Sunday, 5 March 2017

AIMS Ireland Response to the Citizens' Assembly: Article 40.3.3 in the Delivery Room

AIMS Ireland Response to the Citizens' Assembly: Article 40.3.3 in the Delivery Room

AIMS Ireland in December 2016 submitted a factual, evidenced, and referenced submission to the Citizens’ Assembly. This submission was based on legislation, primary and secondary research, and the personal experiences of women supported by AIMS Ireland who were directly affected by the 8th Amendment, ranging from coercion to threats of the involvement of the HSE, child protective services, or the initiation of legal proceedings in the High Court.

In that document AIMS Ireland made submissions on the operation of the 8th Amendment to the Constitution (Article 40.3.3°) in continued pregnancy with respect in particular to the following areas:
  1. Women Experiencing Miscarriage or a Pregnancy with a Diagnosis of Fatal Foetal Abnormality (citing X v Attorney General [1992] IESC 1; A, B, and C v Ireland (2011) 53 EHRR 13; and the tragic cases of Savita Halappanavar, Malak Thawley, and the woman known as Miss Y)
  2. Respect for Informed Consent and Informed Refusal (citing § 7.7.1 of the Health Service Executive’s National Consent Policy QPSD-D-026-1.1 V 1.1, May 2016; the case of HSE v Mother A in March 2013; HSE v B & Anor [2016] IEHC 605; AIMS Ireland’s What Matters To You? Survey in 2014; and Hamilton v HSE [2014] IEHC 393)
  3.  Capacity and advance directives (citing the Assisted Decision Making (Capacity) Act 2015 and P.P. v Health Service Executive [2014] IEHC 622)
During proceedings in the Citizens’ Assembly on Saturday, March 4th 2017, a member of the Assembly asked if there is scope for abuse of Article 40.3.3º in the delivery room, where procedures take place without women’s consent. The response, from the Chair Ms Justice Laffoy, was that the legal opinion is that there is no such scope and that if this were to occur it would be a question of medical negligence.

AIMS Ireland were not asked to present to the Citizens’ Assembly. We wish to take this opportunity, as an organisation consisting of and representing women/people accessing care in the Irish maternity services, to outline the very real and substantial issues arising as a result of and as a consequence of the 8th Amendment functioning in practice as a barrier to consent in continued pregnancy and childbirth. It is our firm belief that the 8th Amendment prevents the successful litigation of these abuses of the rights of women and people accessing maternity care in Ireland; both because of the legal ambiguity it creates in our legal system around rights in maternity care, and also because of the necessary tension it establishes in Irish law between the rights of the mother and of the unborn.

The video of the query from the CA member and the answer from Emily Egan, SC (first) and Ms Justice Laffoy (second – as paraphrased above) can be viewed at this link, at 02:43 mins:  https://www.youtube.com/watch?v=hEknurI2FH0 

Overview

The 8th Amendment hangs like a spectre over reproductive rights in Ireland. Reproductive rights, maternal health, and the provision of maternity services, are inherently interlinked. As a nation, our reporting and collection of data is patchy. We do not have standardised care. Guidelines created to reflect best clinical practice are not implemented at local level and individual maternity units are under no obligation to do so. We barely have accurate, specific, and detailed data on birth and interventions, and we have no data collected on perinatal mental health. Regional variations in practice significantly affect rates of interventions, near misses, and adverse outcomes.  As a result, it is impossible to have an accurate grasp of the scope that the 8th Amendment has in the maternity services.

The Citizens’ Assembly requested data and facts on how the 8th Amendment has a direct legal impact on maternity care. For the foregoing reasons, the only way to access this impact is to listen to, to hear, and to trust the testimonies of women who have been personally affected in their pregnancies and births. We must also listen to and hear the medical professionals when they tell us that they do not feel protected in law to support a woman’s decisions.

No one records in medical notes when they use the 8th Amendment, as outlined in §7.7.1 of the National Consent Policy, to justify a procedure or intervention. In the handful of legal cases where the 8th Amendment and refusal of consent were pleaded in High Court proceedings, and where the issue is addressed at judgment, the jurisprudence is frequently vague on the 8th and the legal implications it has on maternity services. The 8th Amendment itself is ambiguous and that is exactly the concern which was argued by legal experts in 1983. It is was legally ambiguous then and it is still legally ambiguous today. 

The National Consent Policy, the 8th Amendment, and Continued Pregnancy and Childbirth

The right to informed decision making – both the giving of consent and the refusal of it – in in one’s health care is recognised and protected in Irish policy, law, and the Constitution. Informed consent is a cornerstone of medical ethical standards, as well as a key principal of bodily integrity. However, the National Consent Policy directly recognises and cites the 8th Amendment to the Constitution as a barrier to informed consent in continued pregnancy and childbirth, recommending the High Court as the appropriate arbiter where a woman’s decisions in continued pregnancy go against the recommendations of a health care provider.

