Independent Midwife Bridget Sheeran explores the experiences of women travelling long distances from home to hospital in labour
Continued government policy on centralisation of services has led to the closure of local maternity facilities in Ireland, which in turn has necessitated greater travel distances to hospital for women, especially in rural areas. This Irish policy mirrors the experience of centralisation policies internationally in the UK, the USA, Canada and New Zealand. Elsewhere, these policies were underpinned by the largely unsubstantiated claim to greater safety.
Currently in Ireland there are small pockets of community midwifery services unevenly geographically dispersed throughout the country without rhyme nor reason. Some independent midwives are contracted by the Health Service Executive to provide a free home birth service to women. This amounts to approximately 110 births per year. Women seeking home birth may be lucky and find a midwife but for the majority consultant led care is the only option available.
Working as a rural home birth midwife, 80 kilometres from the nearest maternity unit, I have had many calls to be with a woman 'in labour' only to realise much later that what was actually happening for the woman was a 'warmup' in the process of establishing labour, but in medical terms not considered to be in labour at all. On other occasions I have arrived within 35 minutes of being called to find that the baby has been born, so these experiences fuelled my interest in how women having hospital births manage the journey.
The question of knowing whether labour has started is constantly raised in my work with community groups of childbearing women in relation to when they should leave for their planned hospital birth. Women do not want to labour in a car or birth on the roadside.
It is unknown what effects the stimulation and anxiety of being driven long distances to hospital whilst in labour has on the woman and the baby in terms of an adaptive or a maladaptive stress response.
I recently carried out a small pilot study on the impact of women's experiences of travelling to more distant services while in labour because there is little research on this specific issue. I interviewed six women in the Republic of Ireland within six months of their having a baby. The participants were not my clients, and self-selected, based on replying to the advertisement posters.
The study's focus was on women in labour travelling long distances to hospital as opposed to the shorter distances experienced in urban areas. These women especially struggled with the decision of whether they are in labour firstly. Then, secondly, the decision of when to leave home which was usually based on what they had been told and was sometimes in conflict with what they had previously experienced about the onset and progression of labour. It is known that those that arrive too early in labour may be sent home or be more likely to have intervention.
This study highlighted the common problem of accessing centralised hospital care in Ireland and overcrowding which compounds the situation of women who have to travel long distances. Women have no access to an early labour assessment in their community and the pressurised service provided at the hospital does not have a system on arrival that takes into account the women's journey from home. This study emphasises the risks that are taken and the stress which results from travelling long distances in labour. This study also leads us to the question, 'what are women's perceptions of safety in birth?'
The difficulties experienced by these women travelling long distances to a maternity hospital appeared to have created an amount of fear, stress and anxiety for them whilst in labour. Women experienced feelings of isolation and insecurity about accessing services that were under pressure. Some women were told they should return home and come back later.
'I didn't know that it would take fourteen hours for her to be born because people tell you it could take three hours and you never know if it's your first... Having the nearest hospital an hour and a half away... We are isolated here.'
'I mean definitely she was quite straight about it... If I wasn't active enough then there wouldn't necessarily have been a bed for me.'
'...they were going to send us home again because there was nothing really happening and I said no because I don't fancy the journey down and back up again with the history of the first [baby born within 5 minutes of arriving], so they were stuck with me but they did want to off-load me.'
Women revealed details of how they managed the journey to hospital whilst in labour :
'I brought a pillow with me to try to make [it] a bit more comfortable up the bumpy road! I just felt really really drowsy travelling... I was afraid [of] the apathy of the fatigue just taking over my body. I had the hot water bottle up against my back [and] very loose clothing on and at that stage I needed to be quite cool. So I had the window open quite a length of the journey. I brought a towel as well [because] with [first baby] I got as far as [30-45 minutes from the hospital] and I was sick... I was more nauseous [this time]...My husband was playing tapes which he thought would be soothing to me but they did my head in.'
