National Consent Policy - section 7.7.1 - Refusal of Treatment in Pregnancy

National Consent Policy has been fully implemented.
This is the most current wording.


National Consent Policy: http://www.hse.ie/eng/services/list/3/nas/news/National_Consent_Policy.pdf


Page 41: 7.7.1 Refusal of Treatment in Pregnancy

The consent of a pregnant woman is required for all health and social care interventions.
However, because of the constitutional provisions on the right to life of the "unborn" (12), there is significant legal uncertainty regarding the extent of a pregnant woman's right to refuse treatment in circumstances in which the refusal would put the life of a viable foetus at serious risk. In such circumstances, legal advice should be sought as to whether an application to the High Court is necessary.

Citation: (12) Article 40.3.3 of the Irish Constitution (1937)

Relevant factors to be considered in this context may include whether the risk to the life of the unborn is established with a reasonable degree of medical certainty, and whether the imposition of treatment would place a disproportionate burden or risk of harm on the pregnant woman.

 

 

Beverley Beech Responds to Daily Mail article "Giving Birth at Home isn't Bad per se"

While on a visit to Dublin I read your article ‘Giving birth at home isn’t bad per se.  What’s bad is being miles from the ER if anything goes wrong

 

Your article opens with the comment from a coroner that midwives should go to home births in pairs.  While it may be tempting to think that two midwives are better than one, there is no research evidence at all to support that view.  Indeed, this recommendation was first adopted in the UK when it was realised that home births were cheaper than hospital deliveries and in order to increase the costs this recommendation was made.

 

When deciding whether or not to birth at home the parents need to balance the risks of home birth with the risks of hospital deliveries.  The chances of a baby dying at a home birth is exceedingly small and that risk is far too often the focus of warnings about the dangers.  For first babies it is slightly more risky than in hospital (but not significantly different) but for subsequent babies it is far safer to birth at home or in a free-standing midwifery unit.  While transfer to hospital in labour is often painful and very stressful, particularly if there is concern about the baby or the mother, the majority of women who do transfer from a home birth to hospital are not doing so because there is an emergency, but because circumstances may have changed and the midwife is recommending the hospital – just in case.  Furthermore, every women booked for a hospital delivery transfers to hospital in labour, and no-one has assessed the risks of doing that.   Those babies born at the roadside are held up in the press as something wonderful, no-one suggests that the mother and baby would have been far safer not moving but giving birth at home instead.

 

Very few journalists write articles about the risks of hospital deliveries, particularly for the mother, or about babies who are induced far too soon and end up spending time in special care units.  You mentioned the rising caesarean section rates.  I would suggest that if there was a similar rise in major abdominal surgery in the rest of the population there would be a parliamentary enquiry and public outrage yet, because it is childbirth this often unnecessary and avoidable major surgery is accepted and rarely questioned.

 

In the  Confidential Enquiry into Maternal Death suicide was the leading cause following childbirth, and in the latest edition it is still a major problem.  AIMS had persuaded the Enquiry to look at maternal death following childbirth up to three years after the birth, but the statistics are only gathered up to one year; and, of course, Irish statistics are barely worth the paper upon which they are written.  We believe that many more deaths would be recorded were the enquiry period extended.  From our records postnatal depression and post traumatic stress features in far too many of the appeals to our help line.

 

While I acknowledge that a hospital is the place to be if a woman has a problem pregnancy or birth but for low-risk women a large centralised hospital is the last place she should be.  The Birthplace Study revealed that, and now a recent study from Australia has shown that one-to-one midwifery care produces the best outcomes with fewer caesareans, 30% fewer inductions, less severe blood loss and the women were more likely to breastfeed their babies.

 

It is time that articles in the press drew women’s attention to the risks they are taking booking into a hospital for the birth.

