Women's right to be provided with a midwife for a home birth is being tested in appeals to the Supreme Court. The Home Birth Association of Ireland says it's more difficult than ever to have a baby at home, writes Kathryn Holmquist.
When Kate Bevan emerged into the world this day last week, after a nine-hour labour, her first sensation was of floating upwards in warm water nearly the same temperature as the womb that had nurtured her for nine months.
Covered in vernix, which kept her from being too slippery, she was lifted from the birthing pool by her mother, Ronát Lillis (41), who then gently held her above the water while she took her first breaths. Soon, Kate was sucking contentedly at her mother's breast while being cradled in the pool set up in her parents' home in Dunlavin, Co Wicklow.
The umbilical cord remained intact for 90 minutes - minutes that seemed like seconds to a delighted Ronát - while midwife Philomena Canning patiently waited for the delivery of the afterbirth. Kate's father, Michael Bevan, an aircraft engineer with Aer Lingus, was in charge of technical support and the demanding clean-up. Filling a birthing pool with warm water, then disposing of its contents, is no easy feat.
In the midst of this quiet industry and celebration, a friend arrived unexpectedly, not knowing that Kate had been born, and, after recovering from the surprise, cooed over 7lb 15oz Kate before making dinner for Kate's parents and their elder daughter, Hannah, aged 18 months.
Hannah, who had spent the day with her childminder so that her parents wouldn't have to worry about her jumping into the birthing pool, wasn't quite sure what to make of it all. Crawling into bed beside her mother and her new little sister, Hannah was well able to compete for cuddles. But although she kissed her baby sister, she'd be as likely to pinch her, says her mother.
Hannah herself should have been born at home, but instead she was born at Sligo General Hospital, due to her premature entry into the world while her parents were on holiday in a caravan in Enniscrone.
Ronát's experience of Sligo General was very positive, but she says that she hates hospitals and has had some bad experiences of doctors, so was determined to have her second baby at home. Ronát, who worked with Concern before going back to university and becoming a home-school liaison co-ordinator, has half a dozen friends who have had home births.
Ronát says Kate's birth was a wonderful experience, but so too was Hannah's, and she shies away from comparing the two styles of giving birth. She is thrilled, however, that on her second pregnancy she has been able to fulfil her dream of a home birth.
"The real advantage of home birth is that it's like working with skilled friends rather than authoritarian experts," she says.
A trained aromatherapist, Ronát would always tend towards complementary medicine such as homeopathy rather than conventional medicine. When her original GP advised her against home birth, Ronát found another GP - a woman, coincidentally - who has been supportive. Two scans at the National Maternity Hospital, on Holles Street, during Ronát's pregnancy showed that Kate was healthy, meaning a home birth was not an extra risk.
"Philomena was always very calm and steady. She made me understand that if I had to go to hospital to have this baby, then I would. It was no big deal. Choosing a home birth means that you always have to be open to going to hospital if that's what is best for your baby," says Ronát.
Philomena Canning is one of about 12 independent midwives operating in the Republic. Her fee for all pregnancy, birth and post-natal care is €2,000. Ronát will receive about €1,000 from BUPA and claim the other half from the Eastern Regional Health Authority. BUPA pays up to €1,500, depending on which scheme the mother has joined. The VHI covered 97 home births last year.
Ronát had considered giving birth to Kate through the Domino scheme at Holles Street, a programme through which 260 mothers gave birth last year, with the help of a staff of eight domiciliary midwives. This amounted to one in 30 of the 8,000 births at the hospital last year. Most of these mothers ended up having their babies in hospital, although the advantage for them was that they were with the same midwife throughout and spent only six hours in hospital before being sent home in the care of a midwife.
To qualify for the Domino - domiciliary in out - programme, a woman must have a healthy and normal pregnancy and be carrying only one baby, rather than twins or more.
"The advantage of Domino is that we as a team provide continuity of care and choice to low-risk women and their families throughout pregnancy, labour and the post-natal period," says Ann Marie Sliney, a community midwife with the scheme.
Many Dublin women are excluded from Domino because it operates only in community-care areas one, two and three, south of the Liffey to Bray and as far west as Knocklyon. There is also a Domino service in Galway.
