PQ Reply: HSE Draft Consent Guidelines breach Women's Human Rights

QUESTION NO: 1159

DÁIL QUESTION addressed to the Minister for Health (Dr. James Reilly)
by Deputy Clare Daly
for WRITTEN ANSWER on 16/04/2013

* To ask the Minister for Health with regard to the Draft National Consent Policy in relation to refusal of treatment in pregnancy, if the guideline which says that a woman's refusal of treatment which may impact on the life of the foetus must require a legal opinion to be sought and if this is not a serious breach of the woman's human rights regarding her own decision making with regard to giving birth.

Clare Daly T.D.


REPLY.
An adult with capacity can refuse all forms of treatment (including life-sustaining treatment) even where such a refusal may be considered unwise and/or conflict with prevailing medical advice and could lead to his/her death. The case [In the matter of a Ward of Court (withholding medical treatment) (No. 2) [1996] 2 IR 79] established that an adult with capacity has the right to refuse medical treatment to facilitate a natural death. A number of subsequent court cases have reinforced the rulings from the Ward of Court case, in particular JM v The Board of Management of St Vincent’s Hospital[2002] 1 IR 321 and Fitzpatrick v FK (No.2) [2008] IEHC 104. However, this situation becomes more complex in the case of pregnancy given that the rights of both parties (i.e. the mother and unborn) need to be considered. As the HSE's Consent Policy remains in draft form it would be inappropriate for me to comment on it at this stage. I expect the policy to be finalised shortly

Women continue to raise concerns over early pregnancy concerns/miscarriage care in Galway

Since the death of Savita Halappanavar, AIMS Ireland has been contacted by concerned women regarding their care in early pregnancy and during miscarriage in Galway's UCGH. Many women prefer to remain anonymous, others ask to share their stories.

In March, AIMS Ireland shared the story of a woman who was left waiting three weeks during a miscarriage without care. As a result she travelled abroad for treatment.
Her story is available here: STORY

AIMS Ireland has been contacted by another woman today with regards to her treatment and delay for early pregnancy assessment despite bleeding and GP referral. This is her story in her own words.

I want to make you aware of a particularly unhappy situation in Galway University Hospital at present at their EPU.

The wait time for a scan at the early pregnancy unit is currently between a week and two weeks. They do not offer any scan services at weekends.

These scan appointments are following GP referral for bleeding and cramping.

I myself have been spotting, yet following a letter from my doctor, they offered me a scan date 2 weeks later. This is with a previous history of miscarriage. My symptoms worsened and I presented myself at the unit, to be offered an internal and a blood test, but a point blank refusal to scan me despite severe pain and heavy bleeding. The doctors that I dealt with at the EPU this time were actually very nice, but you could see that their hands were tied also. It is difficult to endure any kind of bleeding in pregnancy, but at least a scan gives you peace of mind either way, be it a good or bad outcome. Nobody should have to wait so long to learn of that outcome. I have been so stressed and anxious - difficulty eating/sleeping - as a result of this huge almost inhumane delay to be scanned. It is not good enough. Nobody should have to wait so long to learn of that outcome.

In the end, I resorted to a private scan as I needed to know. Luckily all is ok. But what about those for whom a private scan is not an option? Are we women in Galway not entitled to equivalent care as received in Cork or Limerick or Dublin?

If I broke a bone, would I have to wait two weeks for an X-ray? No. Why then, if a woman bleeds in early pregnancy, should she wait two weeks for an ultrasound?

If you have an experience you would like to share or if you would like support following an experience please contact us at support@aimsireland.com

Guest Blog: Does your doctor love your baby more than you do?

Does your doctor love your baby more than you do?

Guest blog byCristen Pascucci, ImprovingBirth.org, USA

 

The gift of motherhood has been called divine.  To be given a baby—to nurture him in the womb, give birth to him, and bear responsibility for his every physical, emotional, and spiritual need even after that—is perhaps the greatest responsibility we are given as a species. 

