Ireland's Maternal Death Rate - Depends on who you are asking.

In Today's Irish Times, John Fitzgerald shares a piece on CSO statistics for Ireland called, ‘Vital Statistics’ sheds light on inequalities in life expectancy”. The articles states, "While the death rate also fell in the Republic, it was not till the late 1970s that it reached the UK level. Today, in spite of recent tragedies that have received significant media attention, the maternal death rate is very low, at about three per 100,000 births, marginally lower than that in Northern Ireland, England and Wales."

Once again AIMS Ireland need to highlight that CSO figures for maternal death of 3 per 100,000 are inaccurate and under-reported. More accurate figures, using a more appropriate, broader classification system on par with other EU countries, show a very different story.

 One of these stats is not like the other

The recent United Nations Population Fund (UNFPA) report put Ireland's maternal death rate at 9 per 100,000. (Irish Independent)

 

The Maternal Death Enquiry (MDE) Ireland has reported a rate of 8 per 100,000 in their recent report with specific mention to issues in the classification and collection of data, with general hospitals and the Irish coroner system both cited as areas which lead to under-reporting. As described here in the most recent MDE Ireland report (2009-2011):

 

"In Ireland, the Medical Death Notification Form completed by a medical practitioner contains

a question “If the deceased was female, was she known to have been pregnant at the time of

death, or within the previous 42 days?” (Answer “yes” or “no” in all cases)13. The Coroner’s
certificate does not contain this question.

 

In the case of Death Notification Forms, a review of MDE cases to date has shown that the
question on pregnancy status has been not being correctly completed in some cases. Review
of death certificates issued by the GRO office, following receipt of a Coroner’s certificate,dentified information on current or recent pregnancy was absent in many cases of indirect
maternal deaths. These issues clearly impact on ascertainment of reliable maternal mortality
data."

 

From MDE Ireland's 2009-2011 report regarding CSO figures:

 

"Comparative available data for the years 2009 and 2010 showed that all but one maternal

direct death was identified by the CSO. However, none of the thirteen indirect or six

coincidental maternal deaths were identified by the CSO."

Despite these noted inaccuracies, flaws and numerous reports of Ireland's true maternal death rate, it is the CSO figures which are regularly quoted by Government and Political representatives. We've all heard the 'Ireland is the safest place to have a baby' speeches, however, what most of us don't realise is that that with a maternal death rate of 8 per 100,000 we are on par with many of our EU counterparts and actually ranks worse than others. For example:

France 8 per 100,000
UK 10 per 100,000
Germany 7 per 100,000
Belgium 5 per 100,000

AIMS Ireland's position:

 

Calculations for a Nation's Maternal Death rate is an international standard for measuring safety in maternal health services, however, AIMS Ireland feel this statistic alone does not provide full insight into safety of care provided to mothers and babies. As a developed Western nation, with access to ante-natal care, nutrition, hygiene, and technology, it is more appropriate to measure safety not only in terms of death but also the 'near misses' and serious health implications to mothers and babies as a result of a pregnancy/birth (morbidity) - both physical and psychological.

 

From the Irish Times, 13/1/2015 regarding CSO figures:

  http://www.irishtimes.com/business/economy/vital-statistics-sheds-light-on-inequalities-in-life-expectancy-1.2063185

 

 

UNFPA rates - Irish Independent 19/11/2014

 

Ireland scores poorly for rates of maternal death: http://www.independent.ie/irish-news/health/ireland-scores-poorly-for-rates-of-maternal-death-30756530.html

 

Maternal Death Enquiry Ireland (MDE Ireland) 2009-2011 report:

http://www.ucc.ie/en/media/research/maternaldeathenquiryireland/MDEReportForTheTriennium2009-2011.pdf

A Year in Review of Irish Maternity Services - 2014 AIMS Ireland (video) #MadAsHell #AIMSIreland

AIMS Ireland look back over 2014 with this short video. Thank you to everyone who marched with us, shared our information, and supported us over the year.  We would especially like to thank our members and those who made donations to AIMS Ireland – in time as volunteers and financially – AIMS Ireland could not exist without your help!

To view click here: 2014 AIMS Ireland

AIMSI statement on the removal of somatic support to a woman with an unviable foetus of 18 weeks gestation

AIMSI welcomes the High Court Judgement of the 26th December 2014 that somatic support be switched off for a woman who was declared clinically dead on December 3rd 2014. Our sympathies go out to her family and we hope that the family will now be able to grieve the loss of their loved one in dignity and peace.

