin area. How many home births take place in the greater Dublin area? How many women opt for a hospital delivery over a home birth? What is the age profile of women opting for home births and are they generally delivering their first, second or third baby? Does VHI cover home births?

I have huge concerns about safety. The medical insurance bodies no longer want to cover obstetricians and gynaecologists and the State is entering into what is called enterprise liability. What kind of cover do domiciliary midwives have in the event of something going wrong after the delivery as Deputy Devins mentioned? Although these cases are rare, we all know how quickly they can happen. The uterus can fail to contract and there can be considerable uncontrollable bleeding. Who is responsible and what kind of cover exists?

I have not had any children yet and I am not looking forward to the prospect based on what I have heard this morning. I am conscious that my sister may be in the throes of labour as I speak. The first paragraph of the presentation given earlier says that midwifery is not a branch of nursing, nor is it a branch of medicine. I thought this was somewhat irresponsible, as I would have thought that a birth, as the beginning of life, would obviously be a medical situation. Like Deputy Devins I want to know who is responsible.

While the witnesses have made a strong case for what they believe in, I have not heard many of my friends, who have given birth, looking for such options, perhaps because they have no expectations. As Deputy McManus said, people like the comfort of the technology beside them and they may not know they have another option. What kind of demand is there for such births? People have every right to look for what they believe in and should assert themselves if they believe it is not mother and child centred. While I can imagine the medical circumstances of being about to deliver a baby are very trying, this should be exactly when a woman is very sure of what she wants.

Although I accept safety is central as outlined in the delegation's presentation in looking for midwifery driven births, I never heard mention of regulations. I would be very concerned about that because litigation is an enormous problem.

Although every woman is entitled to free maternity care, 40% of them elect to pay approximately €1,200 to get possibly better care. Does this indicate the hospitals are not providing the proper service?

I think there is a general perception that women believe private obstetric care gives them access to a more personalised service where they will see the same obstetrician during the nine months of pregnancy. They understand they will meet a midwife they have never seen before during labour, but there is some element of continuity of care, which is very important to many women. It would be regarded by many health professionals as one of the hallmarks of high quality care. Unfortunately it is a fact that private patients have some degree of continuity of care, which public patients simply do not have.

Mr. Macgheehin

I ask Ms Canning to answer the safety question.

Ms Canning

At the start Ms Ross expressed the concern of midwives and we are increasingly organising ourselves to address the problem in maternity care because of our concern with safety. England, Holland, New Zealand and Canada are examples of countries across the world that are changing the base of their maternity care services from obstetric to midwifery. While movement is taking place, safety is not being undermined. At this stage following umpteen studies and much research, there is recognition internationally that we are talking about normal healthy women who are not sick. The World Health Organisation states it expects that in any country in the world 85% of women in childbirth will be healthy and the midwife is the most appropriate and cost effective care provider.

With respect, one does not know when something may go wrong.

Ms Canning

Let me come to that——

It is fine when everything is going right, as happens most of the time.

Ms Canning

I have 20 years experience——

I have concerns, as a GP.

Ms Canning

——of working in all kinds of situations. With reference to the questions raised in relation to the position of Irish women generally and problems with maternity care services, Irish women have never had an opportunity to voice their opinions. Maternity care services have not been reviewed at a national level in terms of asking women about their experiences of birth. By contrast, in England in the early 1990s the House of Commons commissioned a review of maternity care services. The outcome of that review was that no evidence was found to support the view that childbirth was safer in a hospital context under the care of obstetricians. As a result, maternity care services have been reformed since the early 1990s. What we are saying is that Irish women should have a choice. There will always be women who choose to go to a hospital, be surrounded by technology and have their obstetrician. They are increasingly——

With respect, choice is fine——

The Deputy should not interrupt the witness.

Ms Canning

In 1986 there was a review of women's health care services. As a small part of that, women were asked for their views on maternity care services to the extent that they were asked if they would have liked a home birth. Nationally, 20% of women said they would have liked the option of giving birth at home. That is the only study we have at the moment.

To go back to the issue of safety, which the Deputy mentioned, there are studies as long as my arm showing that, under the care of a midwife, the normal healthy woman in childbirth is safer. The reason for that is——

Is Ms Canning referring to home delivery or midwife delivery within a hospital?