Every individual in Ireland has the right to bodily autonomy, to be the main decision maker in their health care, to control their own life, and to decide what happens to their own body. This includes making informed decisions – to consent to or to refuse treatment – which will have an impact on their current health, as well as any short or long-term consequences for the individual to consider. Health care providers are expected to present all the information pertaining to the procedure in layman's terms (the benefits, risks, and any future implications) in order to provide guidance to informed decision making; however, the decision is ultimately that of the individual. Finally, for consent to be valid, it must be also be voluntary, meaning that it is given without the application of duress or coercion (whether that be by way of threats or intimidation) from health care providers or external agents. These central principles are outlined in §1 of the National Consent Policy:

Consent is the giving of permission or agreement for an intervention, receipt or use of a service or participation in research following a process of communication about the proposed intervention. Consent must be obtained before starting treatment or investigation, or providing personal or social care for a service user or involving a service user in teaching and research (all defined as ‘interventions’ for the purpose of this policy). This requirement is consistent with fundamental ethical principles, with good practice in communication and decision‐making and with national health and social care policy. The need for consent is also recognised in Irish and international law.

Furthermore, § 1.4 states that “Other than in exceptional circumstances, it is important to note that treating service users without their consent is a violation of their legal and constitutional rights.”

The right to refuse consent to a proposed treatment is dealt with in § 7. The Policy states at § 7.7 that “If an adult with capacity to make an informed decision makes a voluntary and appropriately informed decision to refuse treatment or service, this decision must be respected, even where the service user's decision may result in his or her death.” However, the Policy is forced, because of the operation of the 8th Amendment, to dedicate an entire section - § 7.7.1 – to the limitations on the rights of pregnant people around consent to treatment. The constitutional constraints of Article 40.3.3° mean that equal rights must be given to the pregnant person and to the unborn. In other words, informed decision making ability in pregnancy – the right for individuals to make the best decisions for them and their baby in their specific circumstances in pregnancy and childbirth – has been removed.

The operation in practice of § 7.7.1 of the National Consent Policy is as ambiguous as Article 40.3.3 itself. § 7.7.1 cites risk as the yardstick by which the decision to overrule a woman’s refusal to consent to treatment is to be measured, but it fails to define risk or what constitutes risk or ‘risk to life’ of the unborn. This leaves interpretation open to opinion and bias, and leaves pregnant people and health care providers in an unacceptable state of limbo. The definition of risk within the Policy is subjective, and the assessment of risk and whether it is significant enough to justify overruling a refusal of consent requires a health care provider to balance the probability of harm to the unborn against the risk of harm to or the burden placed on the woman by the refused treatment. No guidance is given as to how the threshold between a risk to health and a risk to life is to assessed, and there is no recognition of the practical reality that there are in fact no absolute guarantees in childbirth.

In practice the use of ‘risk’ by health care providers is often cited as an indication to over-ride the right to informed decision making (consent/refusal) in pregnancy, labour, and childbirth. The National Consent Policy of Ireland addresses the issue of risk in § 3.3:

Information about risk should be given in a balanced way. Service users may understand information about risk differently from those providing health and social care. This is particularly true when using descriptive terms such as 'often' or 'uncommon'. Potential biases related to how risks are 'framed' are important; a 1 in a thousand risk to complication also means that 999 out of a thousand service users will not experience that complication.

AIMS Ireland have documented significant accounts of women reporting the use of ‘risk’ coupled with the National Consent Policy as a barrier to informed decision making. ‘Risk’ is often based on the perception of individual health care providers and without supportive evidence. Pregnant women are often told of the risks they are exposed to in refusal of medical recommendations, but often they do not receive explanations of the risk factors inherent in having the procedure, test, or treatment. Many routine practices in Irish maternity units which are recommended by health care providers carry risk factors and do not follow evidence based practice recommendations.

There are no absolute risks in childbirth and each care option poses specific, individual risk potential. Truly informed choice occurs where a woman receives the information that enables them to understand the benefits and risks of each care option, so that she can then select the care option that she feels most comfortable with.

Furthermore, the National Consent Policy suggests that the 8th Amendment impacts only on refusals of consent to treatment, and not on the giving of consent to treatment. Such a position is nonsensical. Refusal of a medical procedure is not separate to, but is an equal facet of the principles encompassing consent. One cannot consent while being unable to refuse. If a person’s ability to refuse consent is constrained then so is their ability to give consent. Consent given in the absence of an ability to refuse is not truly free and voluntary. For consent to be valid by legal definition, it must be voluntary, provided freely, without duress (Fitzpatrick & Anor v K & Anor [2008] IEHC 104).

The ambiguity of the National Consent Policy is further compounded in its failure to provide scope for clarification on exactly when and how the High Court may be considered the appropriate pathway for assessing the validity of a woman’s decision to decline a medical recommendation.

