BBA. Born before arrival. That's what is jotted on the charts of women who deliver before they make it to a maternity hospital. According to reports, recommendations by the Medical Manpower Forum could result in the closure of 12 of the country's 22 maternity units, writes Breda O'Brien
There are plans to annex Holles Street, the Rotunda and the Coombe to the city's acute hospitals, while maternity units in Ballinasloe, Mullingar, Portlaoise, Castlebar, Tralee, Kilkenny, Clonmel and Wexford are to close. If these recommendations are implemented by Micheál Martin, those seemingly innocuous initials, BBA, will become more and more common.
Let's look at the implications. Bronagh Livingstone was born in an ambulance 20 minutes after her mother, Denise, was turned away from Monaghan Hospital, even though a no-longer-used maternity unit lay empty, and midwives were present who had been redeployed to nursing duties. Bronagh died.
Her chances of survival were not high because she was so premature, but to her parents' and family's grief were added the indignity of the circumstances of her delivery, without a midwife in attendance, on the side of a road. If the closures of maternity units go ahead, it will mean longer journeys for women in labour.
Inevitably, it will mean births in cars, in GPs' surgeries, in Garda and fire stations, as desperate mothers look for help wherever they can get it.
What we are talking about is the high probability that babies will die who would otherwise have survived, as the statistics show that deaths in those circumstances are 68 in 1,000, which is eight times as high as birth in hospital.
Furthermore, it will result in any woman who has a history of a short labour being encouraged to come into hospital to be induced, in order to prevent a roadside birth. It will be an intervention made for pragmatic and not medical reasons, as the vast majority of those women would go into labour on their own if they did not have the misfortune to live miles from the maternity unit.
Having experienced an induction of labour, I can testify that the intensity of the contractions is far greater than when you start labour normally. As a result, women are much more likely to request an epidural.
This in turn can lead to a phenomenon which is well documented in the medical literature, of a cascade of interventions such as forceps or ventouse delivery or Caesarean section. Birth moves closer and closer to a medical procedure and farther and farther from the way which nature intended it.
Every intervention in those circumstances increases the degree of risk for the baby and indeed the mother. Tabloid stories about mothers who are "too posh to push" might paint Caesarean section as some kind of lifestyle choice with no medical implications. However, as the Master of Holles Street, Declan Keane, has pointed out: "People forget that it's still a surgical intervention and has immediate and long-term effects on the mother."
We are frustratingly far from a holistic vision of birth in this country. The suspension of the domiciliary midwife and home-birth service provided by the Western Health Board (WHB) is a good example of that. Introduced as a pilot scheme in 1999, the system allowed women to be cared for by a midwife right through pregnancy, to stay at home to give birth or go to hospital for a few hours and come home soon after. The latter was termed the Domino system.
If complications arose, an obstetrician was always available. Most women chose the Domino option, but a number chose home birth. Every year the numbers were increasing due to parental demand. The reason given for suspending the service was that the funding was needed to appoint a consultant neonatalogist and an obstetrician.
What does it say about our health service that one of these things is presented as an alternative to the other? This move must surely embarrass Mr Martin, who recently praised highly the similar Holles Street domiciliary scheme. Even from a financial point of view the domiciliary midwifery scheme made sense, as it cost only €372,000 to administer it.
The good news is that parents are no longer willing to be the passive recipients of bureaucratic decisions which affect them so profoundly. There will be a march today, beginning at 2 p.m. at the Garden of Remembrance in Parnell Square, Dublin, which is supported by the Green Party, one of the few political parties with a progressive policy on birth.
The marchers will include Parents for Choice In Birthing, who are a lobby group set up to contest the WHB decision to suspend the domiciliary scheme. There will be lots of parents from other places who do not want to see their local maternity unit closed.
No doubt there will be many veterans marching from the long-established Home Birth Association who have had a frustrating existence trying to gain support for home birth.
The medical establishment seems severely threatened by the idea that healthy women can give birth at home with the assistance of a midwife, and that many studies show that, not only is it safe, but preferable in many ways for both mother and baby.
Could it be that if it were accepted that home birth is a good option, consultants will lose business? Surely not.
Yet it does seem odd that not only has the WHB scheme which was backed up by hospital expertise been suspended, but there seems to be a concerted effort to make life impossible for independent midwives who work outside the hospital system.
One certain way to make home birth less safe is to marginalise it and treat the expertise of these vastly experienced women with contempt. This has knock-on effects even for midwives who work only in hospitals, who see their profession downgraded and made subservient to consultants.
We are very far in this country from the situation which pertains in say, the Netherlands, where midwives are the recognised experts in normal delivery and home birth is a mainstream option. That's good for mothers, good for babies and good for the profession of midwifery. What's bad for all of them is the possibility of more unnecessary, and potentially lethal, unattended BBAs.