Ms Canning

Wherever. If one considers the developments in England, their current concerns are not as to whether women should have choices in childbirth or be cared for by midwives; the concerns in England at the moment are in terms of incorporating midwifery care within a hospital context. In relation to the issue of safety, that has long since been addressed and well confirmed. In New Zealand, since the early 1990s, maternity care services have been reformed to the point where, only a decade later, 71% of women are under the care of midwives. Why? Because there is a recognition that it is the safest option of care for healthy women in childbirth.

We will take some questions of clarification at this stage.

Just by way of clarification - I do not wish to be misunderstood - I am sympathetic to home births. Choice is fine but at the end of the day safety of the woman and child is paramount. I am very worried by the statement that "patient safety demands an end to the current system of obstetric control." At the end of the day, the consultant is responsible. The GP does most of the care - it is a shared care - but when things go wrong, the mother and child have a right to be as safe as possible. People demand that. The people who are seeking choice would demand that when things go wrong there is a proper system. That is the basis for my concern in that regard. The obstetrician is best suited to say which cases will get into trouble and which will not. I recall a case involving a woman who wished to have her first child at home. I did not agree with that at all and, having discussed it, considered that it was not in that person's interest to have the baby at home. The figures would show that she was one of those likely to have problems, having regard to certain complications. She had her baby, finally, in hospital——

We are dealing with questions of clarification only. I call Deputy Gormley.

How can one say there should be no obstetric control?

Please, Deputy Cowley.

Chairman, before we proceed further, when will we have answers to the questions which have been put?

We will come to that, but first there are some clarification issues. There is a possibility of a vote in the Dáil, in which event we may have to suspend the proceedings. We should proceed as quickly as possible in the meantime.

In terms of clarification, I do not wish to see a battle developing. The maternity hospitals are doing their best under the circumstances. My question earlier was how we change those circumstances. I referred to three steps we could take now. The reforms in Britain were referred to. What must we do here to reform?

I still do not feel that the delegation has addressed the issue of midwife-led services within the maternity hospitals. Have any of the witnesses been to the Liverpool Women's Hospital, which is only a short hop away? Almost every issue the delegation has raised in relation to non-use of pethidine, drips - indeed, everything I would support - is happening there. I know it is within a hospital setting and most of the women are discharged within hours of giving birth.

To good community care.

To good community care. Like Deputy Cowley, I am anxious about the issue of safety being minimised. In relation to some of the studies the delegation has quoted, particularly the ones from the Netherlands where people are within a short distance of a hospital in case of necessity, it is very difficult to compare like with like in the Irish context. For example, a woman from the far end of the Béara peninsula will have to have a home delivery, especially if she is a multipara, because she will not have time, unless she stays with her sister in Macroom, to get into Cork for the delivery. In referring to figures such as born before arrival, one must be in a position to say how many of those babies are very premature. One may find that it is a very high proportion. The figures would be more relevant on that basis.

Naturally, Deputy Dr. Cowley and I have professional experience of cases involving a BBA at about 22 weeks but, irrespective of location, what is one to do in that situation? I suggest the delegation should be careful, in using some of the figures, not to damage their cause. All my children were delivered by midwives not in hospital, but I was one of the 90%. We have to recognise the importance of safety. I again urge the delegation to be careful in their use of statistics. I would greatly welcome information on planned home deliveries where the woman had to be brought to hospital. I phoned the independent midwives about that a few weeks ago and I believe I spoke to Ms Canning who was most helpful. That type of information would be very useful.

Mr. Macgheehin

It will take some time to answer all of those questions.

I believe all of our positions are quite close together. However, there is a core problem, namely who is responsible if something goes wrong. Is it the midwife? Is it the obstetrician, who is confined to the hospital?

Ms Canning

It depends. As a midwife, I am an autonomous practitioner. I have a case-load of clients. I am completely responsible for the clients in my care. If something goes wrong, as the Deputy asked, the buck stops with me.

Not if the patient is transferred to hospital and has not delivered by the time she arrives. This is a very serious problem.