 

The physical ability to create this life and release it into the world is what distinguishes women from men.  It’s what we do.  It is what makes our bodies different.  And it’s what often makes our lives very different; our responsibility as mothers is embedded in our chemistry, in our bones, and in our souls.  We never forget that we are mothers.

 

It is an odd thing to me, then, that so many women are expected to forget what we are during the very event that makes us mothers.  We sacrifice our bodies, time, energy, youth, and our own needs so that we may give to our babies while they are in the womb and after it.  Yet, at the life-changing event of their actual births, we are often expected to hand over the reigns to someone else.  Why is that?

 

A woman is not less deserving of respect at birth.  She is more deserving of respect as she undertakes her greatest responsibility in life.  We were not given the gift of life to be undermined by others as we bring it into the world.

 

Let’s examine the expectations of a mother giving birth.  Ideally, she will have a glowing, healthy baby, and she will come through birth healthy and ready to mother, as well.  She cannot wait for that first precious moment when she catches sight of her mysterious little roommate, and she longs to hold him close, to smell him, to protect and warm him, to nurse him from her body with the best food on the planet.  Her goal is the safest, smoothest birth possible so that she is physically capable of caring for her newborn and no complications are created for future births.  And, of course, because his birth is a major life event for them, she wants her memories to be good ones.

 

If she’s done her research, she’ll know that science firmly backs what she instinctively wants—the skin-to-skin contact regulates his temperature and heart rate, the proximity to his mother and the sound of her voice soothes him.  He cries less than if he is away from her.  The breastmilk he receives supplies him with perfect nutrients.  Science has not come close to duplicating that formula, nor can it reproduce the benefits of bonding that occur with it that are so beneficial to the brain and social development of our babies.

 

Perhaps her care providers have the same expectations; perhaps they don’t.  The truth of the matter is that even the best of care providers is under competing pressures: pressures of time, of cost, of administrative policies, of practices that are meant to keep the healthcare machine running at a certain pace and with certain outcomes as priorities.  Each of these pressures and priorities serves to push the optimal well-being of mom and baby just a little further down the list.

 

In the U.S., for example, we know that the single biggest factor (see here and here) as to whether or not a low-risk woman receives a Cesarean section is the practice patterns of the providers with whom she gives birth—not her individual circumstances.  The odds of a woman giving birth by surgery are as much as 15 times greater in one hospital over another.  In our case, scheduling constraints, legal liability, and insurance reimbursements are very real factors in the care we receive.

 

When other factors take precedent—when surgery, induction by drugs, or instrumental deliveries are used a little more frequently than is necessary for mom’s and baby’s sake—we end up with births that are more traumatic, more complicated, and more risky than they might have been.  We end up with babies whose systems are flooded with drugs at birth, who are bruised and upset, who may be separated from their mothers in those first critical moments.  We end up with mothers who are dealing with negative physical and emotional consequences of birth, feeling “blue,” rather than enjoying their babies at this defining period of attachment.  And when surgery is employed, we end up with women for whom each subsequent birth by surgery is more and more dangerous for her and her babies.

 

Imagine a doctor whose individual practices and preferences lead him to cut open 50% of the women who come to him for his services.  Or, perhaps it's a doctor who believes that Cesarean surgery is "almost risk-free"--contrary to every scrap of current evidence (see here, here, and here).  Would we give these men unilateral authority to decide whether or not we give birth by surgery?

 

These things are not acceptable, in the United States, in Ireland, or anywhere else.  Respect for motherhood, for the mother-baby cycle, and for the life event of birth is a human right.  It’s time to demand that we are respected as the decision-makers about our bodies and our babies. 

 

The state does not have a uterus nor does it have breasts.  It was not given the gift of the creation of life and it is not entitled to your body or your baby.  It is not more invested in our children than we are.

 

Does your doctor love your baby more than you do?  Does your government lie awake watching him breathe at night?  If the answer is “no”—and I believe it is—then who dares to come between a mother and her baby?

