In March 2007, a group of women came together with a common goal: to help other women who had been neglected, coerced, disrespected - and sometimes abused - in their maternity care to realise they are not alone. The Association for Improvements in the Maternity Services Ireland (AIMSI) believed that women were not being supported and respected in their childbirth choices and set out to campaign and lobby to change the culture of birth in Ireland. For the past 6 years, AIMSI has put in thousands of volunteer hours providing support, writing letters, researching evidence-based care in childbirth, participating at committee level to improve maternity services and making certain that the respect of women in childbirth is a right, not a privilege.
There is a long history in Ireland of women and their bodies being the domain of the State. Looking back through the annals of time, there are countless stories of women being told they must give up their babies because they were seen as 'unfit mothers' or that they must be committed to an institution, such as a Magdalene Laundry, often for no other reason other than they were not compliant with the sociocultural 'rules' of the State. Even some things that seem unrelated, such as the State obliging women to leave paid employment after marriage or making it legally impossible for a woman to petition for divorce from an abusive spouse, set the tone for many women to accept that they had very little to no autonomy or self-determination in relation to their bodies and their lives.
In recent years, thanks to the tireless work of activists and advocacy groups, like AIMSI, Ireland has moved on from the explicit discrimination of women, but these cultural attitudes are very hard to shift after years of indoctrination and justification. Recently an article in The Journal described the "grotesque and violent" treatment of women at the hands of surgeon, Dr. Michael Neary. It is widely known that Dr. Neary removed the wombs of at least 129 women and that many of these women are still waiting for compensation for this brutal and unnecessary surgery. The most poignant comment in The Journal article is that of one of Neary's victims when she says:
“Even when the story broke years later, I was still convinced I needed it. I told people, ‘I wouldn’t be one of them’. I believed he totally saved my life. I did actually think he was a good man who knew what he was doing, and that he was doing it for the right reasons.”
This is what many women who attend a hospital birth and who undergo surgical interventions, from an episiotomy to Caesarean section, often are told - that the interventions a woman has been subject to are necessary and have saved her from pain and suffering or even from death. Women who have given birth in Irish maternity hospitals often tell dark stories of being threatened into complying with treatment (usually with the "dead baby card") or of being refused extra time in labour, all for the sake of medically managing their labour. The policy of Active Management of Labour (AML) was devised in the 1970s in the National Maternity Hospital in Dublin and is now practiced and taught internationally. The basic policy of AML includes that:
- each labouring woman will fit into a standardised method of care whereby she will dilate at 1cm/hour
- a woman will have a maximum of 12 hours to labour (including latent labour)
- a woman will undergo routine amniotomy or 'breaking of the waters' by a midwife/doctor
- the administration of synthetic oxytocin (Syntocinon®/Pitocin®) will be used to augment, or speed up, labour
- a medical decision will be made regarding surgical intervention - episiotomy, forceps, ventouse, c-section - in the case of prolonged labour (+12 hours)
- the 3rd stage of labour - delivery of the placenta - will be managed using a uterotonic drug, such as Syntometrine®
On the surface, AML sounds as if it is a method of protecting women from facing complications due to a painful and prolonged labour and birth - but in reality it is an inconsistent and unreliable method of controlling birth that solely focuses on the management of labour and has little regard for the woman who is actively labouring. The consequence of a medicalised birth, such as AML, is that women have begun to lose trust in their ability to manage their own labours. The talk of risk and intervention by midwives and doctors leads women to believe that there are inherent dangers in childbirth. Research that is used to support claims about the risks in childbirth are methodologically weak at best and spurious at worst. Of course, as in any medical emergency, there are instances where surgical intervention is necessary for the health and well being of the patient. But how does this explain the increasing rates of intervention in maternity care, such as a steep rise in inductions, epidurals, episiotomies and c-sections? Or even more telling, how can stark regional variations in these interventions across Ireland be explained?