Ms Canning

Then, of course, I am no longer in charge of her care and, clearly, the obstetrician is then responsible.

What if the midwife has transferred the patient because of problems?

Ms Canning

Then I am transferring her to an obstetrician whom I expect to have the expertise and skills to deal with her problem.

Perhaps he would not have dealt with the delivery in the way in which Ms Canning——

Ms Canning

I will go back to the same point again——

There are several questions that need to be answered. Is Ms O'Connor ready to deal with those?

I would like to reply to a number of questions, firstly that about statistics which is an important issue. There are no publicly available statistics in Ireland on, for example, medical interventions - one of the questions had a bearing on this point. No audit whatsoever is done in our hospitals. Because there is no information on this, it cannot be said how many inductions are ending in caesarean section. It is known that induction is an important factor but not with regard to the number of cases because an audit has yet to be done. I have been told by somebody working on maternity hospital databases at present that, in his view, no hospital in Ireland has an adequate statistical database.

It was asked how the figures in Ireland compare to those in other countries but, because of the lack of statistics, it is difficult to make such a comparison. The statistics quoted to the committee come from the perinatal statistics of 1999, produced by the Economic and Social Research Institute for the Department of Health and Children. The ESRI has recently taken over the function of undertaking the national perinatal reporting system.

As an example, I will take two possible international comparisons. In Spain, some 40% of women give birth by caesarean section, vacuum extraction or forceps delivery. That figure is almost being approached in Ireland but this is based on statistics from a voluntary organisation, Cuidiú Irish Childbirth Trust. It seems completely inappropriate that this task is left to a voluntary agency. In Amsterdam, the caesarean rate is 9.5% whereas the rate for Dublin hospitals is approaching 20%.

Can Ms O'Connor break that figure down between elective and emergency procedures?

I cannot but I make the point that the three Dublin hospitals are the only hospitals in the country to produce annual clinical reports, though the reports are very difficult to get. No other hospital produces an annual clinical report and those that are produced are not available just for the asking.

Deputy Olivia Mitchell asked whether the statistics had changed over time. Caesarean rates have quadrupled in the past 20 to 25 years and have doubled in the last ten years.

To address litigation in broad terms with regard to medical negligence cases, this is a concern for all but it is important to remember that out of 30,000 possible cases every year, only 1,000 are actually taken. I trace the view of the Irish people as litigious to a Medical Defence Union press release issued in 1992. American research shows that lack of communication between professional and client is a big factor in litigation. Perhaps, an improvement in communication should be made.

Three Domino-Homebirth pilot schemes were set up about three years in the National Maternity Hospital, Holles Street, University College Hospital, Galway and in Cork. In Cork, the concept was different. The Southern Health Board went into partnership with self employed midwives to provide a home birth service for the region. Those pilot schemes have now finished and the pilot scheme in University College Hospital, Galway has finished without proper evaluation, thereby nullifying the whole concept of a pilot scheme, which is to carry out evaluation. The schemes are all closed for further bookings.

Deputy Gormley asked about the dangers of intervention for the child, particularly regarding induction. The risks of induction are well established and include increased risk of prematurity, foetal distress, jaundice and maternal infections. Induction is also linked to increased pain during childbirth, greater use of painkillers and increased instrumental and operative delivery rates. The master of the Coombe hospital draws attention to induction as a factor in caesarean section.

Induction may be necessary for the safety of the mother. I am concerned by this aspect of Ms O'Connor's presentation. My sympathies lie with home birth and I would like people to have more choice.

This is not a home birth issue.

I realise that Ms O'Connor is talking about the input of midwives and other matters. However, somebody has to carry the can. The main problem is not about communication but litigation. There needs to be a team approach and I sense a lack of that in Ms O'Connor's presentation. I respectfully suggest to her that while there needs to be a team approach, there also needs to be a captain of the team.

I would like to go ahead with the presentation.

Deputy Cowley mentioned induction being for the safety of mother and baby. I agree, but an induction rate of one in four, as experienced in the Coombe Women's Hospital, has to be questioned. It is a high rate and has increased.