AIMSI were disappointed that this case arose in the first place. It is a well known medical fact that a foetus of 15 weeks is not viable and we fail to see what possible reasons there could have been for medics to invoke the 8th amendment and put the woman's family, especially her children through such distress. The natural course of events is that when a woman dies in such circumstances, the foetus she is carrying dies with her.

This case highlights, the control over women's bodies in maternity care that the State presumes itself to have. Even though this woman was clinically dead, the State still presumed to have control over her womb, and medical professionals thought it appropriate to seek clarification on whether they should continue to use her body to incubate a 15 week old foetus. The Constitution is supposed to maintain the right to bodily autonomy in life and one hopes also in death. This does not appear to have happened in this case. AIMSI sincerely hopes that no other family will ever be subject to such distress in the Irish Maternity System.

Whilst this was a particularly macabre episode of an invocation of the 8th Amendment, AIMSI notes that the 8th Amendment is repeatedly used in the context of maternity rights to deny women the right to bodily autonomy in terms of decision making in pregnancy, in labour in birth and in the postpartum period. Women have reported being  forced into caesarean births, forced into invasive procedures during labour, threatened with social services and in some cases threatened with the Gardai and mental health services for trying to assert their right to bodily autonomy. The 8th Amendment is also repeatedly used to justify a swath of clinical practises during labour and birth which the international research based evidence does not support. Finally, in contrast to maternity guidelines and policies in other countries, where women are given the final choice over their care and that of their baby, the 8th Amendment in Ireland is used to suppress women's choice and give ultimate control over a woman's body when pregnant to the State.

AIMSI continues to call for a repeal of the 8th Amendment to ensure that women and their families are able to make informed choices about the care that they receive during pregnancy, labour and birth in Ireland.

December 31st 2014

FAO: HSE - A helpful synopsis of well respected Clinical Guidelines on the use of Synthetic Oxytocin

 

AIMS Ireland are very surprised to see the HSE state that there are no national or international evidence based guidelines on the use of synthetic oxytocin in labour.

"A spokesperson for the HSE, which jointly operates the National Clinical Programme for Obstetrics and Gynaecology with the RCPI, told MI: “At present, we are not aware of any national or international guidelines to guide practice on oxytocin augmentation in labour. The programme supports the development and use of local guidelines at each maternity unit, but the programme hopes to build a national consensus on a standardised guideline over the next year.” Medical Independent - December 18, 2014

The comment comes from an article on surveys taken by the States Claims Agency to the 19 Irish public maternity hospitals on the use of synthetic oxytocin in labour following observations that there is a frequency in obstetric claims when the drug is used, suggesting synthetic oxytocin to be a contributing factor.

Syntocinon/ Pitocin /Oxytocin is a synthetic version of a hormone present in labour which stimulates contractions. Synthetic Oxytocin is routinely used in Irish maternity units to synthetically start (induce) or speed up labour. It is a common component of Active Management of Labour, in which a woman's labour is managed by health care providers, using intervention and drugs, to 'speed up' process. Synthetic Oxytocin is linked to an increase of adverse effects for women. A recent study has also suggested that synthetic oxytocin is an independent risk factor for adverse effects in full term newborns. With some Irish units reporting use of synthetic oxytocin in nearly half of first time mothers during labour, AIMS Ireland are deeply concerned that our national policy makers within the Health Service Executive appear to be unaware of clinical practice guidelines on its use.


In August 2013, AIMS Ireland reviewed the evidence and international guidelines for induction of labour and the use of synthetic oxytocin for the article "Induction of Labour - Is it Right for You?" as part of our 42 Weeks Campaign.

AIMS Ireland: Induction of Labour - Is it Right for You?

"A hormone drip containing synthetic oxytocin (Syntocinon®) should only be offered if the membrane sweep or prostaglandins have not been effective in starting labour. It is also offered to women who may have been induced by membrane sweep or prostaglandins but whose contractions and cervical dilation have slowed completely or appear to have stopped. It is not recommended for use until at least 6 hours after receiving prostaglandin gel or 12 hours after removal of the prostaglandin pessary. Whether to consent to induction of labour, or not, is a choice that at least 1 out of 3 women will have to make in her maternity care in Ireland."http://aimsireland.ie/induction-of-labour-is-it-right-for-you/


AIMS Ireland felt it would be helpful to provide a synopsis of these practice guidelines from well respected sources.

