AIMSI Statement: HSE breaks contract with Midwife without implementing their own due process

AIMS Ireland is disappointed to learn that while grieving families struggle to get information from authorities about how their partners, mothers and children have died, the HSE has chosen to illegally pursue a midwife who has followed protocol and appropriate practice guidelines set out by the HSE themselves.

In the same week of the long campaigned for inquest of Dhara Kinlevan, we also learn that an independent midwife has had to seek an injunction against the HSE who have broken their contract with her without implementing their own due process. Philomena Canning has been prevented from practicing following transferring a woman to hospital, whom was discharged 10 hours later.

We note that the HSE are quick to close down the evidence based practices of independent midwives with no full inquiry yet rely on a cattle prod from the media to launch investigations into continued bad practice and questionable maternal deaths under obstetric care.

Minister Varadkar and the HSE need to take a long, hard, objective look at where their priorities are in maternity care. It is clearly not with women and babies.

"Big Baby" - Would you put money on that doc?

Induction of labour is a common but serious obstetric procedure. Induction is a big decision that can have serious effects on the health of both a woman and her baby. The research shows that for babies and many women, the best outcomes are when labour starts on its own. Induction for 'big baby' is a  common intervention in Irish maternity care practice. Recommendations of induction of labour for 'big baby' are often based on inaccurate predictive practices of foetal weight measurements; either clinically by a care provider or by ultrasound. There is also significant research which suggests that a care providers beliefs has a direct effect on the way a labour is managed and birth outcomes. In other words, if an obstetrician believes a baby is big, and believes that a 'big baby' is prescriptive of complications, the woman's labour is managed more medically, increasing risks of interventions and surgery, and sometimes contrary to a woman's own beliefs or medical indication.

"I was induced at 39+6 because my baby was measuring 7lbs at my 36 week appointment and they were really worried I would have a hard time as the baby was too big. It scared me and I thought the induction would be the best option. I had a really tough induction cause my body just wasn't ready. Gel, broke waters, and needed a drip. My daughter got into distress and I just narrowly escaped a section but had episiotomy, which then tore as well, and forceps. She was born at 40 weeks and I was really horrified when she was weighed and I was told she was only 7lb 8oz. I felt so cheated. I was told I must have had a lot of waters. My next baby was a homebirth and there was no discussion of weight and it was lovely to not have that fear hanging over me. I didn't doubt myself and had a gorgeous waterbirth at home at 41weeks giving birth all on my own to a healthy 8lb 4oz son."



Research has found that care providers and ultrasound predictions are inaccurate in estimating the size of a baby - predictions of a 'big baby' are wrong HALF of the time. (1)


There is also research to suggest that when women estimated their baby's weight they were more accurate than clinical estimates by care providers or ultrasound measurements. (2)

Despite this, many women report to AIMSI that care providers insist on their recommendations of induction based on clinical predictions which are shown to be inaccurate.

"I was told from about 35 weeks that my baby was measuring big and would be a 'good 10lber'. This was my first baby but I am tall and my mother had us all at home - we were all 9lbs odd - without any problems. My obs wanted to induce me from 39 weeks but I didn't think the baby was that big and I really felt I could do it...or at least try! He wasn't happy when I declined induction and told me that I was risking permanent damage. I gave birth to my son at 40+3 without induction and had a fantastic birth with a minimal tear. He weighed 8lb 4oz"

Induction of Labour is shown to increase the risk of needing a Caesarean Section, increases the risk that the baby will be admitted to NICU, increases risk of forceps or vacuum birth, and means that the woman's labour is now considered 'high risk' which changes how the labour and birth are managed. Recent research has shown that synthetic oxytocin, like Syntocinon or Pitocin, often used in induced labours, is an independent risk factor for distress in babies.