Senator Henry raised the matter of planned home delivery and its results. I do not want to get stuck on this issue as the presentation is not about home births but about centralising maternity care. However, as the issue of home births has arisen many times this morning, I will deal briefly with it. We have no accurate statistics. The perinatal statistics of 1999 contain no breakdown whatsoever for domiciliary births which is extremely regrettable. There is a fundamental problem with the national perinatal reporting system in that no distinction is made between planned and unplanned home births. There is automatically a grey area into which planned home births and unplanned out of hospital emergencies fall. It is a problem related to the instruments used to collect the data, and one we hope is rectified.

It is not possible at present to quote rates. The national rate is 0.4% but it is important to remember that this is an out of hospital birth figure. It was asked whether I had statistics for the Eastern Regional Health Authority region - I do not because they do not exist.

Senator Henry mentioned the Liverpool Women's Hospital. While I have visited Liverpool several times, I have not been to the hospital yet, though I spoke at the university there last year. Community midwifery is well developed in Britain but there is effectively none in Ireland, or post-natal care for women.

What is the number of cases of litigation compared to the total number of births?

It is estimated that, with the patient throughput per annum, there is potential for 30,000 people to suffer some form of injury, whether mild or extremely serious. Out of the pool of 30,000 potential patients, 1,000 bring cases every year against doctors, which is a small number.

It is one in 30, however.

Ms O'Connor said that there is no post-natal care in this country, which I find fascinating.

I should have qualified my statement in that regard. Women who have given birth are discharged after 48 hours.

What about GPs?

I worked as a GP for 27 years and I find that post-natal care is an important part of general practice——

So is ante-natal care.

——for six to eight weeks.

GP services are provided ante-natally and post-natally as part of combined care with hospitals under the maternity and infant care scheme, which also provides for two post-natal visits. It is not regarded as an adequate number of visits for any woman who is trying to establish breastfeeding. I do not mean this as a criticism of general practitioners.

That is a strict interpretation of the matter. Most GPs would see the woman and the baby as often as is necessary during the six weeks.

I agree with Deputy Devins.

I am terribly sorry, but I am totally confused by the figure of 30,000 that has been mentioned. Does it relate to all cases?

It relates to potential cases among patients who have suffered some form of adverse outcome as a result of treatment.

Does Ms O'Connor refer to all patients or mothers giving birth?

I refer to all patients. We do not have a breakdown of the figures for mothers in particular. Some studies have been done in relation to patients as a general body, but not on mothers in particular.

So we do not know.

Questions were asked about fear of childbirth, the nature of midwifery and what can be regarded as normal. Normal birth relates to the normal workings of the body. The body has its own way of working; for example, it sends out certain signals - a call of nature - when one needs to go to the toilet or when one is hungry. It is natural to want to respond to such calls. Certain changes take place when one is under stress, for example when I was rushing to catch the train this morning, I could not eat because my appetite was gone. The ability of the vast majority - perhaps 90% - of women to give birth is affected by fear. An important hormone, which is sometimes called the love hormone, is used for breastfeeding and similar activities. The body does not work properly if one is under stress, something that can happen when one is moved to hospital. I am not saying that hospitals or obstetricians are wrong, but I think we should work together. I ask that birth be redefined physiologically so that it is seen as a normal event. Midwives are qualified to look after mothers during such a normal event.

Is there a difference between a normal birth and the type of natural birth Ms Ross has been talking about? Is a normal birth, according to Ms Ross, one that involves pain control? Can a natural birth take place with or without pain control?

We are splitting hairs in relation to this matter. We are providing a medical approach to care, under the umbrella of the safety and welfare of mothers and babies, based on access to drugs, breaking women's waters, using medication, etc. The procedures being used at present complicate the process. One can laugh at the comparison between moving a hen from one nest to another, but we treat mothers in a similar way. Some mothers do not produce sufficient amounts of the hormone needed as part of the birthing process when they are moved to a clinical environment where they do not necessarily know those around them. Medical assistance has to be provided in such circumstances to help the mother to give birth. The problems I have outlined can lead to more caesarean sections, which are extremely dangerous. The maternal mortality rate is far higher in cases of caesarean sections. More mothers are now dying of blood clots than ever before. A report into maternal mortality produced in the UK showed that women were dying from deep vein thrombosis, secondary to epidurals and caesarean section deliveries, at twice the rate of some years ago.