In our ten years’ experience supporting women accessing maternity care in Ireland, AIMS Ireland has seen patterns emerge in reports of regions’, units’, and even individual health care providers’ use of coercion to achieve women’s compliance with a proposed treatment. Certain maternity units, and even individual health care providers, are named with more frequency than others by women who appeal to AIMS Ireland for help when they feel they are being coerced into accepting a particular proposed treatment or procedure. This coercion takes various forms, from the use of threatening language including the threat of the mother being found responsible for harm coming to the unborn child; to threats of the involvement of child protective services; threats of High Court litigation; and the involvement of legal teams. AIMS Ireland’s support services have assisted individuals who have been threatened with legal action and social protective services in an attempt to coerce consent. The majority of these threats are never carried out, as women are fearful of the implications and comply under duress. 

Differentiating between (a) Medical Negligence and (b) Consent Violations that Occur as a Consequence of Constitutional Constraints

It is important to differentiate between the law of medical negligence, the law of consent as it operates within the tort of assault, and the question of the validity of a consent that is given under duress that has been leveraged as a consequence of the operation in practice of the 8th Amendment.
The law of medical negligence is comprised of four core principles:
  1.  A medical practitioner has a duty of care towards a patient;
  2. A medical practitioner breaches that duty of care by acting in a manner that falls below the expected standard of their profession;
  3. This breach of the duty of care must directly cause damage to the patient, which may be psychological or physical in nature; and
  4. The damage suffered by the patient must be the result of the breach of the duty of care (this is known as the ‘causal connection’).

The idea of consent is comprised of two complimentary facets: (1) the ability to make a decision to have a particular test, treatment or procedure; and (2) the ability to make a decision to decline a particular test, treatment or procedure. Consent actions are often tied in with medical negligence actions but are in fact a cause of action in their own right under the tort of assault. It would not be unusual for a lawsuit that includes a claim for assault that is based on a breach of the rules on informed consent to also seek relief in the tort of negligence. One may succeed in the medical negligence action in the case, and fail in the assault action. In its legal incarnation, the doctrine of consent has three key components:
  1.  The patient must have capacity to give or to refuse consent – meaning they must have the ability, at the moment the decision is being made, to understand the ‘nature, purpose and effects’ of the proposed test, treatment or procedure;
  2. The patient’s decision must be voluntary – meaning it must be given freely, in the absence of coercion or duress; and
  3.  The patient must have received appropriate information regarding the risks and benefits of the proposed test, treatment or procedure (this is known as ‘full disclosure’).
Finally, to succeed in an assault action based on the absence of a valid consent to the treatment administered, the plaintiff will also need to establish (a) that she suffered damage and (b) that she would not have gone ahead with the procedure if she had been advised properly of the risk which has caused the damage. The fact that any litigation on consent will necessarily involve drafting medical negligence pleadings does not negate the fact that the culture around the provision of maternity care in this country is soaked from beginning to end in an atmosphere of subtle coercion, and that culture arises from the legal uncertainty health care providers have to work in due to the ambiguity of their responsibilities and obligations to the foetus under the 8th Amendment. These responsibilities are, because of the way the 8th is drafted, in direct opposition to and in conflict with their responsibilities to the pregnant woman.

AIMS Ireland have supported many women who report experiencing assault on their bodies in the Irish maternity services. Often these assaults take place when medical interventions are administered which do not follow best practice evidence which carry independent risks of morbidity. It is our experience that these women are advised, both when they seek legal advice and in the making of complaints to the relevant professional regulatory bodies, that it is the woman’s word against the medical professional, and that success is unlikely. Women seeking to litigate assault cases founded on violations of consent in pregnancy and childbirth are generally counselled against taking proceedings. A woman’s body being violated is often not enough to build a successful legal case where there is no loss of life or long-term implications on health. The presumption of a risk to the unborn having operated as a medical indicator to justify the intervention is always present and overrides the woman’s refusal.

Medical records rarely self-implicate. Medical professionals do not record consent violations implicating themselves, their colleagues, and their place of work. This means both that an assault action based on a breach of the doctrine of informed consent is notoriously difficult to successfully litigate, but also that there simply does not exist data in medical records illuminating the use of the 8th Amendment in this manner.

The case of Hamilton v HSE [2014] IEHC 393 was an assault case founded on the principle of informed consent, which also contained a consequence action of medical negligence. Ciara Hamilton took legal action against the HSE on the basis of an invasive medical intervention which she argued was performed without her consent. This intervention contributed to long-term health issues for her baby. The High Court found against her, stating in the judgment that it did not believe a woman would deny a medical intervention recommended by a health care professional. As the consent argument had failed, the consequence medical negligence action then also failed and a costs order was made against Ms Hamilton.

In Ireland informed choice for women on ‘how, where and with whom’ they want to give birth is also prohibited by the HSE’s structure of maternity services provision. For many women the only care option available to them – for geographic, financial, and HSE policy reasons – is hospital care. Hospital care in Ireland is obstetric led in practice and policy and includes many routine interventions which increase distress to babies in labour and increase the risk of adverse affects for women – in the form of intervention, assisted delivery, or caesarean section. When a practice is said to be ‘routine’ this means that the practice or procedure is done as a normal practice on every pregnant person, not down to medical necessity or evidence, but hospital policy. Other practices may not be routine for every woman, but are frequent in use despite risks. For example recent research by the American College of Obstetrics & Gynecology has shown the use of oxytocin, for induction of labour or to 'speed up' labour, is an independent risk to babies and increases NICU admission.