 

As American parents, Irish parents, any parents, it is our right and our responsibility to make decisions that affect every facet of our children’s lives.  It is no different in birth.  

We must protect our bodies if we are to protect our babies. And no one can protect your baby like you can.

References:
Huffington Post, March 6, 2013, "C-Section rates vary across U.S. hospitals"

ImprovingBirth.org, January 23, 2013, "U.S. Hospitals held accountable for C-section rates"

VBACFacts.com, December 9, 2012, "Why cesareans are a big deal to you, your wife, and your daughter"

Childbirth Connection, 2012, "Cesarean section: what you need to know about c-section"

American College of Obstetricians and Gynocologists' News Release, March 21, 2013, "Vaginal delivery recommended over maternal request cesarean"

For more current, science-based research, go to www.EvidenceBasedBirth.com

Cristen Pascucci joined ImprovingBirth.org--a national nonprofit in the U.S. run by and for mothers--after the birth of her baby in December 2011.  She is now vice president of the organization, which advocates for evidence-based care and humanity in childbirth, and she writes regularly about the need for respect in childbirth.  Prior to that, she was a political and communications strategist in Baltimore, Maryland.

What do 'Human Rights in Childbirth' look like?

When you think of ‘Human Rights in Childbirth’ – what do you see?

Do you see a certain kind of birth?

Do you see a certain image?

Do you think that it is not about you?

Human Rights in childbirth means that a pregnant woman’s basic rights and freedoms are the same as any other person.  A woman cannot have these rights removed simply for being pregnant or based on where she lives, sexual orientation, nationality, religion, or any other status.  Women can expect appropriate care. ‘Appropriate care’ means that the psychological and physical welfare of a woman is protected. Women shall be treated humanely. Women shall receive care based on the best evidence available rather than based on routine hospital policies - which do not treat women on an individual basis and are sometimes shown to do more harm than good. Appropriate care means a woman is respected in making decisions which will affect her and her baby.

Human Rights in childbirth affects all women, in all types of care.  And these rights must be protected equally.

Unfortunately, at times, these rights can be denied. This is often called a ‘breach’ or ‘violation’ of human rights. Some women who have given birth instinctively feel they have been denied their rights, that something just didn’t feel right. Others may not be sure.

What does a human rights violation look like?

Sometimes, women say they picture a human rights abuse in extremes. AIMSI hear women say all the time “my birth wasn’t that bad compared to others”. In reality, a breach of rights can look a lot more subtle.  Some examples of Human Rights breaches in childbirth are: having an examination or procedure done without your permission, cutting you without asking, or breaking your waters without giving you the full information. Breaches can also be how you were treated. Were you listened to? Were your choices respected? How were you treated? Were you cared for and treated  in a  dignified and respected manner? Were you given information on important decisions during your labour and birth? Sometimes, seeking your permission can be implied. For example: “I am just going to give you some help” as they are cutting you. This is not consent and is a breach of your rights. 

Any denial of a woman’s rights is not OK.

What does Human Rights in Childbirth look like?

The right to choose your hospital.

The right to choose your care provider, doctor or midwife.

The right to choose who supports you in labour – birth partner(s)

The right to choose the type of care for your birth: public, semi private, private consultant led,  midwife led (MLU, DOMINO) in hospital, or home birth.

The right to be an active member in decision making during your pregnancy, labour and birth.

The right to be given all the necessary information – benefits and risks – of a test, treatment, or procedure to help you make a decision. Benefits and risks means that any possible side-effects are explained to you, both for and against. You should also be given the opportunity to discuss 'doing nothing' - asking for more time before making a decision and if there any alternative suggestions you can try.

The right to give your consent, the right to more time, and the right to refuse.

The right to have your concerns and preferences respected.

The right to be treated in a dignified and compassionate manner.

The right to have enough staff to look after you.

The right to privacy.

