Maternity choice - what women really want


By Jene Kelly*

A recent international research review of over 16,000 women concluded that women who received midwifery-led care from a small group of midwives had healthier births than women receiving traditional consultant-led care. Women of both low risk and high risk status participated.

The study, published by the Cochrane Library, showed that women receiving midwife-led care had higher satisfaction ratings of their birth experience and were less likely to require an epidural, had fewer instances of assisted instrumental delivery and fewer episiotomies than women in obstetric-led care.

Babies of women receiving midwife-led care also fared better as there were less instances of birth before 37 weeks and less instances of miscarriages in the midwife-led group.

This research comes at a pivotal time for Ireland. This year has seen obstetric negligence claims that are projected to exceed €100 million, and the recent High Court ruling in the Aja Teehan v HSE case, which has instigated discussion not only on the safety of home birth vs hospital practice but also on the strict HSE criteria for home births.

This discriminatory criteria prevents women from accessing services outside of traditional obstetric-led care and it does not allow for individual assessment.

Hospital care in Ireland is obstetric-led in practice and policy and includes many routine interventions which increase distress to babies in labour and increase the risk of adverse effects on women, for example: higher rates of induction, amniotomy (breaking the waters), epidural analgesia and use of oxytocin.

'Routine' means that the procedure or intervention is standard practice for every woman with no individual assessment, and regardless of medical necessity or robust and reliable evidence.

Some practices may not be routine for every woman, but are frequently in use despite risks. For example recent research by the American College of Gynaecologists has shown the use of oxytocin - for induction of labour or to 'speed-up' labour - poses an independent risk to babies and increases neonatal intensive care admissions.

It is noted with great interest that the recent midwife care review included women of both low and high risk status and that there were no adverse outcomes.

In Ireland, women are prevented from accessing midwife-led care on very tight exclusion grounds.

Many are women who would otherwise be considered low risk in other jurisdictions. Women perceived or deemed to be at moderate or high risk are also excluded.

AIMS Ireland welcomes the rigorous methods, the impartiality and the independence of this Cochrane Review, as it confirms what we already knew: that midwife-led continuity of care options provide safe, cost effective care for mothers and babies and have significantly fewer interventions.

The other important result of this research shows that "midwife-led continuity models of care are associated with a reduction in overall fetal loss and neonatal death by approximately 16%".

This research is supported by countless previous research studies that have all had similar conclusions to the Cochrane Review. These include:

In 2008, the KPMG review of Irish maternity services recommended that midwife-led care options be rolled out nationally.

The HSE's Mid-U study found that the same birth, for the same woman, costs over €300 more for women in consultant-led care (CLU) as compared to a midwife-led unit (MLU). Women in the MLU had fewer interventions, fewer adverse effects and higher satisfaction rates than the women in the CLU.

In a 2007 study of Holles Street Hospital's DOMINO scheme, 5,500 bed days were saved by community midwifery services in Holles Street (Early transfer home and DOMINO home birth). The Study found caesarean section rates were significantly lower in the Domino scheme.

There have been countless international studies with similar results.

Obstetric-led care has a very important place in Irish maternity services and should be available for women who want or need this type of maternity care.

However, in Ireland, 90% of women will have no access to midwife-led care even though it is deemed to be the most appropriate model of care and it is safer and it is less expensive for the majority of women. Failing to provide appropriate care options affects all women.

Our two tiered obstetric-based system means that no choice is afforded to women who prefer to birth under a midwifery-led continuity of care model and that women who do not want or need obstetric led care are using valuable resources and are taking up time and beds from women who want or need a consultant-led care model.

This study on midwife-led care shows that, once again, reliable and valid research strongly suggests that Ireland's obstetric-led model of care is outdated and is of very little benefit to the majority of women.

While there may be an estimated 10% to 15% of women and babies who are in need of obstetric-led care, the Cochrane Review on midwife-led care shows that the large majority benefit from the midwifery-led care model.

The majority of regions in Ireland have no choice in midwife-led services. Women can access public or private obstetric led care in every region and maternity unit.

The same choice should be afforded for midwife-led care options in the community or hospital based. Where midwife-led care is available, the HSE has placed highly restrictive criteria and/or catchment areas that exclude access to a great number of women.

As shown in the case of Aja Teehan versus the HSE, the HSE has developed restrictive criteria - that is not evidence-based - to determine access to midwife-led options (home and hospital based).

There is no provision for individual assessment based on current pregnancy or previous birth experience, nor is informed choice given any consideration.

AIMS Ireland assists in many complaints regarding blanket bans on hospital based midwife-led care options in Ireland.

Women are excluded through arbitrary criteria, such as: a BMI over 30 at the time of booking, age 40 or over at time of birth, IVF, LETZ procedure, VBAC, and transfer from MLU to CLU on suspected ‘big baby'. These women are denied hospital based midwife-led care without individual assessment or discussion and, most importantly, without their informed choice.

Removal of choice is never best practice. Women should be assessed on an individual basis on their current health and their current medical conditions in addition to their previous history. The HSE is not providing women with individual assessment - a fundamental principle in evidence-based care.

Obstetric-led care is defensive practice that has high medical intervention rates and lacks the continuity of midwife-led care.

Obstetricians in Ireland use outdated routine practice such as continuous electronic fetal monitoring (CFM), artificial rupture of membranes (ARM) and active management of labour - all practices that robust and reliable evidence-based research shows to increase risks of unnecessary interventions and adverse outcomes to mothers and babies.

Research studies over the years, including the most recent Cochrane Review, categorically state that best practice in maternity care is to provide a midwife-led continuity of care model in every maternity unit in Ireland with appropriate inclusion criteria, individual assessment and the right to informed choice.

The failure to implement policy that supports this robust research means that the HSE is putting mothers and babies at risk.

*Jene Kelly- Association for Improvements in Maternity Services (AIMS Ireland)

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