Furthermore, best practice clearly states that patients should be assessed on an individual basis on their current health and current medical conditions, as well as their previous history. The HSE in maternity care does not provide women with individual assessment, which is a fundamental principle in evidence-based care. Women in Ireland are given extremely restricted choice around their birth options as the perceived risks to the baby are considered more important than women having control over how they give birth. 

What Women Have Told Us

In the 2014 AIMS Ireland survey, "What Matters to You?" we looked specifically at the issue of consent. The WMTY survey had nearly 3,000 respondents who were self selecting. Our findings illustrated that informed consent and refusal remain an issue of grave concern to women accessing the Irish maternity services, with only 50% of individuals being provided with the necessary information to assist them in informed decision making. The qualitative data, comments from individuals, provide us with very worrying information as many commented that consent was either implied as the procedure was being carried out (e.g. a health care practitioner informing a woman “we are just going to break your waters now” as rupture of membranes was being performed); or that they felt coerced by hospital policy or a perceived risk to their baby; or influenced by care providers’ opinion that was not based on evidence; or that they were not provided with the information necessary to make decisions for themselves and their baby. Some respondents felt that while they consented, they did not have any choice in doing so.

This is a selection of the comments received from women who responded to the WMTY survey:

“At every intervention I was threatened with catastrophic consequences if I refused such as ‘if you don’t have an episiotomy right now the baby won’t make it’…’if you don’t take antibiotics the baby might have cerebral palsy’”

“I was told I had no choice when it came to my treatment, everything was ‘hospital policy’”

“Benefits of procedures to hurry Labour up were told, risks of these procedures were not told. Benefits of waiting were never once told.”

“The tests they did were as far as I was told compulsory and results were just told to me and options were not discussed it was there way is best. When we questioned it we were told we were putting our babies life in danger.”

“At every intervention I was threatened with catostrophic consequences if I refused such as ‘if you don’t have an episiotomy right now the baby won’t make it’… ‘if you don’t take the antibiotics the baby might have cerebral palsy”

“I was given an episiotomy without being asked. I wasn’t even informed that the consultant was going to do one it was just done”

“They broke my waters without consent. I was told by the consultant that she did not need my permission to break my waters.”

“Nothing was done without my ‘consent’ but is it consent when you are bullied into it… as how do you get round the ‘put the baby at risk’ card even if you know that what you are asking is in line with best practice?”

“The following procedures were performed on me without explanation or my consent being sought: ARM, pushing back a cervical lip, a CTG machine was applied to me and when I asked for it to be removed this was refused. My attempts to remove it myself were prevented. I was physically restrained in a position I was not comfortable in (flat on my back) and verbally abused when I did not engage in purple pushing”

The results from the WMTY survey to date are available on the AIMS Ireland website at the following link: http://aimsireland.ie/what-matters-to-you-survey-2015/ 

Conclusion

AIMS Ireland strongly campaigns for recognition of informed choice in maternity care. The decisions we, as pregnant women, as people, make in pregnancy, labour, and birth have serious consequences; for the pregnant individual, for their baby in both short and long-term health and quality of life, and for future pregnancies and births. It is their body; their pregnancy; their baby; their birth. The pregnant person is the best expert on them; their baby; and their circumstances. Only they know what they are feeling and what is important to them. They must be the ones making decisions which will affect them and their baby. They must live with and be happy in the decisions they make. They should be the one to decide 'how', 'where' and 'with whom' they give birth. They should not be asked to give these important decisions away. Medical experts can guide, assist with informed decision making, but they cannot and should not make decisions on the behalf of a pregnant individual. However the 8th Amendment is often used as a method of coercion by the HSE and individual health care providers to obtain consent through coercion.

AIMS Ireland supports pregnant women and other pregnant people. From pre-conception to parenthood, we support a person’s right to informed decision making and freedom to informed consent/refusal as is outlined and protected to all other non-pregnant people in Ireland. The 8th Amendment acts as a legal barrier to informed decision making in pregnancy, labour, and childbirth and is directly cited within HSE policy as a constraint on the ability of individuals to invoke this right. The 8th Amendment must be repealed to ensure human rights are ensured in pregnancy. 

About AIMS Ireland

AIMS Ireland (Association for Improvements in the Maternity Services Ireland) is a voluntary organisation with charity status which was formed in 2007 by women who saw a need for a consumer driven organisation to support pregnant people's human right to informed decision making in all aspects of health; from pre-conception to parenthood and to push for the full implementation of maternity care standards reflecting evidence based best practice across Ireland. It is a consumer led, campaign pressure group operating with a self-regulating committee elect and a body of members. AIMS Ireland members in 2013 unanimously passed a motion to support Repeal of the 8th Amendment and in 2016 to adopt the position of supporting access to free, safe, and legal abortion services in order to support pregnant people in their right to informed choice in their unique and specific circumstances.