As we will be finishing in about 15 minutes, can I suggest that members of committee ask a few wrap-up questions and then we will hear final responses from our guests to allow them to define their positions in relation to the matters under discussion? I will bring in Ms Dowd before I take questions.

Ms Dowd

We are getting caught up in minutiae. Professor Bonner, who was mentioned at the start of this meeting, has said that nine out of ten women should have normal births, a claim that is supported by research since the 18th century. About 90% of women should give birth unassisted, by which I do not mean that they should not be in hospital, but that they should be left to do things naturally. The statistics from our hospitals tell us that just under 50% of first-time mothers are either having caesareans, ventouse or forceps. If 90% of them should be giving birth naturally and normally, why are the figures so high? The fact that something is fundamentally wrong in the system is leading to a high level of litigation. Increased intervention means that litigation is more likely because things are more likely to go wrong.

Why are women being pushed through a system in which 50% of them will experience the forms of intervention I have mentioned? As Deputy Gormley said, there is huge pressure in the system to get women through. Many obstetricians and midwives are sickened by the procedures they have to observe to get women through the system. Many women are totally sickened by what they have to endure. The figures I cited should not be forgotten, as they indicate that something is fundamentally wrong in the system. All the parties involved should work together to resolve the problems so that women can have good experiences and healthy babies. Obstetricians and midwives should be able to feel happy with their work, but many of them are tortured by what they see, as they have no choice but to intervene to rush women through the system.

A member of the committee asked if we had any figures for the numbers of women opting for home births. A study into birthing patterns among Irish women, which was conducted in 1992, showed that most of those who choose home births are professionals in their mid-30s who already have given birth to a child. A proportion of the cost of hiring an independent midwife is met by the VHI, BUPA and the Hospital Saturday Fund. This is part of the central issue of whether midwives should be seen as the professional gatekeepers of normal birth who refer to obstetricians when problems arise, or whether they are subordinate handmaidens. The problem with BUPA and the VHI, however, is that while they will pay for the cost of an obstetrician if one is a private patient, they will not pay the fees of an independent professional midwife in cases of home birth. They are only prepared to pay as if one has been in a hospital bed. This shows that midwifery is not seen as an autonomous profession, even though midwives do most of the work involved in caring for the 90% of mothers who have normal births.

Deputy Gormley asked about the effects on children of birth interventions. A great deal of work has been done by Dr. Michel Odent of the Primal Health Research Centre in London. He is compiling the huge amount of research that has been done in this area. Research suggests that there is a much higher chance that a child will become a user of barbiturates later in life if pethidine was used on him or her before birth. A link has been found between the response of babies to birth trauma and suicide later in life. I do not want to throw statistics at the committee, given that only ten minutes remain, but I can give members copies of the studies to which I have referred. We are talking about the future of the nation. We can make birth better for women and babies. We can save the Department of Health and Children money.

I have been asked who is responsible for some of the problems I have outlined. I have spoken, over many years, to women who have chosen to have a midwife present at birth rather than an obstetrician, who have chosen a home birth, or who were examining their options. Couples who choose something other than the norm and who do not want active management to be present are taking responsibility by saying "we are the people who made this baby and we will make the decisions that will help to make the baby come out safely". One does not see independent midwives who assist with home births being sued by mothers. The parent takes the responsibility. I am due to give birth in August and no one can guarantee me that the baby and I will be fine. I do not seek such a guarantee, but I will do my utmost to care for myself nutritionally and to ensure that I have a trusted care giver. I receive one-to-one care from the same person who was with me for my last two births and that is the option I choose as the safest for my baby and me.

I have great sympathy with everything Ms O'Connor has said. I take issue with her bashing of consultants and her antipathy to the system. The system has evolved as it has for very good reasons as was pointed out. We have gone full circle and I agree that with technology the natural has been taken out of birth to a major extent while control has been taken from the mother and given to the hospital and the consultant. However, that has happened for a reason and the medical and legal professions have important roles to play. The Government must work with them to limit litigation which serves no one and enriches lawyers while resulting in more caesarean sections than should be performed. The answer is not to take the consultant out of the equation, it is to adopt a team approach. Births which can safely take place at home should take place there and I agree with decentralisation, but the bottom line is safety. We must have a mechanism to identify high-risk mothers. I hope there can be more of the natural than the artificial in the birth process. The way to bring that about is to legislate to ensure that the system is less litigious.