In fact, research has shown that induction increases the risk of Caesarean Section 2 fold in first time mothers. (3) ACOG 2009

Ireland's 'self-induced' strain on services

Research in the USA has shown that an uncomplicated caesarean section costs 68% more than an uncomplicated vaginal birth (Childbirth Connection 2011). Women with uncomplicated vaginal birth have shorter hospital stays, less instances of re-admission, and few infections. (3)

Over-reliance of medical interventions is a key component of strain on under-resourced maternity services in obstetric led maternity units in Ireland. It is vital that we reduce the medicalisation of the primary experience with first time mothers in order to reduce maternal morbidity rates and strain on services. Reduction in induction of labour for non-medical reasons is a start - as well as adopting appropriate care options for women such as midwife led care.

 The HSE's Mid-U report found that midwife led care is the most appropriate care option for the majority of women, uses less interventions - which in turn reduces caesarean section, is more cost effective than obstetric led care, and has high satisfaction ratings from women who used it.(5)

Would YOUR obstetrician put money on it?

Given what we know, AIMSI recommends a new tactic.

What if women asked the OB for €1000 for every ounce under the estimated birth weight the baby is born at?

Would YOUR obstetrician put money on it?


Evidence:

What is induction?

An induction of labour is when a doctor or midwife uses various methods to artificially initiate or accelerate labour such as:

• a membrane stretch and sweep
• a pessary or gel
• artificial rupture of membranes (ARM)
• a hormone drip

The Evidence Can Help You Make A Decision

“The National Institute for Health and Care Excellence (NICE) in the UK recommends that induction of labour has a large impact on the health of women and their babies, and so needs to be clearly clinically justified. “

If you are considering an induction of labour or have been offered an induction of labour without medical necessity, it is worth looking at the benefits & risks.

Induction of Labour – Benefits

• You can arrange to be home for a specific event
• Helpful in organising care for other children/work/help when you are home

Induction of Labour – Risks

• higher rates of Caesarean section
• increased risk of your baby being admitted to NICU (neonatal intensive care unit
• increased risk of forceps or vacuum (assisted delivery)
• contractions may be stronger than a spontaneous labour
•  your labour is no longer considered ‘low risk’ – less choices in where and how you birth, restricted birth positions, continuous monitoring CTG, time limits for which to labour in.

Risks specific to your baby

Recent research has shown that the use of oxytocin in labour is an independent risk factor for distress in babies. This means that the baby does not tolerate labour as well when oxytocin is used. This can have implications on the way you give birth and on your baby’s condition after being born.
Other research shows that the use of oxytocin increases your chances of asking for an epidural. In a Cochrane Review, both oxytocin and epidural are discussed as having implications on breastfeeding your baby. You can read more about this here


1) Evidence Based Birth - Big Baby

There is tons of research on the inaccuracy of foetal weight prediction but this article from Evidence Based Birth is fantastic as it looks at all the relevant research, all of high quality, and clearly illustrates the findings all in one article.

On the article based on 'big baby' and the prevalence of induction or caesarean based on weight estimate prediction Rebecca looks at the most relevant quality evidence on 'big baby' and concludes:

Ultrasounds and care providers are equally inaccurate at predicting whether or not a baby will be big. If an ultrasound or a care provider predicts a big baby, they will be wrong half the time.

 If a care provider thinks that you are going to have a big baby, this thought is more harmful than the actual big baby itself

• The suspicion of a big baby leads many care providers to manage a woman’s care in a way that triples her risk of C-section and quadruples the risk of complications.
• Because of this “suspicion problem,” ultrasounds to estimate a baby’s weight probably do more harm than good in most women.

 Induction for big baby does not lower the risk of shoulder dystocia and may increase the risk of C-section, especially in first-time moms

A policy of elective C-sections for big babies likely does more harm than good for most women

• It would take nearly 3,700 elective C-sections to prevent one permanent case of nerve injury in babies who are suspected of weighing more than 9 pounds 15 ounces
• For every 3 permanent nerve injuries that are prevented, there will be 1 maternal death due to the elective C-sections

Full article here: http://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/

2) Women who had given birth before were able to predict their baby's birth weight more accurately than health care providers and ultrasound estimates. http://www.ncbi.nlm.nih.gov/pubmed/20795447

3) Non-Medically Indicated Induction and Augmentation of Labor: http://onlinelibrary.wiley.com/doi/10.1111/1552-6909.12499/full#.VA4GvDPcDGs.twitter

4) Quotes are from women contacting AIMS Ireland, used with permission, anonymously.

