Woman-centred maternity care has been public policy since 1994, but is maternity care really woman-centred or is it consultant-driven? Women have rarely been asked. Maternity care is a significant public-health issue: three out of four women in the Republic become mothers.
The myth that the Republic is the safest country in the world in which to have a baby originated with a 1993 Unicef press release on a report that gave incorrect maternal mortality figures for the Republic. If correct figures had been used, the Republic would have tumbled to seventh place. This myth has long been repeated by those who reject any challenge to the status quo.
The movement towards streamlined, efficient, high-technology production of babies began in 1963 with "active management" (see opposite page). Thirteen years later, Comhairle na n-Ospideal issued a report on hospital maternity care. Each obstetrician, the report recommended, should supervise 1,000 deliveries a year, in "minimum scale" units delivering at least 2,000 babies and containing 53 beds, two of which would be "delivery beds". Each bed was to accommodate at least 1,000 deliveries, or three women per 24 hours. Enter active management.
This Aldous Huxley vision of brave new birthing was set out in Development Of Hospital Maternity Services (1976), a document that led to the closure of most of the State's maternity facilities (see map). From a total of 108 maternity facilities in 1973, only 17 remain. Obstetric thinking worldwide favoured the closure of small units.
The Comhairle report was an exercise in number crunching. In order to implement a births-per-consultant ratio of 1,000:1, women henceforth had to be "delivered" in bigger units. Smaller units were staffed and run by midwives, with GPs providing back-up care.
Women's needs in maternity care were excluded from the frame of Comhairle's maternity-care blueprint. Comhairle is a consultant body whose remit is to structure consultant posts. The service was designed to meet the needs of consultants, who needed very high patient caseloads to maintain their skills, and to train future consultants. All women in childbirth were therefore required to be placed under consultant supervision. This obstetric policy, later adopted by the Department of Health and Children, extended the market for obstetrical services from the small minority of women with health problems in pregnancy or labour to the entire population of childbearing women.
In the Republic, as in France, communities fought long and hard against the closure of their petites maternitΘs. To no avail. Earlier this year, two more maternity units closed, one in Monaghan, the other in Dundalk, where 43,000 people signed a petition demanding that the maternity wing be retained. In Monaghan, a lengthy campaign by a cross-party and trade-union coalition, spearheaded by Caoimhgh∅n ╙ Caolβin, the local TD, failed to halt the closure.
The European Union directive imposing a 48-hour working week on doctors in training will exacerbate the already established trend towards centralisation. Fewer junior hospital doctors will be available. In the UK, plans to cope with future obstetric shortages are well advanced. Midwives, it is anticipated, will take over the running of the services.
Medical consultants here have decided they will work only in threes. This means Comhairle will sanction three consultant posts in any speciality in public hospitals. Or none.
New benchmarks set by the Institute of Obstetricians and Gynaecologists - part of the Royal College of Physicians of Ireland - will also have an impact on hospital care. Today, the recommended annual ratio of births per consultant has dropped from 1,000:1 to between 300:1 and 500:1. The plan is that each unit will have a minimum of 1,000 births, supervised by three obstetricians. Neither Monaghan nor Dundalk met the "viability" criterion.
Births-per-consultant-obstetrician ratios range from 786:1 at Limerick Regional Maternity Hospital - the highest in the Republic - to 280:1 at Cavan General Hospital, the lowest in a public unit. Consultants' active engagement in uncomplicated births is small. Midwives generally deliver all babies in normal birth, regardless of whether their mothers are public or private patients, but one in three midwives is leaving the service. The annual market for private obstetric services is estimated to be worth £25 million, shared among 86 consultant obstetricians.
Obstetrics, much more than any other medical speciality, requires very high levels of centralisation. Obstetrics is the study of complications in pregnancy and labour. But complications are relatively rare. As Professor Bonnar suggests, only 10 per cent of women will develop complications requiring obstetric expertise. Vast numbers of women are therefore required to generate enough "material" for doctors to study obstetrics. Regional hospitals with fewer than three obstetricians will not be accredited for training purposes.
AS Professor John Bonnar, the chairman of the Institute of Obstetricians and Gynaecologists, told the Irish Medical Times: "the country cannot afford to put three or four consultants into a hospital delivering 500 mothers, with only maybe 50 abnormal women in that 500. What experience will they be getting?"
What are the consequences for women - and men - of centralising birth in large units? Rural women in some parts of the Republic are faced with a two-hour drive in pregnancy, and in labour, to access the services for their care. The alternative to a lengthy nightmare journey in labour is social or non-medical induction, or "elective" Caesarean section.
"Women are being penalised for living in rural areas," according to Maire O'Regan, the chairwoman of the Association for Improvements in the Maternity Services (AIMS). Women in country areas, she believes, are being denied the level of service available to their urban peers.
In Monaghan, a number of women have complained to ╙ Caolβin that they were brought in a week, or even two weeks, before their due dates, to be "started off". "It is not for the system to be prescriptive," he says. "Women should have the right to make informed decisions about their care. The hospitals have a tendency to admit them early." Women are not being allowed to carry their pregnancies to "their full, natural term", he says. "Intervention is planned to accommodate service providers." Induction rates - 40 per cent at Cavan General Hospital, in ╙ Caolβin's constituency - have soared in many units.
Rhiannon Shelley, whose baby was born last year at the Erinville Hospital in Cork, says, heroically, that the two-hour drive into the city from Ballydehob, over bumpy roads and in labour, was "not too bad". The contractions, she recalls, were coming every eight minutes. She went into labour at 6 a.m., leaving home at 4 p.m. to go into hospital.
Why the delay? "Because I wanted to avoid intervention," she says. "My midwife antenatal teacher told me the later you leave it to go in, the less chance there is that staff will do something to you, like breaking the waters."
One of the last women to have her baby in Monaghan was Christina McQuaid, from Castleblayney. She felt it important to have Dearbhla, her seven-month-old daughter, at Monaghan General Hospital. Her elder children and her husband were born in the unit. She knew the midwives who looked after her. There was open visiting, something she feels would not be allowed anywhere else.
The hospitals in Cavan and Drogheda, says McQuaid, are like factories. "They're 30 or 40 miles away. In winter, when it freezes, or in heavy rain, it's a long drive."
Centralising birth in large units results in more emergency out-of-hospital births, which, at 68 deaths per 1,000, carry a high risk of mortality. The rate of unintended out-of-hospital birth in the Republic is much higher than it is in Britain. Half of all out-of-hospital births here are unplanned, compared with one-third of such births in England and Wales - a much larger geographical area with more than 12 times the population of the Republic.
Maternity care was allegedly centralised in the best interests of mother and baby. How safe is the service when more babies are being born on the side of the road because mothers cannot get to ever more distant hospitals in time? When more women are being brought to hospital at 38-39 weeks for induction, with all its dangers? When greater numbers of mothers require epidurals, with their risks, to cope with the increased pain of induced labour? When women are caught in the vicious spiral of active management, with its potentially dangerous dynamic of induction, acceleration, epidural, forceps, vacuum and Caesarean section? Two out of five women in the Republic have their babies by scalpel, forceps delivery or vacuum extraction. Is this really in mothers' and babies' best interests?
Marie O'Connor is a research sociologist and author