Tuesday, 21 February 2017

AIMSI Statement - Citizens' Assembly Invitations to Present: 22nd February 2017


AIMSI Statement - Citizens' Assembly Invitations to Present: 22nd February 2017

Aims Ireland were very disappointed that we were not asked to present on the topic of maternity care to the Citizens Assembly
AIMSI made a detailed submission to the Citizens' Assembly on the ramifications of the 8th Amendment on continued pregnancy and childbirth.
As an organisation who has campaigned a decade on this issue, conducted research, and supported many pregnant women/people directly affected, we are disappointed that our extensive experience of the ramifactions of the 8th amendment on maternity care, maternity services and maternity users will not be heard.
AIMSI was asked to make a submission to the Joint Oireachtas Committee in January 2013 (public submission on the Expert Group Report on A,B,C v Ireland - it is published on the Oireachtas website) and made a submission in May of 2013 on the Heads of PLDP Bill.
The ramifications of the 8th Amendment on abortion and the maternity continuum are inherently interlinked. The HSE directly citing the 8th as a barrier to consent once a woman/person becomes pregnant, effectively ensuring that every pregnancy in Ireland is potentially affected. We feel this is a key and overlooked aspect in discussions surrounding repeal of the 8th.
The many thousands of women/people we have supported and continue to support will also share our disappointment.
Speaking earlier today AIMSI Chair Krysia Lynch said "Any maternity service wrorth its salt in the 21st Century would not export women for routine health care procedures to another country, or leave them to self care without professional medical support in their own country. Any maternity service worth its salt would not have to enshrine a consent policy which effectively denies every woman and pregnant person in Ireland the final say in what happens to their body. These issues affect women, pregnant people and their families in continued pregnancy every day in Ireland, We estimate approximately 103,000 users of the maternity services are affected every year."

ENDS

Friday, 2 December 2016

Additional Information regarding Fact Check: Ireland's safety record on maternal health

AIMS Ireland were contacted with regards to the Journal.ie Factcheck on a leaflet used by anti-choice campaigners highlighting an excellent record of safety in Irish maternity services.

The Factcheck can be read here: http://www.thejournal.ie/yes-to-life-life-institute-8th-amendment-abortion-leaflet-facts-3058066-Nov2016/

AIMS Ireland had a brief exchange with Factcheck over twitter and requested to discuss further offline. Several days following the initial discussion, AIMS Ireland then privately sent in information which we feel is vitally important to assist in interpreting statistics provided by Factcheck as well as additional factors relevant in the discussion of the issue of safety.

We have not had a response from Factcheck (2 weeks) so are publishing the additional information provided to Factcheck into the public domain.

AIMS Ireland have been campaigning for improvements in the Irish maternity services, including the implementation of evidence based care practices and basic rights to informed consent, as well as  providing advocacy to thousands of women and other pregnant people since 2007. This issue continuously arises in support services, as well as academic circles and between care providers.



Hi Dan,

Thank you for the offer to engage with us following our brief Twitter chat. Apologies for the delay in getting back to you - we are a wholly voluntary-run organisation with no funding and thus no full-time staff.

AIMS Ireland is a maternity rights organisation which also provides advocacy to women within the continuum of maternity services.

With regards to the Factcheck on Ireland being one of the safest places to have a baby, we have some points that we feel would help clarify. We have been contacted by individuals confused and upset by the Factcheck, as presented.

With regards to WHO data, we feel it is relevant for the following to be quantified in order to assist in people’s understanding of the data.


Ireland is ranked joint 6th in WHO data.

This ranking is made up of a 31 year average
Joint 6th does not mean that we are 6th in the world – there are 26 Countries whom have MMRs lower than Ireland. Ireland at 8 per 100,000 shares this rate with Croatia, France and FYR Macedonia. However the following 26 Countries have rates lower.

Australia 6 Germany 6 Norway 5

Austria 4 Greece 3 Poland 3

Belarus 4 Iceland 3 Slovakia 6

Belgium 7 Italy 4 Spain 5

Canada 7 Japan 5 Sweden 4

Cyprus 7 Israel 5 Switzerland 5

Czech Rep 4 Kuwait 4 United Arab Emirates 6

Denmark 6 Montenegro 7

Finland 3 Netherlands 7


WHO statistics are global, which is problematic as it does not compare like with like; Western Countries (with access to basic hygiene, nutrition, antenatal care, technology, well trained health care providers, maternity units, etc) to Countries without the very basic of care.

Comparatively, looking at EU States, we rank 16th of 28 with the UK (9), Bulgaria (11), Estonia (9), Hungary (17), Latvia (18), Luxemborg (10) Malta (9) and Portugal (10) with higher rates.

For Western nations, with the availability of factors mentioned above, many (including AIMS Ireland) are of the opinion that maternal mortality alone should not be the sole indicator for measuring the safety and quality of our maternity services. Women have reacted strongly on this point, sharing stories of poor quality of care void of basic safety procedures. AIMS Ireland strongly recommends that any discussion of safety and quality must include morbidities; physical and psychological to mother and baby.