 

Yours, Beverley Lawrence Beech

Hon Chair Association for Improvements in the Maternity Services

 

References: 

Birthplace in England Collaborative Group (2011)  Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study, British Medical Journal, 343:d7400 doi: 10.1136/bmj.d7400

Tracy Prof SK et al.  Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial, The Lancet, 17 Sept 2013, doi:10.1016/S0140-6736(13)61406-3

AIMS Ireland response to the 'home versus hospital' debate

PRESS STATEMENT

 

AIMS Ireland response to the ‘home versus hospital birth’ debate

 

(Tuesday, 17 September 2013) AIMS Ireland today expressed their continued support of women making informed decisions on where and how they give birth in Ireland. In recent weeks, the media have given the topic of ‘home versus hospital birth’ extensive coverage. The conclusions drawn by most commentators is that there must be an expansion in health infrastructure to support women in making informed birth choices.

 

The public attention given to the landmark High Court case taken by Aja Teehan and the coverage of the recent Coroner’s inquest in the tragic death of baby Kai David Heneghan in Mayo have dominated the debate and have detracted from the real issues of: (i) Ireland’s maternity care system being almost solely obstetric led and (ii) a woman’s right to make responsible, informed choices in pregnancy and childbirth.

The HSE are currently not offering midwifery-led care options to the majority of women; either at home or in hospital. Yet we know from repeated high quality, robust research that midwifery-led care options (as opposed to midwife attended care in obstetric-led units) is the safest model of care for 85% of women. In the limited locations where such care is available the criteria for accessibility has become increasingly restrictive since the introduction of the Nurses and Midwives Act 2011. This restrictive criteria is not evidence-based and these women are denied midwifery-led care without individual assessment. For many women, a traumatic primary experience in an obstetric led unit is one of the main reasons for choosing midwifery-led care or home birth in a subsequent pregnancy. Yet the physical consequences of a an obstetric led birth often forces a woman back into the same care model irrespective of an informed choice.

 

In addition to the restrictive criteria, a recently published National Consent Policy document clearly states that the HSE has the authority to deny a pregnant woman her inalienable right to refuse medical treatment due to the legal uncertainty inherent in Article 40.3.3 of the Irish Constitution, whereby the life of the unborn is equal to that of the mother. Women are unaware of the fact that their basic maternal and reproductive rights are qualified by Irish law and the impact this has on their right to choose how and where they birth.

 

Obstetric-led care has its place in all maternity services and must be available for women who need or want this type of care. However midwifery-led and home birth care must also be provided as an option to all women in Ireland. These care options must be supported by an infrastructure which enables a seamless maternity service for women. 

Failing to provide appropriate care options affects all women. Our current two tiered obstetric base system means that:

1. No choice is afforded to women who prefer to birth under a midwifery-led continuity of care model 
2. Women who do not need or want obstetric-led care are using valuable resources and are taking up time and beds from women who need or want a obstetric-led care model
3. Women who choose midwifery-led care and home birth may have difficulty accessing these services in the first place, and if they do secure the service face numerous other administrative obstacles that the HSE needs to resolve..

 

If the maternity services are to be more equitable, there has to be more weight given to what women and families want in their maternity services. Many women are satisfied with the care they are receiving but this does not, and should not, silence the many women who are extremely unhappy with their maternity experience. These women’s voices are integral to the development of a fair and equitable maternity service that listens to and collaborates with women on their birth choices.

AIMS Ireland believes that maternity services should be based on robust and up-to-date medical evidence that provides women and families with choices in how and where they give birth. The safety and health of both mother and baby are always the priority, however, good governance should never replace the right to informed consent and informed refusal of any consumer of the health services in Ireland.

 

ENDS

 

For further information:

Krysia Lynch

087 754 3751

Press Statement: AIMS Ireland response to court decision on costs in relation to Aja Teehan vs HSE

PRESS STATEMENT

 

AIMS Ireland response to court decision on costs in relation to Aja Teehan vs HSE

 

(Friday, 6 September 2013) AIMS Ireland today welcomed the decision of Ms Justice Iseult O’Malley to not award costs against Aja Teehan in her High Court case for individual assessment by the HSE in her care pathway for the birth of her baby. This was a public interest case with significant repercussions for women seeking evidence-based maternity care in Ireland.

 

The public attention of this case has been solely focused on homebirth and has detracted from the real issue of women’s rights to make responsible, informed choices in pregnancy and childbirth. Best practice clearly states that patients should be assessed on an individual basis on their current health, current medical conditions, as well as their previous history. The HSE are not providing women with individual assessment, a fundamental principle in evidence based care.