The right to have pain relief, or not.

The right to have maternity care which is based on best evidence available.

The right to a second medical opinion.

The right to make decisions on the care of your baby.

The right to equality – all women are treated the same.

 

A recent decision by the European Court of Human Rights found that it is a basic right for women to decide the terms on which she becomes a parent. That means women have the right to decide where and how she gives birth. If you feel your rights were denied, AIMS Ireland would like to support you. AIMS Ireland will help you in a complaint. We also have legal experts who can talk to you and provide you with advice. Additionally, our legal experts can assist in a legal complaint to the European Court of Human Rights. AIMS Ireland wants to hear from you if you feel your human rights were breached in any way during your pregnancy, labour and birth. We are interested in collecting stories from women with a view to publishing them. Your voice matters and your story  will help gain awareness and protect women’s rights.

If you would like more information on any of the issues here please contact us at

support@aimsireland.com

chair@aimsireland.com

Realise Your Rights - The Birth of AIMSI

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)

NB. Many women attend antenatal classes at the hospital where they are planning to give birth. While the antenatal educators arguably have the good intention of providing information on labour and birth to pregnant women, they are bound by the policies - ie. AML - of the hospital that employs them, so the information is skewed towards how a woman should behave or is allowed to behave during labour and birth. There is no mention of the 'domino effect' of one intervention often leading to the next - referred to as the 'cascade of intervention'. It is recommended to go to these classes with a critically analytical mind so that you are prepared for the policies of the hospital where you are going to labour and birth, and most importantly - you are prepared to ask questions and to exert your rights to informed consent and informed refusal.

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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: info@aimsireland.com or support@aimsireland.com

Submission from Association of Maternity Services Ireland (AIMSI) to the National Steering Committee for Home Births

Submission from Association of Maternity Services Ireland (AIMSI) to the National Steering Committee for Home BirthsDear All,

We have serious difficulties with both the proposed Memorandum of Understanding (MOU) and and the proposed "Agreement"  between midwives and the HSE from a human rights perspective and we write to bring these to the attention of the NSCHB.

AIMSI represents the views of several thousand women who have contacted AIMSI (and the Home Birth Association) over the duration of this Committee's life span. We are the only stakeholders on this Committee who have actively sought to canvass the opinion and views of the service users of a Home Birth Service that will be defined by the new MOU and Agreement that, we understand, this Committee plan to sign off on on 26th March 2013.

1. AIMSI recognizes a women's fundamental right to choose where she gives birth. This is a human right that finds expression in international best practice, such as NICE (UK) and ACOG(USA), which clearly define a woman’s choice as final, regardless of recommendations.

The proposed MOU does not have any provisions that recognize and safeguard a woman's preferences, and the NSCHB has made no effort to accommodate women who want to exercise their choice as to  place of birth. The official response to such women appears to be the exercise of coercion. During the lifetime of this Committee, suggestions, both implied and overt, verbal and in writing, have been made about how a woman who is reluctant to transfer to hospital in home birth might be coerced into doing so, either by the attending midwife or midwives, and/or involving "other stakeholders", included the Garda Siochana, which, as draft NSCHB guidelines were in breach of both the Constitution and European law. In practice, at least one mother has also been threatened with the seeking of a court order against her, making her unborn child being a ward of court at birth should she not agree to a hospital birth.. Indeed, the recent response to Mother A by the HSE suggests that court orders are becoming part of the official approach in Ireland to pregnant women who attempt to exercise their autonomy.

However, what may not be realized is that women who have experienced these tactics of coercion in Ireland are sharing their stories on social media to audiences of tens of thousands. Some pregnant women who read them have concluded that it is better NOT to engage with the HSE at all that their and their baby's best interests will be served by not availing of antenatal care and by birthing unassisted, without professional assistance of any kind.

This is surely not what NSCHB intends by way of outcomes to its intended sign off on the MOU and Agreement, yet, unless these documents are revised in such a way as to ensure that a woman's fundamental right to choose where she gives birth is upheld, an increase in the number of unassisted births, with their attendant risks, seems inevitable.