International Guidelines on Induction and the Use of Synthetic Oxytocin


“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."

NICE Guidance Recommendations 2014: Intrapartum Care
https://www.nice.org.uk/guidance/cg190/chapter/1-recommendations

Key points: quoted directly from NICE

1.12.1 Do not offer or advise clinical intervention if labour is progressing normally and the woman and baby are well. [2007]

1.12.2 In all stages of labour, women who have left the normal care pathway because of the development of complications can return to it if/when the complication is resolved. [2007]

 

1.12.10 Do not routinely offer the package known as active management of labour (one‑to‑one continuous support; strict definition of established labour; early routine amniotomy; routine 2‑hourly vaginal examination; oxytocin if labour becomes slow). [2007]

1.12.12 Do not use combined early amniotomy with use of oxytocin routinely. [2007]

1.12.13 If delay in the established first stage is suspected, take the following into account:

• parity
• cervical dilatation and rate of change
• uterine contractions
• station and position of presenting part
• the woman's emotional state
• referral to the appropriate healthcare professional.
  
  Offer the woman support, hydration, and appropriate and effective pain relief. [2007]

 

1.12.14 If delay in the established first stage is suspected, assess all aspects of progress in labour when diagnosing delay, including:

• cervical dilatation of less than 2 cm in 4 hours for first labours
• cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours
• descent and rotation of the baby's head
• changes in the strength, duration and frequency of uterine contractions. [2007

 

 

1.12.22 If oxytocin is used, ensure that the time between increments of the dose is no more frequent than every 30 minutes. Increase oxytocin until there are 4–5 contractions in 10 minutes. (See also recommendation 1.10.3.) [2007]

1.10.35 If there are any concerns about the baby's wellbeing, think about the possible underlying causes and start one or more of the following conservative measures based on an assessment of the most likely cause(s):

• encourage the woman to mobilise or adopt a left‑lateral position, and in particular to avoid being supine
• offer oral or intravenous fluids
• offer paracetamol if the woman has a raised temperature
• reduce contraction frequency by:
  
  • stopping oxytocin if it is being used (the consultant obstetrician should decide whether and when to restart oxytocin) and/or
  • offering a tocolytic drug (a suggested regimen is subcutaneous terbutaline 0.25 mg). [new 2014]

WHO: recommendations for induction of labour
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241501156/en/

Key Points: Quoted directly fromWHO
* Induction of labour should be performed only when there is a clear medical indication for it and the expected benefits outweigh its potential harms.

* In applying the recommendations, consideration must be given to the actual condition, wishes and preferences of each woman, with emphasis being placed on cervical status, the specific method of induction of labour and associated conditions such as parity and rupture of membranes.           * Induction of labour should be performed with caution since the procedure carries the risk of  uterine hyperstimulation and rupture and fetal distress.

WHO evidence:

Evidence related to the use of intravenous oxytocin for induction of labour at term was available from a Cochrane systematic review (15). Compared with placebo or expectant management, the use of oxytocin alone was associated with fewer vaginal births not achieved within 24 hours of induction of labour (three trials, 399 participants, RR 0.16, 95% CI 0.1–0.25), fewer admissions to a neonatal intensive care unit (seven trials, 4387 participants, RR 0.79, 95% CI 0.68–0.92), and increased risk of caesarean section (24 trials, 6620 participants, RR 1.17, 95% CI 1.01–1.35) (EB Table 2.1.1).

The use of intravenous oxytocin alone has also been compared with prostaglandins (EB Tables 2.1.2, 2.1.3, 2.1.4). Overall, the use of prostaglandins was associated with a reduced risk of vaginal birth not achieved within 24 hours and fewer caesarean births.

ACOG Induction Guidelines revised in 2013

From ACOG press release: "A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery," notes Dr. Ramin. Although rare, there are potential complications with some methods of labor induction. "These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus."