 

AIMS Ireland is a volunteer run charity relying solely on the donations of members of the public to fund our work. Our financial situation currently stands at less than €500 to continue to support women and we would like to express our deepest gratitude to the men, women and families who have freely given their time to come out and support Aja Teehan and AIMS Ireland in this landmark case.

 

AIMSI would like to express our gratitude to Aja Teehan and Charles Brand for taking this landmark case. We wish them the very best in the future and on their upcoming birth.

 

ENDS

 

For further information:

Krysia Lynch

AIMS Ireland

Tel: 087 754 3751

Email: krysia@aimsireland.com

Survivors of Symphysiotomy: "No introductions, just lots of aggressive staring, and plenty of emotional blackmail"

No introductions, just lots of aggressive staring, and plenty of emotional blackmail

Our recent meeting with the Minister for Health was not 'a bid to find a satisfactory resolution', to quote a Government deputy, it was, rather ironically, an all out attempt by his allies to coerce our members into an ill-defined mediation process that aims to buy them off. 

(There were no introductions, just lots of aggressive staring, and plenty of emotional blackmail at this meeting involving top officials and highly paid advisers. One of them sat behind me, while a government ally stared non stop for 2 hours, creating a tunnel of negative energy! At one point, at a signal from that adviser, 2 of the allies suddenly left the room with him: the 3 could be seen having a lengthy confab through the glass door...) 

That bizarre meeting was not about resolution, it was about re-victimisation. Being economical with the truth can be a cost saver for governments.  At no point did the Minister condemn the practice of symphysiotomy: to do so might mean survivors would have to be treated as victims of medical negligence. 

The government has other plans, plans that involve a so-called redress scheme.  

'Compensation', to use the Deputy Regina Doherty's word for redress, is not the same as redress, however, any more than mediation is the same as negotiation. Word do not mean what we say they mean, unless we are Alice in Wonderland. Compensation is generally based on a finding of wrongdoing, and aims to make up to the victim for the loss s/he has suffered, insofar as that can be done, while redress is a token for pain and suffering, with no admission of liability or wrongdoing. 

The Minister expressed a wish to find a quick way forward but showed no interest whatsoever in the fastest way forward of all, a negotiated settlement on foot of the legal actions being taken by our members. Based on an acknowledgement that these operations were wrongful, such a settlement would offer both truth and justice and could be hammered out in weeks, if the political will existed. 

The redress road has been chosen as the preferred solution to the 'problem' of survivors of symphysiotomy. This will take several years and fits perfectly with the 'delay until they die' strategy adopted by the Department of Health 14 years ago.  

There are, of course, different models of redress. The Hepatitis C scheme was exemplary. However, the authorities appear to have chosen the shabbiest one of all. Instead of dealing with survivors of symphysiotomy as victims of medical negligence, the government seems bent on treating with them as though they were Magdalene detainees. This is patently wrong. 

This is a formula that enables the government to deny survivors their rights. The Magdalen women are being forced to sign away their legal and constitutional rights as a condition of entering their scheme.  They are also denied the right to legal representation. This is grossly unfair and manifestly unjust. 

When the Minister talks about 'money going directly to the women', he is implying that money paid to lawyers comes out of the awards made to victims. Nothing could be further from the truth. Every redress board until now has offered access to independent lawyers and independent doctors paid for by the state over and above any awards made to victims.  

The Magdalene model has set the bar at a new low.  The government is simply not prepared to pay for independent legal representation. (Access to independent doctors is also off limits, presumably. But then, why would you need them if you are not a victim of medical negligence?) 

The Government is already set on denying as many women as possible access to justice by blocking our Bill setting aside the statute bar. Whatever scheme is in the pipeline will also likely deny survivors access to the courts, as the Magdalene scheme does.

Survivors will also be offered levels of restitution far below their entitlements. The Minister made it clear that €250,000 was completely out of the question, even for a woman who has had to have 20 operations, including a colostomy, and four colostomy reversals, a woman who has missed communions, confirmations, weddings and christenings, a woman who has all but lost her life as a result of that barbarous surgery, who would undoubtedly be awarded well over €600,000 by a judge for her injuries, yet the Minister deems them to be insufficient to merit one third of that amount. 

