Midwife-led system at heart of future vision

Pregnancy and birth are the most normal of human events and yet the recent history of adverse outcomes in Irish maternity hospitals has been anything but routine.

Politicians often boasted about Ireland's low rates of infant mortality but it took the tragic death of Savita Halappanavar in a Galway hospital in 2012 to trigger realisation all was not well.

Savita’s death prompted a recommendation for the drawing-up of a strategy to allay public concern and provide a new vision. Not much happened until the scandal of baby deaths at Portlaoise hospital reignited controversy and forced the Government to deliver.

The other driving force was the clamour for a re-evaluation of the way maternity services are delivered. At present, midwives, though numerically superior, lead the delivery of less than 5 per cent of babies; the rest are delivered in a consultant-led system that critics claim leads to an over-medicalisation of childbirth as well as restrictions on maternal choice.

Midwives excluded

The tensions between the two philosophies were evident before the implementation group charged with drawing up the strategy even met. The Institute of Obstetricians complained about the preponderance of midwives on the group, and consultants complained about two Portlaoise mothers present as patient representatives.

The institute withdrew its letter of complaint after it was leaked in this newspaper but the unease felt by some obstetricians may resurface following publication of the strategy group report and its call for a move towards a midwife-led system.

The problems were highlighted in many of the 1,300 submissions to the steering group: these complained of overcrowding and a lack of resources, poor staff communications, long waiting times for appointments and poor breastfeeding supports.

Against this, there was praise for staff, both obstetricians and midwives, and regardless of whether care was in hospital or at home.

Culture of normality

The report seeks to prioritise a “culture of normality” in childbirth and to facilitate women’s choice. Central to the document is the creation of three “care pathways” according to the level of risk involved. Most women, at low risk of complications – the report refers to “normal risk” – would be assigned to a named midwife manager and delivered by midwives.

Only medium-risk and high-risk women would normally come under the care of obstetricians, though normal-risk women could choose an obstetric service.

Labour wards would be redesignated “high-intensity birth centres”, but most women with normal or medium risk would be delivered in “low-intensity birth centres” that would not routinely offer epidurals, foetal heart monitoring or oxytocin to speed delivery.

Freestanding birth centres are available in other countries which have moved to a midwife-led system. Missing from the document is any discussion of the private versus public split in the health service, particularly acute in maternity. No figures are provided for the cost of the new strategy.

The document does say 100 extra consultant obstetricians will be needed but no figure is provided for midwives required because research work is ongoing.

Many of Ireland’s 19 maternity units are small by international standards and closing them would make the greatest contribution. However, this is not going to happen, if only for political reasons. The workaround for this involves the creation of maternity networks such as that being developed between the Coombe and Portlaoise hospitals.

If this report is not to join others in gathering dust, it will have to be funded. The HSE service plan for 2016 allocates an extra €3 million for maternity service developments such as the appointment of a director of midwifery in all units, but this is only a drop in the ocean compared to what will be needed.