Guideline on Induction: http://www.acog.org/About-ACOG/ACOG-Departments/Deliveries-Before-39-Weeks/ACOG-Clinical-Guidelines

2013 ACOG: Study Finds Adverse Effects of Pitocin (Synthetic Oxytocin) in Newborns:

“Induction and augmentation of labor with the hormone oxytocin may not be as safe for full-term newborns as previously believed, according to research presented today at the Annual Clinical Meeting of The American College of Obstetricians and Gynecologists. Researchers say this is the first study of its kind to present data on the adverse effects of Pitocin use on newborns...As a community of practitioners, we know the adverse effects of Pitocin from the maternal side,” Dr. Tsimis said, “but much less so from the neonatal side. These results suggest that Pitocin use is associated with adverse effects on neonatal outcomes. It underscores the importance of using valid medical indications when Pitocin is used.”

http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Study-Finds-Adverse-Effects-of-Pitocin-in-Newborns



ACOG: Oxytocin for Induction PDF:

 

"The side effects of oxytocin use are principally dose related; uterine tachysystole and Category II or III FHR tracings are the most common side effects. Uterine tachysystole may result in abruptio placentae or uterine rupture. Uterine rupture secondary to oxytocin use is rare even in parous women"

* Uterine Tachysystole is when a woman's uterus is over-stimulated resulting in more than the normal pattern of contractions in a period of 30 minutes.

"Low- or high-dose oxytocin regimens are appropriate for women in whom induction of labor is indicated"

 

 

"If uterine tachysystole with Category III FHR tracings occur, prompt evaluation is required and intravenous infusion of oxytocin should be decreased or discontinued correct the pattern (32). Additional measures may include turning the woman on her side and administering oxygen or more intravenous fluid. If uterine tachysystole persists, use of terbutaline or other tocolytics may be considered. Hypotension may occur following a rapid intravenous injection of oxytocin; therefore,

is imperative that a dilute oxytocin infusion be used even in the immediate puerperium."

 

"The use of a checklist is highly recommended when administering oxytocin. Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that

require its discontinuation. The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institution’s protocol."
 

 So, with all this information available to consumers at just the click of a mouse how is it that the National Health Service Executive, with governance to make policies affecting the care of women and babies in our maternity services, are not? 








 

Full Article: State Claims Agency surveys maternity services on oxytocin http://www.medicalindependent.ie/57516/state_claims_agency_surveys_maternity_services_on_oxytocin

Midwife-Led Birth is Safe Birth

Midwife-Led Birth is Safe Birth. At Home, Hospital or Freestanding.
Safe for women and babies. Better outcomes for women and babies
Cost effective for health services.


Read the latest evidence:...

NICE recommendations re home births in England and Wales, Intrapartum Care, May 2014: http://www.nice.org.uk/guidance/indevelopment/GID-CGWAVER109

Low-risk women (women without medical conditions or other factors that put them at increased risk) who have given birth before should be advised to plan to give birth at home or at a midwifery-led unit (freestanding or alongside).

_____________________________

Findings from the National Perinatal Epidemiology Unit, Oxford, Birthplace Cohort Study, 2011
https://www.npeu.ox.ac.uk/birthplace/results

For women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother

_____________________________

HSE Mid-U Report: http://www.hse.ie/eng/services/news/newsarchive/200920082007Archive/dec09/MidUstudy.html

The 'MidU' ('Midwifery Unit') study showed that midwifery-led care, as practised in these units, is as safe as consultant-led care but uses less intervention in pregnancy and childbirth.

Women's satisfaction with the facilities was apparent in the study and 85% of those attending the MLUs said they would recommend the care they had received to a friend, compared with 70% of those having usual care. Although facilities in the MLUs were quite luxurious, the cost of care for each woman was €332.80 less than in the usual hospital system

A Midwife for Every Woman: Open Letter by one of Philomena's Clients, 38wks pregnant, to the HSE - Re: failures to date.

Open Letter by one of Philomena's Clients, 38wks pregnant, to HSE - Re: failures to date. #isupportphilomenacanning #Midwife4EveryWoman #WomenFirst

One of the women who was booked in with Philomena Canning has written this brave, honest, open letter and asked AIMSI to publish it on our page based on her experiences with the HSE to date, on trying to access a replacement midwife, the failures she has encountered thus far, and th...e blatant disregard for patient safety. The woman has asked for her name to be included but to remove identifiable references of the replacement midwife.

We feel this letter highlights the failures of the HSE to provide these 25 women with appropriate care solutions following the removal of Philomena Canning's indemnity.

Dear Ms Clarke,

Further to our conversation yesterday I wish to clarify some details of my care.

You called me yesterday to inform me that you had sourced me a midwife, and that this midwife was immediately available to me for the duration of my pregnancy. This is something I clarified with you again when you arrived to my home to drop off a home birth pack.

I have since spoken to the midwife (name provided) which you said was available to me.