He also made it clear that he wanted to see money paid across a woman's lifetime: this suggests weekly instalments, as per the Magdalenes. Their financial entitlements have been shamefully downgraded: any award in excess of 50,000 is paid at a rate of €9 per week. What a cynical scheme to offer 70 and 80 year olds!   

Survivors may be advancing in age, but they are also advancing in determination. After so many years spent fighting for justice, our members will not be fobbed off with this blatant denial of their legal and constitutional rights, which is founded in the fiction that the practice of symphysiotomy was medically acceptable, a fiction that the Institute of Obstetricians and Gynaecologists and its members have nurtured since 1999. 

While government allies may witter on about the 'healing' that comes from 'telling your story' in mediation-manipulation, closure cannot come from a lie. 

 

Marie O'Connor
Chairperson Survivors of Symphysiotomy (SoS) 

Author: Bodily Harm: symphysiotomy and pubiotomy in Ireland 1944-92

AIMS Ireland Statement on " Midwifery-Led continuity models versus other models of care for childbearing women", Cochrane Review August 2013

 

 

AIMS Ireland Statement on Midwife-led continuity models versus other models of care for childbearing women, Cochrane Review (August 21, 2013) 

A research review of over 16,000 women, in different jurisdictions, was released on August 21, 2013 concluding that women who received midwifery-led care from a small group of midwives had healthier births than women receiving traditional consultant led care. Women of both low risk and high risk status participated.

 

The study, published by the Cochrane Library, showed that women receiving midwife-led care had higher satisfaction ratings of their birth experience and were less likely to require an epidural, had less instances of assisted instrumental delivery and less episiotomies than women in obstetric-led care. Babies of women receiving midwife-led care also fared better as there were less instances of birth before 37 weeks and less instances of miscarriages in the midwife-led group.

 

AIMS Ireland Statement

 

This research comes at a pivotal time for Ireland. This year has seen obstetric negligence claims that are projected to exceed €100 million and the recent High Court ruling in the Aja Teehan v HSE case, which has instigated discussion not only on the safety of home birth vs hospital practice but also on the strict HSE criteria. This discriminatory criteria prevents women from accessing services outside of traditional obstetric-led care and it does not allow for individual assessment.

 

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 effects on women, for example: higher rates of induction, amniotomy (breaking the waters), epidural analgesia and use of oxytocin. Routine means that the procedure or intervention is standard practice for every woman with no individual assessment and regardless of medical necessity or robust and reliable evidence. Some practices may not be routine for every woman, but are frequently in use despite risks. For example recent research by the ACOG has shown the use of oxytocin - for induction of labour or to 'speed up' labour - poses an independent risk to babies and increases NICU admission.

 

It is noted with great interest that this review included women of both low and high risk status and that there were no adverse outcomes. In Ireland, women are prevented from midwife-led care on very tight exclusion grounds. Many are women who would otherwise be considered low risk in other jurisdictions. Women perceived or deemed to be moderate or high risk are also excluded.

 

 

AIMS Ireland welcomes the rigorous methods, the impartiality and the independence of this Cochrane Review as it confirms what we already knew: that midwife-led continuity of care options provide safe, cost effective care for mothers and babies and have significantly fewer interventions. The other important result of this research shows that “midwife-led continuity models of care are associated with a reduction in overall fetal loss and neonatal death by approximately 16%”. This research is supported by countless previous research studies that have all had similar conclusions to the Cochrane Review. These include:

 

• In 2008 KPMG reviewed Irish maternity services and recommended the implementation of Midwife-Led care options to be rolled out nationally.

 

• The HSE’s Mid-U study found that the same birth, for the same woman, costs over €300 more for women in Consultant Led Care (CLU) as compared to a Midwife-Led Unit (MLU). Women in the MLU had less interventions, less adverse effects and higher satisfaction rates than the women in the CLU.