We all want to see a healthy mother and a healthy baby at the end of the exercise and I welcome Ms O'Connor's comments. My preference is for the establishment of units on hospital grounds which can provide specialist care if it is needed. Given our geography and the demands on the health service, I am not sure it is possible to provide units everywhere, but I agree that what was said about decentralisation makes a great deal of sense.

Mr. Macgheehin

The debate has been most interesting. I detected some resistance to the notion of midwife autonomy from those Deputies with medical backgrounds. That notion is central to the case we have made here as midwives are perfectly capable of detecting any pathology and of transferring patients to another expert whom they respect. We would like to see medical people practising medicine and we would like to see midwives practising what they do best which is assisting mothers with natural births. I remind Deputies that EU legislation gives very high status to midwives by making it incumbent on member states to ensure they are entitled to engage in a range of activities, some of which are denied them here. That should be examined as there is nothing to fear from empowering midwives to do the job they do best. If that course were followed we would see more satisfied customers and less litigation. We lawyers would start losing out very quickly.

Ms Canning

The development of midwifery does not suit the economic or power interests of obstetricians. There are only 14 self-employed midwives working here and there is a concerted effort by obstetricians to curtail our practice. I have tried to practice for three years, but despite EU legislation I cannot access the resources and requisites I need to operate safely. I cannot get access to oxygen, ergometrine or intravenous fluids to deal with emergencies during home births. I have to beg, borrow and otherwise contrive to fill my bag in order to practice safely. Only two weeks ago, I received a letter from the master of a Dublin hospital which informed me that he and his two colleagues, the masters of the two other maternity hospitals in the city, had decided that no self-employed midwife in Dublin could bring bloods from a mother opting for a home birth to be analysed. We are no longer permitted to book ultrasound scans. This is very serious and it undermines the safety of women. It is scandalous.

It is scandalous.

Why has this been done?

Ms Canning

The development of midwifery does not suit the economic or power interests of the medical profession.

In fairness to people who are not here, they made a decision——

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make that official identifiable. I point that out to persons making presentations also.

What are the views of An Bord Altranais on this, with particular reference to prescribing? Midwives do not have the right the prescribe and they are governed by the board.

Ms Canning

When I began to practice two and a half years ago, I went first to An Bord Altranais. I had a bag to fill and I was directed by that body to the health board which I was told would provide me with the requisites. The health board told me that there were no mechanisms in place to provide the midwife with the requisites of practice. I went to the Department of Health and Children and pointed out the scandalous circumstances obtaining, but nothing has been done. I was told by An Bord Altranais to go to a GP. Rather than fill my bag with requisites which I would need once in a blue moon during an emergency, the health board suggests that I overcome problems by asking a GP to prescribe ergometrine, drips and oxygen in the case of each mother having a home birth. I have numerous letters from GPs refusing to give me prescriptions for what I need.

Ms O'Connor said that this is the result of consultants trying to control people. This is the result of a system which means one cannot point the finger and bash consultants. Midwives are registered with An Bord Altranais. Ms Monica O'Connor's problem lies with the board with which she is registered and she should try to get it to sort the matter out.

Deputy Gormley asked about the changes we are seeking. I understand a nursing Bill will be introduced in the Houses in the next legislative session. We hope it will make the changes needed to return to midwives the autonomy they were given through their training. Our system needs to change.

Midwives are not allowed to prescribe. Is that correct?

Ms Canning

That is correct.

If a midwife requests a drug from a GP or consultant, effectively he or she is being ask to cede control of something against the rules. If, as Ms Monica O'Connor has stated, midwives feel they have the ability to prescribe, they should try to get the current laws changed. As things stand, it is wrong to attack GPs and consultants.