5) MID-U study: http://www.hse.ie/eng/services/publications/Hospitals/midwifery%20north%20east.pdf

 

CTG: Common routine intervention in Irish maternity units despite 99% false positive rate

A strong, evidence-based and referenced piece of research which lays out the case that "electronic fetal monitoring is based on 19th-century childbirth myths, a virtually nonexistent scientific foundation, and has a false positive rate exceeding 99%. It has not affected the incidence of cerebral palsy. Electronic fetal monitoring has, however, increased the caesarian section rate, with the expected increase in mortality and morbidity risks to mothers and babies alike".

CTG is one of the most common routine interventions used in obstetric led Irish maternity hospitals with women of all risk groups. It is not evidence based practice and it's been shown to do more harm than good.

Routine use of CTG and admission trace is not supported by evidence nor is it recommended practice in Irish National Clinical Guidelines. Despite this, the overwhelming majority of obstetric led units in Ireland routinely use this intervention. Its use is so normalised in Ireland many women, HCPs, and indeed the Courts, do not consider routine use of CTG and Admission trace an 'intervention' and base standards of care and practice on CTG readings despite a 99% false positive rate.

Some Irish obstetric units have taken this a step further, when women make an informed refusal on admission trace or CTG an intervention 'bartering system' is put in place - telling women they can only refuse the CTG if they have an ARM (also not evidence based or best practice).

Women giving birth in Ireland and their babies deserve evidence based care.

Healthy Births for Healthy Mums & Babies.

#demandevidencebasedcare #informedchoice #informedrefusal

Read the article here:

Cerebral Palsy Litigation

Change Course or Abandon Ship

1. Thomas P. Sartwelle, BBA, LLB1
2. James C. Johnston, MD, JD2⇑

http://jcn.sagepub.com/content/early/2014/09/01/0883073814543306

The Constitution is not the only legal enemy of Irish Women

The Constitution is not the only legal enemy of Irish Women

by Breda Kerans, AIMS Ireland

It has been said many times that this is no country for pregnant women, and it is true. Most of us are very familiar with the role that the 8th Amendment to the Constitution plays in removing rights from pregnant women in terms of abortion rights. Some people are familiar with how this same amendment removes a woman’s right to informed consent and refusal to medical procedures during pregnancy and birth. But I would imagine that most people outside the dry and dusty corridors of the courts would be familiar with the role a man called Mr. Bolam plays in the removal of pregnant women’s rights.

In 1957 Mr. Bolam was a patient in Friern Hospital. Friern was a mental health institution in the UK. He underwent electro convulsive therapy, to which he had consented. However he was not given any muscle relaxant & was not restrained. As a result he sustained serious injuries. He sued on the grounds that a. he was not given relaxants, b. he was not restrained and c. he was not informed of the possible risks.

Mr Bolam lost his case. Mr. McNair, judge, took on board the evidence of expert witnesses, which stated that some medical opinion was opposed to using relaxants or restraints. They also stated that many did not warn patients of small risks, unless asked.

The judge summed up the point of law to the jury as follows: "….he is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. I do not think there is much difference in sense. It is just a different way of expressing the same thought. Putting it the other way round, a man is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion who would take a contrary view. At the same time, that does not mean that a medical man can obstinately and pig-headedly carry on with some old technique if it has been proved to be contrary to what is really substantially the whole of informed medical opinion."[1]

The jury delivered a verdict in favour of the hospital. That passage is quoted very frequently, and has served as the basic rule for professional negligence over the last fifty years. So with that judgment, the Bolom principle entered both legal and medical practice.

