AIMSI Statement on the Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area Monday, 23rd February, 2009 in the Greater Dublin Area. AIMSI welcome the publication of the Independent Review of Maternity & Gynaecology Services in the Greater Dublin Area. In particular we welcome the recommendation for increased choice for women regarding models of care and the recognition that there is considerable evidence for the development of midwifery led units. We agree with the finding that the GDA is out of step in being able to offer a woman-centred service, providing choice and access to services .We share the belief that the GDA needs to place much more emphasis on community based maternity services, as 60% of women will experience a normal birth. We note the link between the policy of active management of labour and the high levels of assisted deliveries in the three GDA hospitals and the fact that the majority of Caesarean sections are carried out on first time mothers. We feel the report, given its limited brief, does not highlight the very significant implications of these findings—findings, of which AIMSI has long been aware. However, we welcome the conclusion that an increase in midwife led care will lead to a reduction in the active management of labour. We believe the emphasis on reducing the average length of stay (ALOS) unfortunately focused more on the resultant freeing up of capacity rather than the impact on mother and baby and the consequent need for heavy investment in community based postnatal care. We note with concern the fact that all three Dublin hospital exceeded their designated proportion of private patients with the result that public patients are more likely to be seen by a non consulting hospital doctor. We note with regret the exclusion of the precedent established by home births with the assistance of Self Employed Community Midwives (formerly known as Independent Midwives). AIMSI has long called for the provision of shared evidence-based clinical guidelines regarding the provision of care in the maternity services and welcome the fact that the report validates this call. AIMSI in meeting with the Minister for Health have called for the creation of National Guidelines for Maternity Care, including consent- related procedures and public access to data on all maternity-related procedures, practices and outcomes, by hospital and by health provider. We feel this will promote transparency and facilitate service users in choosing their preferred model of care. We call on the Minister to honour the recommendations of the Report and ensure that the "Proposed Pathway of Care" is established before the predicted fertility boom of 2014. Gillian Kane Chairperson AIMS Ireland For more information or questions please contact gillian@aimsireland.com Independent Review for Maternity and Gynaecology Services in the Greater Dublin Area.
Independent Review for Maternity and Gynaecology Services in the Greater Dublin Area. The criteria agreed during the consultation period were services to be provided by the most appropriate clinical profession, close to the mother’s home and ensuring intervention at the right time, women and Infant centred care, equity for all women, access, accountability, infrastructure, value for money training and research and workforce. The unique features of the Irish system highlighted were the Mastership system and the whole private insurance effect. The extreme limitations of the physical infrastructure were noted and commented upon whilst lauding the efforts of the staff working within them. International evidence was looked at and it was decided that no single model of care could be incorporated into Dublin. It was noted that we are comparable in relation to clinical outcomes. The response of the service users for more choice, more social models of care and more MLU’s was noted. Main Recommendations for future model are as follows; • Increase service offering a) choice of different models b) wider range of settings • Development & expansion midwifery led/managed services and MLUs • 3 new hospitals – Rotunda to relocate to Mater, Coombe to relocate to Tallaght and NMH, Holles St to relocate to St Vincents • Relocate elements of current maternity & Gynae services to community & primary care setting • Increase in consultant and midwife numbers • Fetal medicine: one unit as centre of excellence for specific abnormalities but all hospitals to have ability to deal with maternal disease and congenital defects. • Neonatology: all three hospitals should have a level 3 NICU, one should have level 4 • Gynaecology: services to be concentrated in 3 main units. One unit as centre of excellence for sub specialities e.g. Oncology • 5-10 year program of change • Look at extending this model nationwide to reduce potential inequalities in service Questions & Answers: Gillian Kane from AIMSI asked the panel speaker for Maternity, Prof Suzanne Tuttero, what options for non-hospital birth did she foresee, given she recommends more non-hospital births. She admitted that they only considered hospital births: no mention of home births etc. She wants a public awareness campaign and a minimum of 2000 MLU’s per each hospital’s 8000 births. AIMSI also asked about the consideration of outcomes other than clinical ones. She said they did not look into them but she hoped the philosophy of birth would be better with more MLU’s. Other audience questions related mainly to implementation and finance issues. The full KPMG Independent Review Report will be available on HSE website w/e 21/12/08
October 27th 2008 An AIMSI letter to Minister Harney and the HSE, dated October 15, 2008, calling for a national independent review of consent related practices in Ireland was the focus of an article in the Daily Mail on Sunday, October 26th, 2008. The article narrowly focused on specific comments and practices at the National Maternity Hospital in Dublin and more personally, Director of Midwifery, Mary Brosnan. The Association for Improvements in the Maternity Services, Ireland (AIMSI) wish to reiterate that this campaign is not a local issue limited to one Director of Midwifery in one specific maternity unit in Ireland. The lack of (informed) consent sought from women in labour has very serious legal implications. AIMSI recognises that the large majority of midwives act as advocates to women in labour, however, feedback from women on consent continuously illustrate that consent related practices remain a sizable national issue. In an AIMSI national survey, 75.6% of respondents stated that they felt that consent is an issue of concern in the Irish maternity system. AIMSI will continue to campaign for full informed consent for labouring women regarding all clinical maternity care procedures in Irish maternity units as highlighted in the letter to Minister Harney and HSE. Statement re: The Irish Pregnancy Book, by Dr Peter Boylan, as reviewed by Beverley Lawrence Beech, AIMS UK The Association for Improvements in the Maternity Services (AIMS) Ireland would like the opportunity to respond to comments made by Dr. Peter Boylan in response to the review of his book by Beverley Lawrence Beech of AIMS UK.
