A good birth is no holiday, but it helps to know your options

Sheila Wayman, The Irish Times

Renting a holiday home to give yourself the option of a home birth may sound a bit extreme but that’s what some women in the southeast have done to ensure they are in the catchment area for Waterford Regional Hospital.

It is one of only two maternity hospitals in the Republic that currently offers a home birth option as part of its midwifery-led care. But unless the WRH is the nearest maternity hospital to where you plan to give birth, the midwives there cannot consider you for a home birth.

If transfer to hospital is needed during labour, ambulances are obliged to take you to the nearest maternity unit and WRH midwives cannot go to a hospital in Cork, Kilkenny or Wexford where they are not employed, their patient is not registered and there are no patient notes.
In other parts of the southeast, as in most of the State, self-employed midwives attend home births.

Great lengths
While a few women will go to great lengths to have a home birth, there were only 168 home births attended by independent midwives in 2011 – the latest year for which perinatal statistics are available. This is just 0.2 per cent of the 74,377 births that year but does not include those under hospital-administered home birth schemes, such as those in Waterford and also the National Maternity Hospital in Dublin, because they are recorded as hospital births.

The number is minimal, partly because it is so difficult to organise one due to the shortage of midwives but mainly because it is not something most Irish women want. (Although Eva Early of the Home Birth Association says for every one woman having a home birth, another 10 want one but don’t get it for a variety of reasons, such as not fitting the strict criteria or not being able to book a midwife.)

But the other main choice is, arguably, for low-risk pregnant women the other extreme – consultant-led care.

“Most women don’t like being faced with an utterly polarised choice,” says Krysia Lynch of Aims Ireland – the Association for Improvements in the Maternity Services. “The majority would probably be happy with something in between and that is the one thing we don’t offer” – at least not in many places.

Aims has just launched a new campaign, “42 Weeks” to give women “non-biased, evidence-based information on having healthy births and positive experiences in Ireland”. Its name (as well as its duration, from June 9th last to Mother’s Day next year) was chosen to highlight the fact that most women go into spontaneous labour when their babies are ready to arrive, which may be anytime between 37 and 42 weeks of gestation.

Becoming fixated
It is something women can overlook when becoming fixated on their estimated due date (EDD) and this could be a factor in our high induction rate, suggests Lynch, that in turn contributes to our high Caesarean rate – 27 per cent of all births here are by C-section, compared with a European average of 19 per cent.

“A lot of women come from the stance that the ultimate marker is 40 weeks, so when she gets to 40 plus one, she thinks, ‘Oh my God this baby is late, something bad could happen’.” So she is more likely to agree to an induction, if not actually ask for one.

Women don’t realise that by taking an induction, she says, they are likely to get a cascade of interventions, which increases the chances of needing a C-section.

The campaign’s tag line is “healthy births for healthy mothers and babies” and the emphasis is on sharing positive birth experiences, as horror stories inevitably grab the attention of women themselves.

“A healthy birth makes a healthy mother so she can look after her baby,” she points out. “If you have a birth that has been less than that, you are less empowered as a mother and you feel less confident.”

Jo Murphy-Lawless, sociologist at the School of Nursing and Midwifery in Trinity College Dublin, agrees. “It is about an experience of support and confidence, which takes a woman into new motherhood feeling very able in herself. This is what is at stake.”

She points to the UK Birthplace study of outcomes for almost 65,000 low-risk pregnancies, which found that women who planned birth in a midwifery unit had significantly fewer interventions and more “normal births” than women who planned birth in an obstetric unit.

Some 75 per cent of women who attended midwifery-led units alongside maternity hospitals had normal births, compared with only 58 per cent of low-risk women who gave birth in consultant-led units.

Part of the empowering process for motherhood is making an informed choice of the maternity care that suits you.

“Women need to know what it is they are getting from a package of care and there can be confusion,” agrees the director of midwifery at the Coombe Women & Infants University Hospital in Dublin, Patricia Hughes. “Women should know if they are not booked under a consultant team, they are booked under a team of midwives but that there are very clear pathways for them to transfer – if they want to or if the midwife needs to transfer them.