This is the principle which was can see running through many judgments against women who have questioned the medical procedures carried out on them in Irish maternity hospitals. The Bolom principle has been criticized by many, in that it is heavily weighted in favour of the professional and not in favour of the patient. In effect it is merely necessary for a medical professional to find a number of expert witnesses to attest that the practice carried out was one they themselves would do. It is irrelevant if such practice is not recogonised best practice. It was seen very clearly in the case taken by Ciara Hamilton, Co Kerry who sued the HSE over her care at Kerry General Hospital, Tralee, when she was having her second baby in 2011. The midwife caring for her carried out Artificial rupture of the membranes on her, causing cord prolapse and a subsequent emergency C-section became necessary. Following Judge Ryan’s, the Irish Examiner reported: Mr Justice Ryan found that it was reasonable for the midwife involved to seek reassurance with an artificial rupture of the membranes. The midwife was the person entitled, authorised and qualified to make the decision, the judge said. “In the circumstances, I do not consider that the midwife was negligent.” He said he accepted the evidence of the midwife supported by two expert witnesses that the treatment provided by the midwife was not deserving of criticism or condemnation and that the prolapse of the cord was a rare but known complication of the procedure. “The midwife responded in a competent manner, as did the hospital,” Mr Justice Ryan ruled. He added that the management of Ms Hamilton accorded with a practice supported by a responsible body of expert opinion. [2] This is the Bolom principle at work. It would be a similar principle at work in a court ordered Caesarean or other procedure. The judge would take into account that the medical procedure recommended was supported by a responsible body of expert opinion, not that it was grounded in best practice. And there can be a very big difference between what a few expert witnesses agree is reasonable practice and what is defined as best practice by internationally respected bodies such as NICE or the WHO. These guidelines are based on huge bodies of research. Don’t all women deserve to be treated with the best evidenced based care?

For that to happen in Ireland then two things must happen. Firstly the 8th amendment to the constitution must be removed. Secondly we must demand that our courts move away from the Bolom principle, which as Ruth Fletcher of Queens University of London notes “continues to adopt a more professional oriented, rather than a patient oriented, standard of care” [3]

These issues are at the very heart of why pregnant women in Ireland have little or no rights to informed consent or refusal in any meaningful way. Until both this issues are tackled we will continue to see woman after woman abused in our hospitals and in our courts. [1]http://en.m.wikipedia.org/wiki/Bolam_v_Friern_Hospital_Management_Committee
[2]http://www.irishexaminer.com/ireland/mother-whosued-over-care-at-kerry-general-hospitalfaces-massive-legal-bill-277461.html
[3]http://humanrights.ie/constitution-of-ireland/contestin-cruel-treatment-ruth-fletcher/

Think the 8th Amendment is only an abortion issue? Please read.

What does maternity rights have to do with the 8th Amendment?

AIMSI have been asked this many times over the last year. Further discussion has been ignited this week, following events in which an abortion was denied to a suicidal teen who became pregnant following a rape. Many consider repealing the 8th Amendment only in the context of reproductive health and abortion. But the 8th Amendment is a piece of legislation which directly affects every pregnant women, over-lapping on choices for contraception, abortion, and in continued pregnancy, labour, and birth.

With the 8th Amendment in place, pregnant women do not have the same rights as non-pregnant women. Pregnancy immediately reducing a woman's right to make informed decisions on her care and decisions which will affect her and her baby in pregnancy, labour, and birth.

AIMS Ireland strongly campaigns for recognition of informed choice in maternity care. The issue of informed consent/informed refusal and coercion (threats of legal/child protection orders) to obtain consent are prevalent in reporting to AIMSI by women accessing services and health care providers who offer witness accounts of consent violations. Many of the interventions performed without consent have implications for the health and welfare of the birthing woman and or baby.

The HSE's published National Consent Policy restricts informed consent and informed refusal of treatment for pregnant women. It is important that all women are aware of this Consent Policy and the legal ramifications of the 8th Amendment (Article 40.3.3 of the Irish Constitution) on their right to informed decision making in their maternity care. See as follows:

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."

AIMS Ireland firmly believes that in order to offer full support to women and campaign for improvements in maternity services, we must recognise all women in their right to autonomy of choice. The 8th Amendment of the Constitution, Article 40.3.3, affects all pregnant women, their birth choices, their right to accept or refuse a test or treatment, their right to individual assessment, their right to be pregnant or not.