Maternal Morbidities MAMMI Study Ireland 2016

1/7 women in Ireland who die, die from suicide
¼ of maternal deaths have mental health issues and the State is not addressing this. There are 3 perinatal psychiatrists, all in Dublin, for the entire Irish population. Ireland also has no Mother-Baby units.
Ireland has the highest rates of postnatal depression in the OECD
4/10 women who give birth in Ireland are readmitted to hospital for their own health.
10% of maternal deaths in Ireland are due to maternal haemorrhage
Major Obstetric Haemorrhage (MOH) has increased from 1.5% to 4.1% in Ireland from 2001-2011
24% of MOH in Ireland are admitted to the UCU (near misses)
11.2% of MOH have hysterectomy
The National rate of MOH is 2.6 per 1000
Almost 2/3 of women report sexual health problems post birth. 1 in 5 women reported painful sex a year following birth.
Anal incontinence 12% of women who gave birth in Ireland


Also worthy of mention, the HSE directly cites the 8th Amendment in the National Consent Policy as a barrier to consent in continued pregnancy and childbirth. Informed consent/refusal is the cornerstone of medical ethics and evidenced best practice. A health system void of this most basic but core value is incapable of being considered in highest ranking.

While AIMS Ireland understands that the Factcheck was in relation to accessibility to abortion, all care within the maternity continuum are inherently linked and should be inclusive of the full data.

Regards,

Jene and Sinéad

** In addition, AIMS Ireland would like to reiterate that Ireland's ranking in WHO documentation is based on a 31 year average. However, Ireland has only participated in the Maternal Death Enqiry (MDE Ireland) surveilance system since 2009. Disparities between MDE statistics and methods of classification/collection of these statistics prior to 2009 (under-reporting in CSO figures) are widely disucssed and it should be noted that our statistical ranking from a 31 year average is based on recognised classification definitions only since 2009. Further, MDE Ireland's recent report continues to highlight challenges within the Irish system, particularly through regional units and coroner's reports, which contribute to under-reporting of maternal deaths in ireland.

Additional information on MDE Ireland ia available to read here: https://www.ucc.ie/en/mde/about/


AIMS Ireland Statement on the publication of Judge Maureen Harding-Clark’s report into the Surgical Symphysiotomy Ex Gratia Payment Scheme and media commentary on the same.

AIMS Ireland Statement on the publication of Judge Maureen Harding-Clark’s report into the Surgical Symphysiotomy Ex Gratia Payment Scheme and media commentary on the same.

The Association for Improvements in the Maternity Services (AIMS) Ireland  is outraged at the suggestion that the survivors of symphysiotomy have exaggerated, or been in some way dishonest, in their claims in what has been a long and difficult struggle for them, in the pursuit of justice.
We at AIMS Ireland know that women are very slow to expose themselves to legal proceedings, especially when they have been traumatised in the past. The fact of the matter here is that medical records are missing.

We are very disappointed that Judge Maureen Harding-Clark has made completely unfounded accusations of dishonesty against elderly women and their supporters, based on a lack of documentation and records.  At the same time, she fails to hold the hospitals and medics responsible for not keeping that documentation, as is their responsibility.

The claim that a woman’s medical record could prove or disprove that a procedure had taken place is laughable. Medical record keeping of the time was minimal to say the least. Many women’s medical records for a birth consist of a few lines, hardly comprehensive proof. All medical records prove is that a midwife or obstetrician wrote something once upon a time on a chart. Whether this is an accurate reflection of events is another story entirely. It is not uncommon to see issues with medical record keeping to this day.

Further, AIMS Ireland is at a loss to understand why, in an era where women not only had no access to abortion, but also had no access to contraception as well as no legal right to not be raped within marriage, women who had further pregnancies after symphysiotomy are deemed by the judge to not have been traumatised by the symphysiotomy. Women of the time had no say over whether they became pregnant or not regardless of their state of health and wellbeing, and as of course is still the case, they had no say over whether they remained pregnant or not. Becoming pregnant was not something a woman had any say whatsoever in. 

This report is a further violation of those women, who are and were entitled, in their latter years, to expect more of a state that claims, with little evidence, to be more enlightened.

Women who have experienced mistreatment know that it has happened. They are neither hysterical nor litigious as suggested by those who should know better. It is beyond belief, that those practicing medicine in today’s world, would turn to the ancient argument of the hysterical woman.

The biggest issue for AIMS Ireland today, is the establishment’s complete failure to hold a mirror to its practices both past and present.  It demonstrates to women today how little value is placed in their well-being.  It further illustrates that ‘the professionals’ in this country have rights over women’s bodies which would not be given in other jurisdictions.

In media commentary this week, the point has been made that symphysiotomy is still used in poorer countries where alternatives are lacking. The key point here is “where alternatives are lacking”.  This was not the case in Irish hospitals in 1965, with access to trained surgeons, surgical theatres and antibiotics.