On our first phone call (Midwife's name) did not know who I was, had never heard of me and was very apologetic that she couldn’t take me on as a client. As I am sure you can understand, this was very distressing for me. On a later phone call with (Midwife's name) she thought perhaps a mistake had been made and she had been given a wrong name and she could attend to me up until the 20thth October when she is due to go on night duty.

I am 100% completely dissatisfied with this ‘solution’ to the unlawful removal of my midwife Philomena Canning. The replacement midwife cannot provide me with continuity of care, as she is not available for the full duration of the 37-42 week window. This is completely unsafe and puts myself and my baby in danger. You told me yesterday that if I went into labour I could call this midwife and she would come to me. Again completely unsafe, as I have never met this woman, she has never met me and I still don’t have any prescription for the emergency drugs needed if I have a PPH. If I went into labour and followed your advice then the HSE would be liable for the bad management of my care should something go wrong. Furthermore, as per your own protocol under the heading ‘Issues to be discussed in pregnancy’, as I have not had a visit from any SECM midwife in more than four weeks, the following have not been discussed with me.

- Monitoring in Labour
- Third Stage Management
- PPH/Shoulder Dystocia
- Vitamin K
- PKU test
- Preparation for Breastfeeding
- When to Call

In fact, none of these issues have been discussed.

This is YOUR protocol and yet You are not following it.

Just to reiterate the facts here.

I have not had an antenatal appointment with a SECM midwife in 4 weeks and 2 days.

Your own protocol has not been followed with regards to Issues to be discussed during pregnancy.

You have assigned me a midwife who is not available for the duration of my pregnancy.

This midwife is taking clients on under duress.

This midwife is not as experienced in homebirth as Ms Canning.

This midwife does not know me or has ever met me to date.

You have advised me to call this midwife should I go in to labour. Which could be today.

Some other issues I would like to clarify. The replacement midwife is not trained in water birth and is not as experienced in homebirth as Ms. Canning due to her only taking on approximately six clients per year and also due to the fact that she is in employment at the (names an Irish maternity unit). This again in my opinion is unsafe. In order for a homebirth to take place there must be a build-up of trust and care between the midwife and client. This has not happened here. In fact, even though I spoke to the midwife yesterday, no antenatal appointment has been organised at all.

I find it extremely distressing that you have removed my midwife at this stage of my pregnancy, I am now entering my 38th week. I find it absolutely unacceptable that you are using the removal of insurance against Ms Canning and yet expect (Midwife's name) to take on the responsibility of my care, which would break many of the rules of the memorandum of understanding. You are creating an environment that would leave both myself and (Midwife's name) vulnerable. (Midwife's name) vulnerable to the removal of insurance in similar circumstances to Ms Canning, and myself vulnerable to an unsafe birth and dangerous outcome if a homebirth were to go ahead under these circumstances.

Lastly, I want to make it very clear, that should I decide to take the HSE up on its ludicrous offer of a midwife that appears to be unavailable. Should anything adverse happen to me or my baby, I will be holding the HSE fully liable.

Regards,

Lesleyann Wylie
Kilpedder, Co. Wicklow.

A Midwife for every Woman: A well evidenced letter by a 32wk pregnant woman affected by the Philomena Canning Case.

A well evidenced letter by a 32wk pregnant woman affected by the Philomena Canning Case.

#isupportphilomenacanning #WomenFirst #Midwife4EveryWoman

 The decision of the High Court to uphold the suspension of SECM Philomena Canning’s indemnity insurance highlights a number of important areas around maternity service provision in Ireland - the treatment of women within the maternity services, particularly those seeking homebirths, ...the treatment of self-employed community midwives, and the HSE’s non-adherence to its own protocols of investigating clinical matters. The rhetoric of the HSE is about safety and public health, yet developments in maternity care policy has consistently ignored the findings and recommendations of research reports, including the 2008 KPMG Report and the 2013 HIQA Report into the death of Savita Halappanavar. The HSE would do well to base its understanding of the concept of safety on the vast body of national and international research in favour of developing midwifery-led services, including home birth, instead of shutting down the practices of SECMs in the absence of evidence, and in doing so forcing women into a non-working hospital system.

There remains in Ireland a deeply entrenched social perception that pregnancy and birth are inherently dangerous, and that hospital-based care equates to safer care, regardless of the circumstances or women’s risk status. Women who want to have a home birth are often seen as reckless; the midwives who care for them as mavericks. The reality could not be further from this belief: the vast majority of women who decide to have a home birth are extremely well informed about the risks and benefits of both home and hospital birth, and the midwives who care for them are without exception highly skilled and experienced, and committed to providing excellent clinical care.

