Unearthing the truth about Ireland’s maternity services is like peeling an onion. The Hiqa investigation into the Midland Regional Hospital, Portlaoise, has revealed another layer. No doubt several more will be uncovered before the whole truth emerges. The truth is that providers of maternity services – hospital midwives and obstetricians – have been abusing women’s rights for decades. Unnecessary interventions, forced labours, symphysiotomies, Caesarean hysterectomies . . . the list goes on. At the heart is the misogynistic model of maternity care introduced 60 years ago. The Department of Health set up the free Mother and Infant Care Scheme (a revised version of the abandoned Mother and Child Scheme) in 1956, which meant women had little choice but to give birth in consultant-led maternity units.
Dr James Deeny, chief medical adviser in the Department of Health from 1946 to 1956, described the opposition to the scheme in his 1986 memoir, To Cure and to Care: Memoirs of a Chief Medical Officer. "During the 10 years while people messed about with [the scheme], the most incredible things happened to it; bloody-mindedness, bad luck, folly, idiocy, scheming, religious obscurancy, politics . . . between the lot of them they made a right mess of the Mother and Child scheme."
Incubator women
The Catholic Church was vehemently opposed to the scheme and in a letter to the government wrote that “to educate women in regard to health, and to provide them with gynaecological services, is directly and entirely contrary to Catholic social teaching, the rights of the family, the rights of the church, and the rights of the medical profession”. Everyone’s rights, particularly men’s rights, mattered more than the rights of women, who were regarded as little more than incubators.
In the 1960s, the consultant-controlled maternity units introduced a policy of "active management of labour (AML)", which ensured pregnant women lost all power over childbirth. A breathtakingly arrogant paper on AML written by three obstetricians from the National Maternity Hospital, Dublin, was published in the British Medical Journal in 1973. According to the authors, AML was developed because a long labour "may cause permanent damage to a woman's personality". With AML "every labour is controlled", and "every woman who attends this hospital for a first birth will give birth within 12 hours". Intervention – including, in all cases, artificial rupture of the membranes followed by oxytocin infusion – was mandatory unless cervical dilation exceeded 1cm per hour. "The aim should be to deliver every woman within eight hours." No pressure, then.
A paper published in the Journal of Obstetrics and Gynaecology in 2003 shows this approach to childbirth was then, and is still, the norm in Irish hospitals. A recent High Court judgment from Mr Justice Kevin Cross, on a symphysiotomy performed in 1963 (the plaintiff lost her case), praised "the extremely successful practice of AML". In effect, according to the judge, AML did women a huge favour. (The full judgment is at www.courts.ie/Judgments.nsf/ 09859e7a3f34669680256ef3004a27de/b6a16e2404e604ee80257e4300504dbd?OpenDocument)
Consultant-led maternity services are not safer for women and nor is AML. Forced labour is an abuse of power. Caesarean section rates in Ireland are double (30 per cent) that recommended by the World Health Organisation (10-15 per cent). A 2013 Cochrane collaboration study found midwife-led continuity models of care are better for women and babies than models of consultant-led care. Ireland’s 60-year-old medical model of maternity services must go.
Indeed, there is a whiff of the 1950s about the behaviour of health professionals in the Midland Regional Hospital, Portlaoise. Parents who lost babies were reprimanded for crying, shown no compassion and ignored. Women reported “feeling terrified”, and made to feel like naughty children or troublemakers if they asked questions.
The Hiqa report reiterated the need for a national maternity strategy to ensure women have access to "modern-day models of maternity care" and called the delay in introducing this strategy "unacceptable". In response, Minister for Health Leo Varadkar has set up a Maternity Strategy Group which has a good mix of members, including two service users, the Association for Improvements in the Maternity Services (Aims), and professionals from primary care, midwifery and obstetrics. The strategy will "put the needs of mothers, babies and their families at its centre". The group could save time and copy the Strategy for Maternity Care in Northern Ireland 2012-2018, which stressed the normalisation of childbirth. Midwives "lead maternity care in straightforward pregnancies" (80 per cent) with antenatal care provided in the community. Consultant-led care is provided only for women with "complex conditions" (20 per cent). We need a similar strategy here. Let's hope scrambles for power do not lead to another 60-year wait before women get the services they deserve.
Dr Jacky Jones is a former HSE regional manager of health promotion and a member of the Healthy Ireland Council.