Anne Matthews and Jene Kelly look at the challenges for maternity services in Ireland
Irish maternity services are almost exclusively hospital-based and highly medicalised. Over 50% of the population of Ireland have private health insurance, mainly for reasons of continuity of private consultant care and private accommodation and this is reflected in the high level of private maternity care practice in Ireland. Registered midwives fulfil the international requirements as independent practitioners and champions of normal birth, but in this privatised, medicalised environment, this is a difficult challenge.
Expected legislation to statutorily recognise the distinct identity of midwives is impatiently awaited by midwives and childbirth activists. A report of the recent review of Dublin maternity services by management consultancy company KMPG is expected in autumn 2008 and seems focused on the co-location of maternity services with general hospital services and with the 'rationalisation' of the existing three maternity hospitals in Dublin. It may promote alternative models of care to the existing orthodoxy, hopefully midwifery-led care, probably on the grounds of cost-effectiveness, but delays to its publication mean that this is only speculative at present.
There have been some other recent signs of change which offer some hope. There have been several midwifery-led initiatives across the country (most notably the Midwifery-Led Unit (MLU) in the north-east of the country, the site of a prospective randomised controlled trial being carried out by midwifery researchers at Trinity College Dublin). Home births continue to be available on a limited basis, provided by the fewer than 20 independent midwives working nationally. However, recently, the threatened discontinuation of insurance for independent midwives has caused alarm within midwifery and women wishing to access home birth services. In the south of the country, independent midwives provide home births for the statutory services.
It is within these mixed contexts, that AIMS Ireland (AIMSI) was established in May 2007 by a small core of people dissatisfied with the maternity care system and ready to campaign for changes. It is a consumer led, campaign pressure group operating with a self-regulating committee elect and a body of members consisting of parents, consumers, health professionals, and support group representatives throughout Ireland. AIMS Ireland was set up with the support of AIMS UK. In addition to a national committee, AIMS Ireland has adopted a regional structure which matches that of the Health Service Executive (HSE): South,West, Dublin-Nor th East and Dublin-Mid Leinster. This facilitates having a local presence and voice for women. In the short time since its establishment, the membership and activities of AIMSI have expanded hugely and this seems set to continue. The main activities of the AIMSI committee and other members are the provision of support and information to women and campaigning for improved maternity services.
Between May 2007 and May 2008, 103 women contacted AIMSI for support services or information. A further 29 women shared their stories with AIMSI, both positive birth stories and raising awareness stories. In particular the positive birth stories have been welcomed by visitors to the AIMSI website. AIMSI also received 41 queries about birth healing workshops and two workshops were run in 2008. AIMSI assisted 51 women with making their complaints. The nature of complaints covered issues such as limited birth partner policies, problems with antenatal care and classes, lack of choice for breech delivery, mistreatment, bullying from staff, lack of support, lack of information about services and being unhappy with vaginal birth after caesarean (VBAC) policies.
A total of 735 women took part in five electronic surveys over the year. The main two surveys were one on the topic of 'Availability of Information and Consent' (161 participants) and one on 'What matters to you?' (326 participants). All respondents who voluntarily complete AIMSI surveys are anonymous.
The first survey findings highlight serious deficiencies in information and consent. For example, more than half of respondents (61%) said that in pregnancy (outside of antenatal classes) they had no opportunity to discuss choices and information regarding hospital policies, routine procedures and common procedures, tests or treatments which they may need to make a decision about during their pregnancy, labour or birth. This is particularly important while intervention rates in Irish maternity services are so high. Of the 39% who responded that they did have opportunities, over half (53.1%) had to be the one to initiate the discussion to gain access to information. This places a serious onus on women to initiate such discussion, which can be difficult in such a disempowered position within current services.
Over three quar ters of respondents (75.6%) stated that they felt that consent is an issue of concern in the Irish maternity system. Participants were asked if their consent was fully sought and given in pregnancy, during labour, during the baby's birth and after the baby's birth and the percentages of women who answered yes across these time periods were 48.4%, 38.4%, 33.3% and 41.5% respectively. These findings highlight that during all stages, women are vulnerable to not consenting to their care. More than half of respondents (57.6%) were not given the option to refuse a procedure, test or treatment and only 23% responded that they were given information and choice for all procedures.
The unavailability of unbiased information and a serious lack of regard for consent within maternity care settings in Ireland were shockingly highlighted within this sur vey. Women's choice appears to be backed up by information obtained by themselves and the majority of women surveyed were not happy with the current levels of information available to them by their care providers. AIMSI can also conclude that there are major issues surrounding consent in the Irish maternity system. Women's accounts regarding consent appear to suggest that it is not always sought or obtained where needed and that care providers are not always clear when consent is and should be obtained. There appear to be very few instances when informed consent and refusal was apparent.
In the second survey being highlighted here, women were asked about what matters most to them and their families, how they were affected by previous experience and what improvements they would like to see. The survey was aimed at women who have had a baby in Ireland in the last five years. Of those who completed the survey, 39.3% had received public care, 21.2% semiprivate care and 39.6% private care. Over one third rated information regarding choices of care as 'poor'. Just over one-fifth (21.8%) would have liked local midwife-led care and 16.9% would have liked midwife-led hospital care. Over half of respondents (56.1%) said their care in labour was 'excellent', while only 35.5% said that information given during labour was 'excellent'. Again, women raised their concerns about lack of information and consent. Regarding postnatal care/suppor t, only 35% of respondents said their care was 'good' and the main issues of dissatisfaction were lack of feeding support, difficulties after caesarean section or when baby unwell, poor hygiene and lack of care and support when at home. These reflect the lack of community based midwifery services and variable breastfeeding support in particular.
Overall across AIMSI's recent surveys the main issues of concern to women about maternity services have been found to be: lack of information, choice, informed consent and support - very basic requirements.
AIMSI has been actively campaigning and lobbying to meet its current goals of
AIMSI representatives have had two meetings with the Minister for Health and Children and the Health Service Executive, as well as meetings with the Health Information and Quality Authority (HIQA) and local and national public representatives. AIMSI has also had meetings with a number of hospitals, community and voluntary groups who have expressed concern about their service users' experience of maternity care in Ireland. AIMSI is also represented on the Home Birth - Domino Implementation Group (which is looking at how best to roll out home birth/domino choices for women). We are seeking to make links with other voluntary groups across Ireland with similar concerns to ours
In the coming months and years, AIMSI will continue, as required, to support and provide information to women and to campaign for improvements in Irish maternity services to address the serious problems facing women that are reflected in this article.
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