A new report recommends offering home births to low-risk women. Fiona Gartland reports
A report on domiciliary births in Ireland that recommends home birth be offered to low-risk women around the country is a positive step towards woman-centred maternity care services, but could prove difficult to implement, according to a Trinity College Dublin (TCD) professor of midwifery.
Prof Cecily Begley, chairwoman of Nursing and Midwifery Studies in TCD, says that one of the difficulties in Ireland is that maternity care is consultant led.
The Domiciliary Births Group (DBG) report, submitted to the HSE last December, but not yet published, found that home birth is a safe option for low-risk women "where adequately resourced and supported".
It recommends that the service be offered throughout the country and integrated hospital and community midwifery services should be developed and extended nationally.
It also recommends that midwifery-led units be established by all maternity hospitals and continuity of care should be a feature of all models of maternity care.
The group found that continuity of care, when a woman sees the same health practitioner throughout her pregnancy and labour, has been associated with a lower rate of interventions and increased satisfaction in childbirth. And it found that evidence does not support high levels of monitoring and intervention for all pregnant women.
It also found that people want a woman-centred maternity service and that those who used outreach pilot schemes around the country were happy with them.
"Midwives are key providers of care to pregnant women throughout pregnancy, childbirth and the postnatal period," it says. "They should be the lead carers for low-risk pregnancies."
The group was set up following a Supreme Court ruling in 2003 which said health boards were not legally obliged to provide home birth services. It examined various models of maternity care around the country, including private home births, community outreach projects and pilot programmes offered in some health board areas such as the Western Health Board Integrated Home Birth Project.
It also examined available literature and strategy documents on maternity care. It held information sessions with women around the State and reviewed submissions on maternity care from individuals and interest groups.
The group recommended that in the absence of a structured, funded domiciliary service, a standard grant should be paid to women who wish to engage private midwives and a second midwife attend home births where feasible.
The report also recommended the continuation of the National Maternity Hospital's domino/hospital outreach home birth service, and the continuation and development of the south eastern area's integrated hospital and community midwifery service and the southern area Home Birth Service.
The maternity system, not withstanding a small number of outreach programmes, offers hospital-based services to women using a largely medical model.
Some 15 independent midwives offer private home birth services to a small but growing number of women each year. The service is patchy and midwives have experienced difficulties when trying to obtain scans and blood tests for their clients. The DBG report could help change attitudes to, and supports for, this service.
And a groundbreaking pilot programme based in Drogheda and Cavan currently being evaluated by TCD could also help change the emphasis of maternity care here.
But the system will be hard to change. TCD's Prof Begley, says that maternity care is consultant led.
"The system is not good for low-risk women, because they end up with more interventions," she says. "That costs the consumer more and the State more and we end up with a lesser maternity service than if we had a more collaborative model."
But creating a collaborative model, with women being referred from midwife care to obstetrician-led care and vice-versa in a fully integrated system, will pose difficulties.
Income earned by obstetricians is undoubtedly a barrier, with one consultant obstetrician reported to have earned €2 million from private practice last year.
If home birth and maternity-led units were to become the norm, obstetricians in private practice would experience a drop in clients. "If obstetricians had to give up part of their private practice they would be giving up a lot of money," Begley says.
"There is bound to be opposition to that. However, there are a number of great obstetricians around the country that would recognise the value of a collaborative model of care."
TCD is examining a pilot project involving two midwifery-led units in Drogheda and Cavan. The study is the first of its kind in Europe, in that the units were specifically established to be part of a trial from the outset.
The aim of the study is to evaluate the safety of midwifery-led units and 1,000 women have already registered for maternity care under the programme.
The units are attached to maternity hospitals and women are assessed for suitability and may be referred to an obstetrician during pregnancy or labour should complications arise.
The research team will evaluate whether it is possible to move the units into the community while maintaining safety standards for mother and baby. It will also examine the running costs of the units and evaluate the economic implications for the health service.
Begley believes midwifery-led units are ideal places into which independent domiciliary midwives could be linked.
"The independent midwife could refer clients there to have scans and blood tests done. They would also have the opportunity to mix with other midwives and get training and peer group support instead of working in isolation," she says.
But she does not believe that DBG recommendations to establish midwifery-led units should proceed until the TCD pilot study has yielded results in 2007. She agrees that home birth should be offered to low-risk women.
"Home birth is safe for low-risk women. All international literature points in that direction," she says.
"Figures have been used showing incidents where things went wrong during home birth, but on closer inspection they do not stand up, you find that recommendations and protocols were not followed," she says.
Prof John Bonnar, former chairman of the Institute of Obstetricians and Gynaecologists, says he would have reservations about women having home confinements in remote areas.
"There is a small additional risk to having a baby at home which women should be aware of," he says. "If problems arise in labour, you may require a Caesarean section and when you are in hospital a baby can always have immediate access to resuscitation. But the likelihood of the baby of a low-risk mother requiring resuscitation is small."
He says that home birth could be offered as an option to low-risk women provided there are agreed protocols in place. He also sees midwifery-led units as positive options in an integrated maternity care service. But he believes a shortage of midwives could prevent the establishment of the units.
"We are short of midwives at the moment and we are very concerned that a large number of trained midwives don't practise," Bonnar says. "The work is very demanding and not many professionals have this commitment. We need to pay them a lot more."
An HSE spokeswoman says the recommendations of the DBG report are being considered by the management team and it would not be appropriate to comment on their implementation at present.