 

• In a 2007 study at NMH’s DOMINO scheme 5,500 bed days were saved by Community Midwifery services in NMH Holles Street (Early transfer home and DOMINO home birth). The Study also found Caesarean Section rates are significantly lower LSCS in NMH 18.92% vs LSCS in DOMINO NMH were 5.86% - however this is not reflected in the results of this Cochrane Review.

·        

• There have been countless international studies with similar results.

 

 

Obstetric-led care has a very important place in Irish maternity services and should be available for women who want or need this type of maternity care. In Ireland, 90% of women will have no access to midwife-led care even though it is deemed to be the most appropriate model of care, it is safer and it is less expensive for the majority of women. Failing to provide appropriate care options affects all women. Our two tiered obstetric base system means that: 

1. no choice is afforded to women who prefer to birth under a midwifery-led continuity of care model and
2. women who do not want or need obstetric led care are using valuable resources and are taking up time and beds from women who want or need a consultant led care model.

 

This current study shows that, once again, reliable and valid research stronlgy suggests that Ireland's obstetric-led model of care is outdated and is of very little benefit to the majority of women. While there may be an estimated 10% to 15% of women and babies who are in need of obstetric-led care, the Cochrane Review on midwife-led care shows that the large majority benefit from the Midwifery-Led care model.

 

The majority of regions in Ireland have no choice of midwife-led services. Women can access public or private obstetric led care in every region and maternity unit. The same choice should be afforded for Midwife-Led care options in the community or hospital based. Where midwife-led care is available, the HSE has placed highly restrictive criteria and/or catchment areas that exclude access to a great number of women . As in the case of Aja Teehan v HSE, the HSE have developed restrictive criteria - that is not evidence-based - to determine access to midwife-led options (home and hospital based) There is no provision for individual assessment based on current pregnancy or previous birth experience nor is informed choice given any consideration. Women who would have access to midwife-led care in the UK, the EU and even the North of Ireland are blocked from accessing midwife-led care due to the ambiguous and discriminatory HSE blanket bans.

AIMS Ireland assists in many complaints regarding blanket bans on hospital based midwife-led care options in Ireland. Women are excluded for arbitrary criteria, such as: a BMI over 30 at the  time of booking, age 40 or over at time of birth, IVF, LETZ procedure, VBAC, and transfer from MLU to CLU on suspected ‘big baby’. These women are denied hospital based midwife-led care without individual assessment or discussion and, most importantly, without their informed choice.

 

 The expert who provided evidence against Aja Teehan is also one of the policy makers who created the HSE criteria for homebirth in Ireland. He also published an article in the BMJ supporting a mother’s right to choose a non-medically indicated Caesarean Section, citing directly the right to informed choice despite the associated risks. So, why are women who choose to birth outside an obstetric care model (home or hospital based Midwife-Led care) not afforded the same right?

 

AIMS Ireland Conclusions

 

Removal of choice is never best practice. Women should be assessed on an individual basis on their current health and their current medical conditions in addition to their previous history. The HSE are not providing women with individual assessment - a fundamental principle in evidence-based care.

 

Obstetric-led care is defensive practice that has high medical intervention rates and lacks the continuity of midwife-led care. Obstetricians in Ireland use outdated routine practice such as continuous electronic fetal monitoring (CFM), artificial rupture of membranes (ARM) and Active Management of Labour - all practices that robust and reliable evidence-based research shows to increase risks of unnecessary interventions and adverse outcomes to mothers and babies.  

 

Research studies over the years, including the most recent Cochrane Review, categorically state that best practice in maternity care is to provide a midwife-led continuity of care model in every maternity unit in Ireland with appropriate inclusion criteria, individual assessment and the right to informed choice. The failure to implement policy that supports this robust research means that the HSE are putting mothers and babies at risk.

 

AIMS Ireland

 

ENDS

Three women walk into a hospital.....

Three women walk into a hospital......

 

Irene Irishwoman, Polly Polish woman, and Lisa Lithuanian woman.

 Irene the Irishwoman says "I'm a first time mum I need to see a consultant"   

 Polly the Polish woman says 'I'm a healthy first time mum - why do I need to see a doctor?”

and Lisa the Lithuanian woman says “why am I in hospital?” 