The Southern Health Board has taken a different approach with its home births pilot project, which many midwives regard as a model for the rest of the country. Since January 2001, 160 babies have been born through this free service.
Mothers do not have to pay their independent midwives directly, as they do elsewhere in the country. To be eligible, the mother must have a healthy pregnancy and no previous Caesarian sections and live within 40 miles of her midwife. This is especially useful for mothers in west Cork, many of whom live two and a half hours from the nearest hospital.
Jo Delaney, a midwife and co-ordinator of the project, expects a further 50 babies to be born this year through the project, which has stopped taking bookings. It will soon be evaluated by the Department of Health and Children, which will decide whether to extend it.
Like many home-birth parents, Ronát researched extensively before choosing a private midwife and a home birth. "I found it difficult to get information from the hospitals about their services," she says. One hospital didn't get back to her at all, one sent a brochure and another took three weeks to answer her queries. "I thought that if it was this hard to get information before I had my baby, what would it be like once I was in their care?"
The situation certainly is confusing, especially if you want a home birth. Different health boards have different policies on reimbursing parents who opt for home birth. "Women in Dublin have very little support compared to the rest of the country," says Canning. "Their only option is to go to hospital, where they experience the most medicalised system in Europe," she says. Caesarean sections, oxytocin drips that speed labour, the routine breaking of the waters and constant monitoring are unappealing to many women, who want to give birth naturally, she says.
The southern and midlands health boards have reputations for supporting women who wish to give birth at home, but some others are regarded as problematic. When I phoned the Eastern Regional Health Authority to ask about its policy, it referred me to the Northern Area Health Board, which it said was in charge of policy for the entire ERHA. The response from the northern area, however, was that its policy, which is to offer €1,300 to mothers who opt for home birth, covers only the city and county north of the Liffey.
Section 62 of the 1970 Health Act requires health boards to provide "medical, surgical and midwifery services without charge to all expectant mothers". The Act had been interpreted as giving some entitlement to assistance with home births, but the High Court last year ruled that it does not oblige health boards to provide home-birth services.
Several such cases have been taken to the High Court by Colm MacGeehin, a solicitor, who is now appealing them to the Supreme Court and expects four to be heard before the summer. The situation, ashe sees it, is that under the Act, women who give birth at home have the same rights to maternity services as women who elect to have babies in hospital.
The Office of the Ombudsman responded to complaints from mothers six years ago by recommending that health boards should have a consistent overall policy towards reimbursing the costs of home births. A scheme was introduced in the early 1990s that let mothers who wanted home deliveries to employ private, independent midwives, then reclaim up to €1,300 of the fees after delivery.
In practice, women receive different levels of reimbursement - and service - depending on where they live. The Northern Area Health Board is among the more encouraging, as it has continued to operate the scheme and has made ex-gratia payments of up to €1,300 in a number of cases. It plans to deal with any future cases in the same way.
Otherwise, says MacGeehin, who has negotiated home-birth payments with several health boards, the rules remain contentious. If a health board believes it is unsafe for a particular woman to have a home birth, it may refuse to reimburse her, regardless of whether or not her home birth is ultimately safe.
In an attempt to clarify the issues, a home-births group is being established to consider the future of home births in the eastern region. The group, which will be chaired by Sheila O'Malley, director of nursing and midwifery at the Eastern Regional Health Authority, has its first meeting later this month.
These events will be watched closely by the Home Birth Association of Ireland, which celebrates its 21st anniversary this year. Pádraicín Ní Mhurchú, its co-ordinator, says organising a home birth is now more difficult than ever, partly due to the shortage of midwives but mostly due to problems getting information and co-operation from the health boards.
The association argues that it is in the medical profession's interest to keep births in hospital. Ní Mhurchú sees a culture clash between midwives involved in the home-birth movement and the medical status quo. For her, home birth is a huge feminist issue.
"Because giving birth is a uniquely female experience rather than an equality issue, it has not been incorporated into the feminist perspective. Women have been so undermined that they no longer believe they can give birth physiologically - in other words, naturally, without medical intervention."
The association will celebrate its 21st anniversary with a seminar on February 22nd, including an address by the renowned obstetrician Michel Odent, at Taney Hall, Dundrum, Dublin, 9.30 a.m.-5.30 p.m.. Tickets (at door): €20 a person, €30 a couple, €7 unwaged