At the our 2013 AGM, the committee asked its members to ratify AIMS Ireland’s stance to support all women in their right to autonomy of choice and to call for the repeal of the 8th Amendment to ensure women’s human rights in childbirth in Ireland. The motion was unanimously carried by AIMS Ireland members.

We hope that the discussion around the 8th Amendment is broadened to include the rights of women in continued pregnancy, labour, and birth and practices which violate these rights within Irish maternity services.

AIMSI Statement on Irish Independent article 'Pregnant woman refused abortion gives birth by caesarean' August 15, 2014

AIMSI made this statement in relation to this article by Dearbhail McDonald posted online late Friday August 15th, 2014 in the Irish Independent:

http://www.independent.ie/irish-news/news/pregnant-woman-refused-abortion-gives-birth-by-caesarean-30512038.html

In May 2013, AIMSI made a submission to the Joint Oireachtas Committee on the Heads of Bill that would eventually become the Protection of Life During Pregnancy Act (2013). One of the statements made in this submission was that “as long as Article 40.3.3 remains as an impervious legal barrier to a woman’s right to a termination...the risk to a mother’s life will precariously hang in the balance. The stark reality for a pregnant woman in Ireland is that Article 40.3.3 hangs like a spectre over her care as there are myriad instances where this ambiguously worded and legally flawed amendment overrides a pregnant woman’s human rights.”

This chilling case is a bleak reminder of how this legislation is profoundly flawed. Rather than doing anything to help mitigate the stigma attached to both mental health difficulties and abortion, the legislation continues to distance the medical profession and the government from the woman at the heart of the matter and it further perpetuates a negative stereotype. The discrimination of women who find themselves in this emotionally devastating position – of carrying an unintended pregnancy and of seeing no way out of this difficulty - only serves to isolate women at an extremely vulnerable time and to highlight power differences between a woman and so called ‘experts’. While there is very little detail reported on this story, there is enough to tell us that a woman’s right to bodily autonomy, consent and dignity continues to be eroded in the name of legislation that is supposed to protect her life. The fact that current legislation was used to deny a woman her legal right to an abortion, due to risk of self destruction, and then used to force her to undergo major abdominal surgery (presumably against her will) is unconscionable in a civilised society. 

The main thrust of the argument for supporting the rights of women across the maternity services, whether they are choosing a home birth, a cesarean section, an intervention-free birth or an abortion is summed up succinctly by Anand Grover, UN Special Rapporteur on the Right to Health. At a UN General Assembly in August 2011, Mr Grover presented a report, in accordance with the Human Rights Council entitled: Right of everyone to the enjoyment of the highest attainable standard of physical and mental health. This report is seen as a milestone in the area of rights to reproductive and sexual health as it plainly articulates the reasons why legal restrictions in this area constitute a violation of a woman’s right to health and an “unjustifiable form of State-sanctioned coercion” (UN, 2011, p. 5). The report is disparaging of the human rights violations that are perpetuated in the few remaining countries, such as Ireland, where abortion is completely criminalised or where it is only allowed to save the life of a woman. Anand Grover said at the UN General Assembly meeting, when presenting this report: 

“Realization of the right to health requires the removal of barriers that interfere with individual decision-making on health-related issues and with access to health services, education and information, in particular on health conditions that only affect women and girls. In cases where a barrier is created by a criminal law or other legal restriction, it is the obligation of the State to remove it. The removal of such laws and legal restrictions is not subject to resource constraints and can thus not be seen as requiring only progressive realization. Barriers arising from criminal laws and other laws and policies affecting sexual and reproductive health must therefore be immediately removed in order to ensure full enjoyment of the right to health.” (UN, 2011, p. 2)

AIMSI fully supports the reproductive rights and choices of ALL women and we will continue to advocate and campaign for these rights. 