 
Who ends up with the unnecessary caesarean section?   

 

 

AIMSI have just been sent some new research called:

"International variation in caesarean section rates and maternal obesity".
V. O’ Dwyer1 , R. Layte2 , C. O’ Connor1 , N. Farah1 , M. M. Kennelly1 & M. J. Turner 1

Study Purpose:

"This study examined variations in caesarean section (CS) rates associated with a woman ’ s birthplace and differences in maternal adiposity. Women were enrolled in the 1st trimester. Maternal adiposity was assessed by body mass index (BMI) and bioelectrical impedance analysis (BIA). Irish women were compared with women born in the 14 countries who joined the European Union (EU) before 2004 (EU 14), and with those born in 12 countries who joined following enlargement (EU 12)."

"Based on place of birth, the women in this study were grouped

into Irish women, those from all the other 14 European Union
(EU) member countries before EU enlargement in 2004 (Austria,
Belgium, Denmark, Finland, France, Germany, Greece, Italy, Luxembourg, Netherlands, Spain, Sweden, Portugal, UK) and those from the EU 12 countries that joined the EU aft er 2004 (Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia, Bulgaria and Romania)."
 

 Findings:

"We found that the emergency CS rate in primigravidas was increased in Irish women compared with the rate in women born in the countries admitted to the EU since 2004. The increase in CS rate was associated with increased maternal obesity in the women born in Ireland."
 

"There was no difference in the rate of pre-eclampsia between the three groups (Table I). There was a higher rate of gestational diabetes mellitus (GDM) among Irish and EU 14 women compared with EU 12 women (Table I). Of the women with GDM, nine had a normal BMI, 13 were overweight and 40 were obese. Labour and delivery details are shown in Table III.

There was a higher rate of induction of labour among the Irish compared with the EU 12 primigravidas (p 0.05).

The emergency CS rate was higher in Irish primigravidas compared with EU primigravidas (p 0.001).

The main indication for CS was fetal distress in labour (54.0%).

There was no difference in the CS rate between multigravidas from Ireland and multigravidas from other EU countries.

There was no difference in the mean gestation at delivery, mean birth weight or number of babies born weighing 4kg between the three groups.

There was no difference in the mean age between the three groups. Irish women were more likely to smoke than other EU women. However, the CS rate was not affected by smoking status."

 

 AIMSI Thoughts:

 AIMS Ireland fully accepts that maternal obesity is a growing concern in relation to perinatal and maternal health, however, previous studies may suggest other factors which could have affected outcome.

 * First time Irish mothers are more likely to have private health insurance and attend a private obstetrician compared to non-nationals. As we have seen from several studies, attending a private obstetrician increases the risk of Caesarean Section significantly, this Irish Times article suggests as much as 74%

Caesarean rate higher in private care http://www.irishtimes.com/news/health/caesarean-rate-higher-in-private-care-1.1403506

* Non-Nationals are less likely to use epidural in labour. The epidural means that your labour is considered 'high risk' and will require different management to 'low risk' labours. This includes the use of continuous monitoring (CTG) which is shown to have high rates of false positives, increasing a women's risk of intervention and caesarean section.

"Three quarters of non-national women have a normal vaginal birth rather than a caesarean section or vacuum birth. This is far higher than the rate for Irish women of 65%. A fifth of non-nationals (23%) had induced labour, a third lower than the Irish rate of 31%. "

29% of non-nationals used epidural compared with 42% of Irish women.

Non-nationals opt for natural births http://www.irishexaminer.com/archives/2006/1025/world/non-nationals-opt-for-natural-births-16606.html

* This study was done in the Coombe, which follows an induction policy of term+ 10 days. Private Patients often have a shorter post dates period.

If you look at the results for this study Irish while Irish first time mothers had higher Caesarean rates than their EU counterparts. Interestingly, the results between Irish and Non-national women appear to be the same if they have given birth before. AIMSI feels this illustrates the point that the cultural beliefs of Irish women put them at a greater risk of Caesarean Section by going private as first time mothers.

It would be interesting to see the results of a similar study with public patients within a unit of term+14 days induction policy.