These are the questions that AIMSI vigorously investigates on behalf of all women who are involved in the Irish maternity services. Our mission is not to deny that some births will necessitate medical intervention - it is to ask for the validity and respect of the woman's voice when making informed decisions in her maternity care, whether it involves an emergency or not. While the vast majority of births are non-emergencies and require no intervention, the following statistics in maternity care contradict this and demand closer scrutiny:
- the sharp rise in inductions of labour (approximately 1 in 3 pregnancies are induced in Ireland)
- the increased use of epidural for pain relief (this occurs for approximately 70% of first time births in Ireland, and at slightly lower rates for subsequent births)
- the inconsistency in rates of episotomy (from less than 2% to more than 27% across maternity units in Ireland)
- the broad variations in c-section rates in Irish hospitals (anywhere from 22% to 43%)
It is simply implausible to say that these increased rates of intervention have saved lives. All scientific research is governed by the phrase: correlation does not imply causation. Therefore, it is almost impossible to determine the validity of interventions in childbirth after the fact. The glaring omission in AML is the risk that the above interventions all carry. The misperception of these interventions being "almost risk free" means that there is very little chance of accurately assessing the risk to the mother versus the risk to the unborn baby. This is further confounded by Draft HSE National Guidelines on Consent which state that a pregnant woman's right to refuse treatment must be balanced with the right to life of the unborn.
Many women will report to friends and family that if it weren't for a given intervention, her baby may not have been born healthy or alive. This is the power that a policy such as AML has over women who are pregnant, labouring or giving birth. The control of her labour and delivery by the 'experts' means that she should be grateful that they have intervened. Like the quote from one of Dr. Neary's victims above - a woman is expected not to ask questions and to accept that she and her birthing baby "needed" the intervention(s). AML has not only ensured that women's labour is managed, it has also perpetuated a myth that all interventions are being done "for the right reasons". Even the doctors who originally invented AML were very open about the primary reason for controlling labour, and it was not to simply reduce c-sections or to nobly save lives - it was invented to reduce the number of hours each woman would require the care of the obstetric team. It is aptly summed up in this article by Dr. Marsden Wagner. He in turn quotes from an article by Marc Keirse called A final comment - managing the uterus, the woman or whom? that appeared in the journal, Birth in 1993:
"It would appear that there are a large number of situations in which augmentation of labor is not directed at correcting a perceived abnormality in a woman's labor, but at shortening the labor commitment of her care givers"
It is a fallacy of logic to take a result, such as a healthy baby, and to attribute a number of interventions as the cause of that baby being healthy. Likewise, it is difficult to gather reliable and accurate statistics on the number of births that require no intervention because the standard of care in Ireland includes routine intervention, whether it is needed or not. One only has to flip through the partograms in any birth unit or to talk to a student midwife to get a clear picture of how rare it is to have a birth that is intervention-free. The strongest argument for the revision of AML is that it was originally introduced as a method of reducing c-sections and "the labor commitment of caregivers", but the rapid increase in c-sections and other interventions across Ireland (and internationally, since we exported AML) show that it has patently failed in this outcome. The paucity of reliable statistical data coupled with the lack of a national policy in maternity services makes for an ad hoc system of care. It is impossible to have consistent, evidence-based research policies and standards of care in pregnancy, labour and childbirth when each unit is operating as its own self-regulated medical outpost.
AIMS Ireland are trying to change these unsupported policies one woman at a time. Education, information and support are integral to bolstering women's confidence in their ability to birth and in their choices of how and where they wish to birth. Until the veil has been lifted on the dearth of evidence that supports AML and the risk of many of these interventions is highlighted and shared with birthing mothers, then improvements in the maternity services will be slow to positively change.
AIMS Ireland urges women to realise their rights in their choices on how and where to birth:
- the right to an informed second opinion
- the right to informed choice in the case of routine procedures such as electronic fetal monitoring (EFM), amniotomy, induction, movement in labour and position for birth
- the right to informed refusal in the case of the procedures listed above and other routine interventions, such as pain relief (epidural, pethidine, gas and air), valsalva maneuver - or 'purple pushing' - and episiotomy
- the right to choose between a home birth or hospital birth (in spite of restrictions that the HSE are attempting to place on this choice)
Look out for a follow up blog post that will look at the reliance on technology in maternity services and a more detailed explanation on the 'cascade of intervention'.
More information on birth statistics in Ireland can be found here.
If you have any queries or would like more information or if you have been affected by your birth experience, please contact AIMS Ireland: firstname.lastname@example.org or email@example.com