“I think we have a good deal of work to do in educating the population – and also what a midwife can do. I think a lot of people still think you have to book a consultant.”

Maternity care options in Ireland tend to be viewed in terms of public, semi-private and private when this is more a reflection of how maternity care is paid for, rather than the type of care that is provided, says Lynch. So what choices do pregnant women in the Republic have for delivering their babies?

Consultant-led care
This is the only universal option for pregnant women, countrywide, and the one chosen by the vast majority.

For the estimated 15-20 per cent of women who are classed as high-risk pregnancies from the outset, it is preferable they are in the care of an obstetrician.

Scare stories leave many women petrified at the idea of giving birth.

And if women are frightened from the start, says Lynch, they tend to opt for a consultant, who is trained to deal with births that go wrong and who oversees the only form of care where an epidural is available for pain relief.

Also, women are not always aware that if they choose midwifery-led care initially, they can move to consultant-led care at any time if they want to, or if the midwife needs to transfer them. On the other hand, nor may they be aware that paying an obstetrician privately does not guarantee that he/she will be at the birth.

All going well, a woman who is attending a consultant privately may have her birth managed by exactly the same midwives who are delivering the baby of a woman in a next door room under the free service.

Midwife-led units
The Republic’s only two midwife-led units (MLUs) are in Drogheda and Cavan, attached to Our Lady of Lourdes Hospital and Cavan General Hospital respectively.

They offer women with uncomplicated pregnancies and anticipating a normal birth the opportunity to experience childbirth in a more home-like atmosphere. The midwife is the lead professional, sharing the woman’s antenatal care with her GP.

Midwife-led schemes
Women with low-risk pregnancies can entrust their care to midwives through a variety of schemes at a number of hospitals. Strict criteria apply for eligibility and women classed as low-risk at the outset may find their status changes during pregnancy and they have to be transferred to a consultant.

One attraction of attending midwives is the continuity of care from a small team of people through the pregnancy and birth and they also hold local ante-natal clinics.

At the NMH in Holles St, Dublin, community midwives offer other options, some of which are also available at the city’s two other public maternity hospitals:

The term is derived from a shortening of “Domiciliary Care In and Out of Hospital” and involves midwifery care from the beginning of pregnancy, through labour to between five and 10 days after birth. While women go into the hospital to give birth, they can go home with their baby, provided there are no complications, within six to 12 hours. The midwives continue to provide support and advice through visits for a few days afterwards and will do the baby’s heel prick test at home.

At both Holles Street and the Rotunda, community midwives are available only to women living in certain areas and they are quickly booked up.

The Coombe Women & Infants University Hospital in Dublin only started a Domino scheme in 2011 and is still not dealing with the numbers it could, according to the director of midwifery, Patricia Hughes.

Last year it had 140 bookings but fewer than 30 births and she says the “water-tight” criteria governing eligibility is being re-examined. Outside Dublin, there are Domino schemes at Wexford General Hospital and Waterford Regional Hospital.

Home births
Only two hospitals, Waterford Regional Hospital and the National Maternity Hospital in Dublin, have community midwives who will either deliver your baby in the hospital or at home.

Meanwhile, most women who want a home birth need to book a self-employed community midwife (SECM). Contracted and insured by the HSE, these midwives have signed a “memorandum of understanding” that governs their work.

The SECMs are clustered in the Dublin, Galway and Cork/Kerry areas with none, for instance, in Donegal.

The Cork University Maternity Hospital (CUMH) is unique in that it hosts a monthly clinic where self-employed midwives can attend with the women booked into their care and meet a consultant obstetrician to plan the care for the rest of the pregnancy and birth.

Should the women need to transfer into CUMH for the birth, the SECM can remain with her. If the woman requires obstetric intervention then, following discussion with the woman, care is handed over to the CUMH staff but the SECM may remain in a supportive role.

For more information on the Aims campaign, see 42weeks.ie.