There is no valid reason for the fact that though symphysiotomy was dropped and even banned as a procedure in other Western countries, it  continued to be used in Ireland as late as the 1980’s, no matter how frequent its use was.  Points have also been made regarding the life-saving potential of symphysiotomy in specific situations. No one is questioning that.   We are questioning the medical need to perform these procedures in Irish hospitals in the years in question, when evidence showed a caesarean section was a viable alternative.

We at AIMS Ireland find it appalling that women’s experiences, trauma and injuries at the hands of what was a highly patriarchal and religious-led maternity care system, could be so lightly dismissed, and their suffering labelled as in some way “normal”.

Women should not be suffering either emotionally or physically after childbirth in Ireland.

#ENDS

Tuesday, 8 November 2016

Statement from AIMSI on the publication of the MAMMI STUDY 
Stat
Dublin, Tuesday November 8th 2016
The Association for Improvements in the Maternity Services in Ireland (AIMSI) welcomes today’s publication of the MAMMI (Maternal health And Maternal Morbidity in Ireland) study.  AIMSI is keen to point out, however, that up until this point, the safety of the Irish maternity system has been measured purely by maternal mortality, which according to AIMSI Chair Krysia Lynch is “crude and uninformative”.
The study findings show alarming prevalence of life changing health issues - issues that make everyday life hugely challenging for Ireland’s mothers.  AIMSI is also concerned by the under-reporting of such issues illustrated in the findings, for example 70% of women reporting pelvic pain in pregnancy, but only 5.8% documented as having such issues in hospital records.
Speaking in Dublin following the publication of the study, AIMSI Chair, Krysia Lynch said, “Women enter our maternity services every day feeling well and leave feeling unwell with morbidities that are rarely discussed; pelvic floor problems, mental health problems, incontinence, scar breakdown and infection. Women need to be aware of these risks and how to minimise them.  The only way to do this is for women to be able to access high quality evidenced based information such as this study illustrates.”
"Women need to know that certain settings and care providers have greater associations with certain morbidities” she added,  “a fact which is rarely discussed in Ireland. In particular, given our soaring birth by caesarian rate, women need to be aware that birth by c-section carries morbidities for both mother and baby and women should factor them into any choices made about their birth setting, care provider and mode of birth".
AIMSI also notes commentary that suggests women are not reporting or discussing health issues because of inexperience, embarrassment and fear.  The Association would prefer if society could stop blaming women asks if we should be asking our health professionals if they are listening instead.

Friday, 4 November 2016

AIMS Ireland: Maternity Care based on medical best practice, NOT Constitutional Amendment.




Maternity : adjective,  
 
"of, relating to, or for the period in which a woman is pregnant or has just given birth to a child."
 
 
 
 
What is Maternity Care?
 
Maternity Care covers a wide base of health services to women and other pregnant people, responding to the needs of various eventualities in the Maternity Continuum which may occur from the moment a woman becomes pregnant, to birth and the postnatal period. This definition covers a wide range of services, including abortion. As a campaign and support organisation, AIMS Ireland further extends this definition to include women planning a pregnancy, (pregnancy prevention, fertility services, etc,) and we also supports women whom contact us years (sometimes decades) after a traumatic birth.
 
AIMS Ireland campaigns for the implementation of evidence based best medical practice. Any discussion on evidence based best practice cannot be had without the inclusion of bodily integrity, autonomy, informed decision making. Whatever your terminology of preference, this issue, the right to informed consent / informed refusal, is the very cornerstone of medical ethics and best care practice in all realms of health. This right is eroded in Ireland in maternal health; reproduction, abortion and in continued pregnancy, labour & childbirth due to the 8th Amendment of the Irish Constitution. A non-pregnant woman with full capacity is legally recognised to make decisions on her health care - the right to informed consent/refusal. However, the moment she becomes pregnant, her capacity is immediately diminished.

The State removes viable care options from her.
The State owns her decisions and body.
The HSE directly cites the Constitution as a barrier to consent in her health care should she decided to continue her pregnancy.
 
A health care system which fails to provide the full range of safe, accessible care options with scope for informed decision making is void of best care practice. Removal of choice is never best practice. As a Maternity Rights and Advocacy organisation, is futile to have a position on rights violations in continued pregnancy and birth under the 8th without also including abortion. And vice versa. The two are inherently linked as part of the maternity continuum and equally restricted by ramifications of the 8th Amendment.
 
 AIMS Ireland holds a position which supports full autonomy, to all women, in all aspects of her healthcare. As elected unanimously by our members. We support a position of maternal requested abortion and birthing autonomy. A maternity system based on full care options, medical best practice, and maternal autonomy. Not Constitutional Amendment.
 
Maternal Requested: What is it? Why does AIMS Ireland support it?
 
AIMS Irleand supports every woman to make an informed decision on her healthcare in her personal circumstances. It is never about the choice, or if you would make it for yourself. Its about supporting a woman's right to weigh the risks, for and against, the options being presented to her in order to make the best decision for her, in her current personal circumstances, taking on board her medical history. There are no absolutes in maternity care, its about balancing risks and making a decision you feel safest in *at that moment* with scope to revisit the issue if medical indication arises.
 