While the HSE recognizes the right to informed choice in medical treatment and health, maternal choice is recognized only if it reflects the prevailing model of obstetric care, apparently: the official approach does not seem to recognize women's right to make birth choices which reflect a midwifery model of care.For example, there appears to be no problem with c- sections on maternal request, despite the risks that this procedure carries.

2. But denying women their constitutional and human rights to autonomy, self determination, bodily integrity, etc leaves the State exposed to legal challenge. Both the MOU and the Agreement are in breach of Article 8 of the European Convention on Human Rights, which enshrines the fundamental right to bodily integrity. The MOU is also in in breach with the decision taken by the European Court of Human Rights in Ternovsky vs Hungary (2010), which found in favour of the right to choose the circumstances of becoming a parent. Here in Ireland, the Constitution enshrines the rights to autonomy, self determination, and bodily integrity, and the right to refuse medical treatment, yet the proposed MOU clearly breaches Article 8 of the ECHR.

3. For many women, one of the reasons they want to birth at home is because their previous experience of care in an obstetric setting left them with significant post traumatic stress. Ironically, these women may now find themselves in Tables 1 or 2 of the MOU, thereby preventing them exercising home birth choices in subsequent pregnancies, and forcing them back into the very same model of care that traumatized them in the first place..  Outlawing choice in this way runs the risk of further traumatizing women emotionally, which in turn will have knock on effects for already overstretched mental health and GP services.

4. AIMSI is particularly concerned, inter alia, about making mandatory a requirement that two midwives be present at every birth. The NSCHB's insistence on a second midwife who has signed the Agreement will severely curtail the home birth service in many areas of the country. This will lead to severe geographic inequities in service provision and will deny women their constitutional and human rights in childbirth.

This requirement is not evidence based: there is no good evidence to show improved outcomes for mother or baby when two midwives assist at a home birth. While this may have become practice in some parts of the country, due to local preferences,  imposing  this in the Greater Dublin area, where there are simply not enough midwives that meet the stringent criterion wrongly laid down by the NSCHB for the second midwives will potentially eliminate the choice of home birth services provided by SECMs in the region. NSCHB's unreasonable insistence that second midwives are required to have three years' prior experience in a Maternity Hospital will significantly reduce the pool of midwives available to act as second midwives: This requirement is also not evidence-based and appears to runs contrary to ABA's guidelines.

The requirement to have a second midwife will leave women in a very vulnerable position. Should a second midwife not be available at the last minute, women will be forced to transfer to hospital in the height of labour, an unsafe and traumatic scenario. The inevitable result will be more babies born before arrival in hospital. Birthing in the back of a car or on the side of a road with one midwife or a paramedic team with minimal training in the management of childbirth is infinitely less safe for mother and baby than birthing at home with one SECM. Another issue that has been raised is that women should be able to chose whether or not they wish to have a second midwife, whom they may not know, in attendance at their home birth. Many women specifically choose home birth so that they will have continuity of care from a known and trusted midwife.

5. Our presence on this committee was to bring the perspective of the service user to the table so that this could be factored into the new instruments (MOU and Midwife's Agreement) that will define the home birth services that these women and their families will have available to them. AIMSI has repeatedly been denied that opportunity, however. The MOU was drawn up in September 2008 under severe time pressure, at the behest of the then Minister of Health, Mary Harney. It was always AIMSI's understanding that the MOU was an interim document and that issues, such as VBAC at home, would be revisited and re-assessed. This review process excluded all such issues from consideration, leaving large groups of women excluded from the State's home birth services.