'He would have been born here [at home] had I not got into the car sitting down. Literally every contraction I was just sitting on his head and it was not fun. Horrendous it was!... But... thankfully [husband's name] didn't realise that I was as close to giving birth as I was because he had to keep his head together to drive.'
Risks were taken to get to the hospital fast and to avoid giving birth on the way.
'We got from here to the hospital in forty minutes. It normally takes an hour and a quarter... In fairness we had to speed with the first and the third. We had no choice but we also did not have time to call for help.'
'it was very, very wet. There were floods and everything all around... I was afraid in case we would end up in the ditch. When we were going around the bends and he kept going fast, and I was holding onto my seat'
Since the journey was fraught with anxiety, most women expected to receive prompt attention at their reception.
'All I could think of was this baby is coming. All that I need is to get somewhere where he will be safe. I don't fancy doing it here in the car or in the wheelchair.'
However, they were usually disappointed due to delays and the bureaucracy of the admission procedures. Women perceived that their reception lacked the acknowledgement of their circumstances.
'I had to sign something I swear, and... jeesas I didn't care! ... Jeesas your one was asking [husbands name] what my doctors name was, my mobile phone number was and this and that and [raised alarmed shrill voice] they weren't looking at me at all! Then my waters broke and I said "Will I start pushing or what?"... she forgot about her paper work after! [then the baby was born]'
'she was asking questions like is there a family history of hearing difficulties... we got about half way through and my waters broke on the chair... She just dropped her pen... and two more contractions... and that was it - baby was there! [laughs].'
Some found that the hospital was 'full' and women perceived that their needs were in conflict with the midwives' perceptions of them.
'... she said "There's no beds in labour ward we're quite busy would you be happy enough to walk around the corridor?" I said "Yep grand but as soon as my waters break are you" ready to help me in the corridor?"'
One woman who had been sent away from the hospital sought nearby accommodation. After being turned away from the first hotel, the next hotel accommodated them. While this was being arranged the woman recounts her feelings:
'You are physically in pain... ok, and then there are people passing the car who are drunk and you are feeling very insecure sitting in the car... You know, it's mad and you are thinking what am I doing?... And I could remember the midwife telling me you should go for a walk!
'we ended up in a four star hotel. But it wasn't appropriate. I didn't feel secure.'
The hotel had the comforts and privacy they were looking for but lacked the reassurance women in labour need.
Midwives have an ethical responsibility to promote basic human rights for mothers and babies, and a moral duty to ensure that current evidence of safety in childbirth, including community based care, is used to benefit women's autonomy in birth. The potential is for midwives to gain a better understanding of the complexity of this issue for women, and the broadening of midwifery knowledge of labour cues so as to help in the validation and empowerment of women's decision making. This study suggests a greater priority needs to be given to listening to women's experiences of travelling in labour. Policy at the highest level should enable midwives to respond to the needs of women within their communities and reflect the Government's commitment to women centred care in Ireland. The focus of this study needs to be further researched to explore women's perception of risk in the context of geographical location and its impact on the safety of birth.
My personal view is that we have created a human rights issue by assuming and expecting that women can arrive at the hospital at the 'correct' stage of labour to suit the promise of safety and the practice of professionals offering a limited service. What do you think?
Centralisation of services is not a problem restricted to the Republic of Ireland, the same situation affects women in many rural areas of the UK. Clearly some good quality research is needed to ensure that the potential emotional and physical effects of closures of small units and the concentration of maternity ser vices in a central location is understood.
Although somewhat different in focus, there is some fur ther research on centralisation and problems when travelling long distances, Recent research in Finland noted an increased mor tality rate following the centralisation of services in remote areas. This is from Viisainen, Kirsi (1999). Accidental out-of-hospital bir ths in Finland: Incidence and geographical distribution. Acta Ob Gyn Scandinavica, 79, 372-378.
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