Ms Canning

If I am attending a woman in childbirth, I have a professional obligation to be able to deal with an emergency in the interests of the safety of the mother and child. It is not a question of prescribing, but of getting access to——

Ultimately, the person who is responsible in law is the person who prescribes, which brings me back to my original point. If something goes wrong as a result of a midwife administering a drug which she is not entitled to prescribe, the person held responsible and sued will be the person with the authority to prescribe.

The provision of maternity care services——

In French a midwife is called a sage-femme. This is an appropriate description of the role of midwives. Do the witnesses believe matters will improve now that there are midwifery courses de novo for which one does not have to be a qualified nurse? Will this result in midwives being given more autonomy?

I hope so. I have spoken to some of the women taking part in the course in question. Direct entry midwifery will remove the medical focus of childbirth. We have already had a dispute about whether birth is a medical event and failed to reach a consensus on the issue.

I listened with interest to the comments on what happens when something goes wrong. The bottom line in my experience is that when things go wrong, regardless of whether it occurs at the dentist or with a midwife, the GP must deal with the matter. Everybody has a role to play. The issue should be viewed not in terms of who is top dog, but as a team working together. In my experience, GPs are involved in a process of shared care with consultants. I would be happy to share care with any other professional, provided it was done in a rational, co-ordinated fashion which ensured the main focus was on the safety of the patient, both mother and child.

We did not come here today to discuss home birth, as we do not regard it as the main issue, which is the question of the provider. We came here to raise the possibility of moving from a base of obstetrics to one of midwifery for the 90% of women who do not need obstetrics. Everybody agrees this is the appropriate mode.

Deputy Cowley took me to task about my description of midwives as neither doctors nor nurses. Midwifery is a separate profession. However, partly due to the influence of active management, its identity has been obscured in this country in recent years and many people no longer know what a midwife is or what she does. I find it amusing when I do radio broadcasts that radio journalists often have difficulty with the term midwifery.

Midwives taking part in the direct entry course in Trinity College Dublin are expected to graduate this year. Unfortunately, as yet no decision has been made to repeat this pilot scheme, whereby for the first time——

Over the years Deputy Devins and I have worked alongside midwives in hospital.

For the first time the restriction on entry to midwifery as a profession, namely the requirement to have a nursing qualification, has been lifted. Denmark, which many of us regard as an advanced country, has had 200 years of what can be described, albeit ahistorically, as direct entry. In other words, the graduates of the Danish School of Midwifery where I gave a lecture 18 months ago have never been nurses, but have been directly inducted in the school. Our model of care is effectively a British model which is a legacy of another era.

Deputy Devins mentioned multi-sited units and asked how realistic it was to think in terms of decentralising care. If we consider New Zealand, which is similar to Ireland in many respects, including population and territory size and the existence of an outlying scattered population, no woman there has to travel for two hours to access care in labour. They did not close their small units as we have, which has caused a problem for us. I agree with the Deputy that it is extremely unlikely we will achieve our objective of decentralising care under current plans. We have some 20 maternity units. If 14 units are left at the end of the process, we will clearly be moving towards greater centralisation which would be an unwelcome development.

On the issue of safety, we have a legendary study carried out in Amsterdam by eminent Dutch obstetricians on the safety of midwife provided care. It is important to note in this context that the debate on home birth cloaks a debate about a deeper issue, namely, who is the appropriate person to provide services to a normal, healthy woman in childbirth. In the study in question, which was a long-term prospective study of 8,000 women, the perinatal mortality rate was 1.3 per 1,000. Our perinatal mortality rate is currently 8.2 per 1,000, which is the worst in the European Union.

We plead with the committee to adopt maternity care as one of the tasks in its programme for the next couple of years. We seek a fundamental review of maternity care and ask Members to bear in mind we have not reviewed maternity care policy here since 1976. We would like the maternity and infant care scheme to be extended to include midwives. The scheme is about midwives practising midwifery in the community, not home birth. We seek circumstances in which midwives can give mothers antenatal care in the community.

I thank the group for its informative presentation and members of the committee. We will consider the presentation for inclusion in our work programme.

Perhaps some obstetricians will apply for direct entry into midwifery in the future.

The joint committee adjourned at 11.30 a.m. until 9.30 a.m. on Thursday, 6 March 2003.