Maternal requested - the woman is the lead decisioin maker in HER healthcare based on HER personal circumstances.
 
Maternal requested abortion.
Maternal requested Caesarean.
Maternal requested Homebirth.
Maternal requested Foetal screening.
Maternal Requested.
 
AIMS Ireland work with pregnant women. We have supported thousands of women in the last decade. Women make good decisions. They are articulate, informed, and acutely aware of their circumstances and what they are capable of. To deny women agency over their decisions and body, to ask them to give their decisions away to strangers, is a gross violation of rights of half the Irish population. It also creates an unsafe medio-legal environment for service users and health care providers alike. The 8th Amendment fails to protect anyone, and in fact, actually creates more risk for all individuals within the maternity continuum. Women needing abortion. Women in happy healthy pregnancies, prevented from making decisions in pregnancy, labour and birth which they feel is best, safest, for themselves and their baby. Failure to provide a full continuum of services, failure to provide evidenced best practice.
 
 
AIMSIreland believe all maternity services should be publicly funded
 
With all its many flaws, which are very serious and at times dangerous, one of the most positive aspects about the Irish maternity system is that it is free to all who enter its doors, whether resident here or visiting at any time, and that the midwives are highly trained to 4 yr degree standard. Healthcare should  not be dependent on ability to pay nor should it differienciate duty to care by whom is worthy, or not, based on their personal circumstances, needs, choices, or medical history. Abortion should be a part of any evidenced safe maternity services in order to maintain a duty of care for all within the maternity continuum. The moment we begin selecting whom may or may not have duty to care, a medio-legal conflict is created with devastating direct consequences on the most vulnerable service users. As recent and past cases have shown.

Shiela Hodges.
Michelle Harte.
Savita Halappanavar.
Mother A.
Ms Y.
Mother B.
 
 
 
Repealing the 8th and Maternity Care
 

The 8th Amendment affects women's autonomy to birth. The HSE directly citing it as a barrier to consent in continued pregnancy and childbirth. AIMS Ireland have reiterated this issue since 2010, that the 8th Amendment has direct consequences on the rights of birthing women in Ireland. AIMS Ireland has supported many women whom have been threatened with High Court proceedings for their birth choices, most consent under duress of the threats, however recent court proceedings - HSE v Mother B - realises the extent of this issue to the public issues which we have witness for a decade.
 
Repealing the 8th and replacing it with similar legislation which gives equal rights to the foetus in some instances will result in no changes for pregnant women/people in happily continued pregnancy. With shared rights a pregnant women/person is automatically considered of reduced capacity in the ability to make an informed decision, consent to, or decline care options and interventions in continued pregnancy, labour, and childbirth.
 
The HSE directly cites the 8th as a barrier to consent in continued pregnancy and childbirth. Further, The Capacity Act legislation outlines the importance of Advanced Health Care Directives, as being legally binding to ensure patient wishes, but outlines that these directives can be overruled in the case of pregnancy.
 
Pregnant women/people should be the lead decision maker on their care - if, where, how, with whom they give birth. In no other realm of health is a person with full capacity's right to bodily autonomy diminished.
 
Bodily autonomy is the cornerstone of medical ethics. Removal of this right in the instance of pregnancy is discrimination. Removal of choice is never best practice.
 
The Repeal conversation must be opened to include continued pregnancy and the dangerous ramifications the 8th has on ALL aspects of maternity care in Ireland. The 8th Amendment effects EVERY pregnancy.
 
** Note: AIMS Ireland fully recognises that not all individuals who become pregnant identify themselves as women. We try to use inclusive language as much as possible. The use of "woman" is reflective of the majority of individuals seeking our support. However, we fully recognise that discussions surrounding maternity services and the 8th Amendment should be inclusive to all whom are affected.

Thursday, 3 November 2016

What people are missing - HSE v Mother B

There has been a lot of commentary in the last 24 hours in regards to the HSE v Mother B case questioning the decision VBAC3; Why would a woman question medical advice and take this case to the High Court.

What people are missing - it's not about the choice, or if you would make it for yourself. It's about supporting a woman's right to weigh risks for and against each care option and make the best decisions for her in her current circumstances taking on board her medical history. Informed choice. A cornerstone of medical ethics.

The unit in question refused to engage with this woman and instead decided threatening her & taking her to court was the best option. And they were backed by our National Health Service under Constitutional personhood law.

 The foetus, like many other cases, had its own legal representation against it's mother.

If we want to make it about "risk", if discussing the 3% chance of uterine rupture, we must discuss all the risks and that it's up to the woman to weigh them out. There are real and substantial risks in repeat Caesarean; most severe maternal morbidities in Ireland (the near misses) are involving repeat Caesarean section. There are no absolutes in maternity care, it's about balancing risk and making the decision you feel safest in *at that moment * with scope to revisit the issue if medical indication arises. As in this case. The woman requested a Caesarean when she no longer felt vbac was a safe option.

Women are not stupid. Women do not take risks. They make good decisions for themselves and their baby. They need to be supported, not violated and threatened.