A growing body of high quality research in favour of home birth supports the view that planned home birth among low risk women is closely associated with significantly reduced interventions, and no increased risk for perinatal outcomes. Recent research in the UK, Holland and Scandinavia found that for women having their second or subsequent baby, birth in a non-obstetric unit significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy; a large scale longitudinal study into the association between planned place of birth and severe adverse maternal outcomes which reviewed the data for over half a million women found that low risk women with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital births. Further, there was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system. The issue of a wider supportive structure for home birth services has also been emphasised: midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulted in favourable outcomes for women planning both home or hospital births. These key elements – the existence of good communication and infrastructure between health professionals, and the creation of a safe environment that enables supportive relationships between women and caregivers – are foundational to good clinical outcomes. Philomena Canning’s commitment to communication, collaboration and transparency is clear in how she conducts her practice, including in relation to the current case in which she reported a woman’s transfer to hospital in accordance with HSE procedures. In contrast, the HSE has displayed no such commitment to collaboration, either with women, or with SECMs, and appears pitted against them at every turn. The track record of the HSE does not inspire confidence: the findings of the HIQA report on the wider maternity care services emphasised its lack of responsiveness and accountability, an institutional resistance to change, and an inability to learn from service users’ experiences. Greater home birth provision requires development of infrastructure to support integrated services: the lack of such services in Ireland are cited as the barrier to home birth development, yet the centralisation of maternity care services in large urban areas has resulted in many women living significant distances away from maternity units, and increasing numbers of babies being born on the way to hospital. In other words, existing infrastructure supports neither home nor hospital birth, nor does it support the women who are supposedly at the centre of service provision.

Any claims that the HSE may make that e.g. the woman is respected as the primary decision maker cannot be seen as anything other than a sham. Policy documents that are peppered by terms like “choice” and commitment to a “woman-centred care”, yet any autonomy that women are claimed to have is trammelled by the fact that her role as primary decision maker is conditional on those decisions being the “right” ones, according to the criteria laid down by the HSE, and based on the interpretation of evidence that strengthens its position. This places the HSE in a virtually impregnable position of power, not only as the primary decision maker in care, but as the body who can decide the criteria upon which those decisions are drawn.

The women in Philomena’s care are now in the position of having to decide what to do next. Many of her clients have not been contacted by the HSE at all. I received a text message asking whether I had any queries about the home birth service: I did indeed, and when I rang I had a number of queries – what are my options now? What the implications of the suspension of Philomena Canning’s insurance for my care and the care of my baby? What is the HSE doing to expedite this issue? Why has the HSE not contacted me in writing to inform me of any developments? I did not receive satisfactory answers to any of my questions; I was told that a text message is technically speaking, “written correspondence”, and that if I wanted to find out more details about the implications of the High Court decision, I should consult the national media. I was also told that I would be contacted by Wednesday evening with the details of replacement midwife. It’s Friday, I have not yet been contacted by the HSE.

There is no national home birth service, despite HSE claims that “The National Domiciliary Midwifery service is available to eligible expectant mothers who wish to avail of a home birth service under the care of a self employed community midwife”. There are currently fewer SECMs providing a home birth service than there are counties in Ireland. Why? Largely because the HSE has intimidated SECMs to the extent that few midwives are willing to put themselves in a position where their practice is under continual surveillance and where their professional autonomy is compromised and undermined at every turn. For the majority of Philomena’s clients, there are no other SECMs available at short notice, because they are in such high demand. Hospital-based Domino Schemes that provide a home birth service are equally over-subscribed, and the geographical inequity of home birth services means that women’s choices of care model are limited to whatever is available in their area. For most women in the area covered by Philomena, this means going into hospital. The most recent guidelines issued by the National Institute for Health and Care Excellence (NICE) in the UK recommend that low-risk multiparous women be advised to give birth at home or in a midwifery-led unit (free-standing or alongside a maternity hospital). Obstetric Units are considered inappropriate to the needs of women considered low risk, as they increase the likelihood of caesarean section and other interventions. These recommendations echo those of the 2013 HIQA report in Ireland which states that all women should have access to the right level of care and support at any given time. Since all women deemed eligible to access home birth services in Ireland are by definition low-risk, this suggests that the only option now available to us is the least appropriate, and therefore the least safe.