Reference:

United Nations Human Rights Council (UNHRC), 66th Session. Interim report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Anand Grover (A/66/254). 3 August 2011. http://daccess-dds-ny.un.org/doc/UNDOC/GEN/N11/443/58/PDF/N1144358.pdf?OpenElement

For more information and commentary on this case, please see the following:

Human Rights in Ireland blog post 16/08/2014 - http://humanrights.ie/constitution-of-ireland/suicide-and-the-protection-of-life-in-pregnancy-act-2013/

Sunday Times article 17/08/2014 - http://www.thesundaytimes.co.uk/sto/homeV2/article1447800.ece

New Statesman article 17/08/2014 - http://www.newstatesman.com/politics/2014/08/violation-after-violation-why-did-ireland-force-woman-hunger-strike-bear-her

The Guardian 17/08/2014 - http://www.theguardian.com/world/2014/aug/17/ireland-woman-forced-birth-denied-abortion

Choice Ireland 17/08/2014 - http://choiceireland.org/content/choice-ireland-call-demonstration-protest-treatment-suicidal-pregnant-woman-who-was-refused-

Doctors for Choice Ireland blog post 17/08/2014 - www.doctorsforchoiceireland.com

Is this 2014 or the dark ages in Ireland? Guest Blog by Noreen Barron

Is this 2014 or the dark ages in Ireland?

Guest Blog post by AIMS Ireland member, Noreen Barron

 

The recent high court ruling by Judge Sean Ryan has made a mockery of a woman's human and legal right to informed consent and refusal. Ryan's judgement also sets a very dangerous and frightening precedent for any woman giving birth in Ireland. In a nutshell, pregnant women in Ireland no longer have any legal or human rights to bodily autonomy.

 

Essentially what this means is that the bodies of pregnant women belong to the state and it is the state who will decide what procedures will be performed on a pregnant woman. A woman's consent, whether informed or not, is negligible and not needed. This is demonstrated by Ryan stating that: “The midwife was the person entitled, authorised and qualified to make the decision”. Read that statement again and again until the reality of it sinks in. It means that women are not the people who are entitled, authorised or qualified to make the decision about whether or not a medical procedure is performed on them. His ruling is morally and ethically reprehensible.

 

I don’t believe that the majority of women realise the gravity of Sean Ryan’s ruling, because if they did, there would be a major outcry. At least I hope there would be. Maybe that outcry will only happen when enough women suffer the effects of the fact that they have absolutely no legal say anymore about what happens to them during pregnancy or birth when issues arise. They will be “performed on” whether they like it or not. Maybe they'll even be strapped down, or dragged by the police to the hospital ... who knows where this precedent will lead?

 

We have seen evidence of what other countries are capable of when it comes to pregnant women, Adelir Carmen Lemos de Goés, from Brazil, was forced to have a caesarean section against her will for example. And right here in Ireland, Waterford Regional Hospital brought a woman to the high court in 2013 in order to force her to have a caesarean. She decided to have the procedure herself before a judgement could be made, under extreme distress I am sure, but rest assured of the fact that a hospital prepared to go to those lengths is not a good sign for any pregnant woman. Women should be absolutely outraged at this recent ruling.

 

Along with this appalling ruling, Ryan has also sent out a clear message that if any woman dare have the audacity to stand up for themselves and sue the state, they will have the state’s costs awarded against them. Now, is it just me, or does that seem like a bullying tactic? Might that decision have been made in order to deter other women from coming forward because they don’t want to be saddled with massive legal bills? Is it not intimidatory? Does that decision have anything to do with the fact that we are in a recession because we bailed out the private debt of banks and there's not much money left in the coffers for women who have been injured (or have died), both physically and psychologically, as a direct result of the state's actions or inactions?

 

What is interesting about legal precedents being set, is that, on any particular day, and with any particular prejudices, a single judge can decide on a legal matter, set a precedent, and the entire legal system will follow suit from thereon. No judge undergoes any psychological evaluation to make sure that they are up to the very important job of settling legal matters and setting legal precedents. Perhaps it is a good idea that this be changed? After all, the law is a very serious matter and it affects each and every one of us, which is why we need to care very much about the people who make and implement the law.