The only two groups that have not been consulted in the drafting of these key documents are the service users and the service providers (as in SECMs), even though both groups are theoretically represented on this HSE National Steering Committee. Consultation means more than engineering a fait accompli, it means parity of esteem, with each participant an equal partner in the drafting process. This has never applied to the NSCHB, however, where some delegates have always been "more equal" than others. AIMSI has been persistently denied the opportunity to consult these documents during drafting; and once drafted, the organization was informed that no changes were permitted; with repeated requests for the most recent versions falling on deaf ears.  Two days before these documents are scheduled for final approval, AIMSI has still not seen the final drafts.


In conclusion, AIMSI cannot reasonably be expected to sign off on any document that will radically affect the provision of the State home birth services without proper prior consultation and without being afforded the opportunity to input into these highly important contractual agreements. Until these issues are resolved, AIMSI will not be a signatory to any instrument seeking to restrict the provision of State home birth services that flies in the face of women's human rights in childbirth.


Yours faithfully


Krysia Lynch and the AIMSI National Executive

cc. Laverne McGuinness, National Director of Integrated Services, HSE
cc. Dr James Reilly, Minister of Health,

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Update 11am Monday 25th March: AIMSI has received a letter from a woman to Patient Focus, the other consumer representative on NSCHB. Please see below - posted with permissions.


Dear Sheila O' Connor and Patient Focus,

As a Mother and pregnant Mother,  I strongly object to the MOU and how it will be  implemented as categorical exclusion rules. This means my maternity system is and will continue to treat me as a sheep in a herd. It denies me individual assessment for care options, it denies me an equal input into my care options, it denies my Midwife autonomy work in her professional it denies me evidence best practice.

If you vote for the MOU to go through, you will part-take in an ongoing battle of women's oppression and you will be in support of denying Women their Human Rights.
You will NOT represent me.

This MOU is flawed, how it has been drafted is flawed, it's current implementation is flawed and it's news content is flawed. Given the recent statement via AIMS Ireland, I cannot and could never say that anyone voting in agreement with the MOU represents me.
 http://nocountryforpregnantwomen.blogspot.ie/2013/03/submission-from-association-of.html

Your deeply concerned about our birthing future
Annette Harkness

If you would like to send a similar letter, please consider the following recipients:

Sheila Sugrue - National Midwifery Lead, Ireland: sheila.sugrue@hse.ie    
Michael Turner - National Obstetric Lead, Ireland: michael.turner@ucd.ie
Sheila O'Connor - Patient Focus, Consumer Rep: sheila.oconnor@patientfocus.ie
James Reilly - Minister for Health: james.reilly@oireachtas.ie 
Michael Shannon - Chair of NSCHB: michael.shannon@hse.ie  

AIMSI have been approached by a legal firm who are looking for women/a woman to make a complaint to the Committee on the Elimination of Discrimination Against Women (CEDAW). We are looking for women who are prepared to make a complaint to the CEDAW because of a threat that their right to autonomy will be violated or because their rights have been violated. please contact: chair@aimsireland.com



* Please see earlier blog posts on draft HSE guidelines for consent in pregnancy for further background.

HSE set to dismantle Cavan MLU? For a non-maternity surgical day ward.

The measuring tapes are out and it would appear the Cavan MLU's days are numbered as a two room unit, according to several sources contacting Birth Matters Cavan and AIMS Ireland over the past 24 hours.

 If reports are correct, Cavan are transforming one of the two MLU birthing suites, the MLU ante-natal room and waiting rooms,the offices of the ADON for women's & children's services, the clinical midwifery managers and one of the OB consultants, and the early pregnancy unit) into a day ward for non-maternity surgical services. It would seem the remaining MLU birthing room and MLU office will be sandwiched between rooms being converted into the surgical day ward.

This will have immediate impact on the ability to provide MLU services to the full number of booking capacity MLU women - if a woman is already using the birth room there is nowhere for ante-natal checks or room for another woman to labour.

The Midwife Led Units (MLUs) were created as a pilot scheme in Cavan and Drogheda. They offer women normal birth practice and offer a unique gold standard of care within a hospital setting. AIMSI and many organizations have hoped that the MLUs would be rolled out nationally. The MLUs have been proven to provide women with safe midwifery led care, have high satisfaction ratings, and are cost effective. You can read more about the MLUs in the Mid-U study seen on this link HERE

This is not the first attempt to cease or reduce services in the Cavan MLU. In December 2011, the HSE made moves to close the unit based on 'uptake'; fewer bookings from women. So why the low uptake?

This Facebook post from December 2011 shows the low down:

AIMSI have been informed that the rationale for closing Cavan MLU is that it is functioning below capacity. How could this be so? We know that MLU in OLOL is fully booked, we know that women WANT midwifery led care (see recent study out of the Coombe showing a 42% preference for ML care. Is there something particular going on in Cavan. AIMSI have had many reports of women saying that they were (a) not informed of MLU option by their GP (b) that they wee dissuaded from care at the Cavan MLU by both their GP AND staff at the CLU, even thought they fit the criteria for low risk care.Women must be made aware of the fact that they can SELF REFER if this is the case.

In the past the women could refer themselves to the MLU, now they have to go through the Consultants. The feedback we have had from women is the Consultants and GPs are not referring women, even if they meet criteria, for the MLUs. Women have also told us bookings are left 'too late' if they indicate they want the MLU; women must be booked in by 20wks as per policy of the MLU but some women who indicated MLU preference, won't get an appointment til 24wks - too late for the Consultant to 'sign off' for MLU. AIMSI have also heard from women whom were told MLU care is risky.


Over the next few days, we will probably see a variety of excuses from the HSE as to why they are dismantling the MLU. AIMSI wants to preempt these before they begin.

This is NOT about money. The Mid-U report clearly states that for the same woman, having the same birth, the MLU costs  €400 less than the woman in CLU. For the SAME birth. Though, maybe it is...the obstetricians will certainly be getting more bookings.

This is NOT about safety. Midwife led care has been proven to be a safe option. The Mid-Ustudy shows us that midwifery- led care as practiced in these units, is as safe as consultant-led care but uses less intervention in pregnancy and childbirth.

This is NOT about women's preferences. Various research in Ireland has shown that women have high satisfaction ratings using midwife led care and women want access to MLUs nationwide. 85% of women using the MLUs would 'recommend it' to a friend.

So what is the REAL issue here?
Who benefits?
Is this another attempt by GPs and Consultants to prevent women from accessing midwife led care?

Looks like the Consultants are finally getting their way.

What can you do?

Join the Defend Cavan's MLU - facebook page: http://www.facebook.com/#!/pages/Defend-Cavan-MLU/322709951092529

Contact your local TDs
Contact AIMS Ireland at info@aimsireland.com

** UPDATE**

BIRTH MATTERS: "Measurements of the unit were taken yesterday. Our main concern was that we would be kept informed if any changes were to be made. I have received clarification from Cavan that the entire footprint of the hospital is being surveyed to try to accommodate a day surgery facility. A representative has explicitly stated that the MLU is NOT closing. I woukd interpret this as meaning som...e facilities will be rearranged. I understand that his is a highly emotive issue, and under present cost cutting measures across the country, it appears that no service is sacred, but we need to stay focused & calm & make sure our information is accurate if we are to be taken seriously at regional level. Thank you all for rallying round as usual. It is a huge comfort to know that there are vigilant people out there who value their services & are willing to fight for them......No immediate plans at present. Whole hospital survey underway. I have been led to believe that it would be a case of moving/ rearranging facilities rather than removing them."

AIMSI response:

This is good news if services to the MLU in Cavan are to remain fully operational with the current level of services; antenatal waiting room, booking room, 2 birth rooms. We look forward to being further updated on this issue. The MLUs are about 10yrs old and still in immacculate condition. The 2 birth suites are beautifully designed with state of the art facilities, including private ensuite toilets/showers and birth pools. 

Wonder how they plan on rearranging and moving them?

                                                           Birth Suite in Cavan MLU