further discussion. In the article, Peter Boylan states "that childbirth is a emotive issue and that experts can be at odds about what constitutes best practice." He then adds that, " Beech does not know how the Irish Health system works" and "she clearly does not understand what goes on here." These statements clearly illustrate Dr. Boylan's short-sightedness of the true issues at hand and sadly, he appears to hold no regard for utilising international guidelines for Normal Birth in the Irish maternity system. The research and information present in Beech's review are based on International Normal Birth guidelines as per the World Health Organisation. Evidence based research has concluded that Normal Birth practices are best practice for the majority of women worldwide; to suggest that the Irish system is somehow excluded from these guidelines is extremely concerning. WHO guidelines exclude practices such as routine use of episiotomy (when all women's perineum are cut regardless of medical need), routine ARM, with holding food and drinks to labouring women, recommendations for women to give birth on their backs on a bed, etc - all of which are recommended in The Irish Pregnancy Book. AIMS Ireland appreciates the opportunity to highlight these issues regarding the Irish Maternity System. Regards, Jene Kelly Chair of AIMS Ireland
"The Irish Pregnancy Book –A Guide for Expectant Mothers Reviewed by Beverley Lawrence Beech, AIMS UK
What is the point of being a professional? It ensures a certain status, it usually requires many years of training and professionals are held in higher esteem and trust than a common or garden lay person. When the professional is an obstetrician the majority of women feel confident that they are the best people to approach when they are pregnant and are confident that the information they give is accurate and without bias. A book written by an obstetrician, therefore, would have a certain cachet. On my visit to Ireland to help launch the AIMS Ireland group I was given a copy of The Irish Pregnancy Book with the suggestion that I might review it. Obstetricians in Ireland have closed down small, free standing maternity units, as did obstetricians in most of Britain. In Ireland, two midwifery units have just opened, in Britain they are still always under threat of closure as we described in our Journal on Birth Centres. As I was intrigued to see what was on offer, I began reading. The book is written by Dr Peter Boylan who was ‘The Master’ of the National Maternity Hospital, at Hollis Street, in Dublin – a hospital that delivers (and I use that word advisedly) over 8,000 babies a year. The fact that the head of obstetrics in the hospital is called the Master speaks volumes and is a reflection of the presumption that the women are there to do as they are told. The book began well enough (it does have a pretty cover) but it did not take long for my blood pressure to climb. Not only because of the amount of misinformation but also in the way it is delivered. Patronising is, perhaps, an understatement: ‘Is there such a thing as a stupid question? There is, of course, but that shouldn’t stop you asking’ ‘Nobody expects you to know anything or to take responsibility for anything so don’t be scared!’ ‘If you have already had a child, and are used to being pregnant, it can be difficult to assimilate the fact that each pregnancy is different and needs to be treated individually’ ‘The key to coping with your disappointment is to have realistic expectations about birth and keep an open mind as labour unfolds.’ ‘The choice is yours, but remember you are not making it just for yourself ’. The National Maternity Hospital was the home of Keiran O’Driscoll, the promoter of Active Management of Labour. The obstetricians in Ireland closed down small, free standing, maternity units so that there were four large centralised ones left. Their campaign resulted in a huge increase in the numbers of women being processed through the deliver y rooms and in order to do so Active Management was introduced and promoted on the grounds ‘that effective uterine action is the key to normal delivery’. As the numbers increased so the ‘advice’ about the length of a normal labour decreased, but women were not told the reasons for that. In 1963 women were told that a ‘normal labour’ lasted 36 hours. As the numbers of women going to the large centralised obstetric units increased so the length of labour decreased (O’Regan, 1998) so that now, in this book, women are told that ‘if your labour had started twelve hours ago there is a better than 90% chance that you would be sitting in bed holding your newborn baby! In fact the average length of time a first labour takes from arrival in the labour ward to delivery, is less than seven hours in the National Maternity Hospital.’ Instead of informing women that their labours are being induced and accelerated in order to get them through the labour wards as quickly as possible (in Dublin there are over 20,000 births for 30 deliver y beds) active management of labour is referred to as ‘A sensitive approach to the care of women in their birth labours.’ It is clear, throughout the book, that Dr Boylan has little understanding of normal birth. ‘Birth can only be defined as perfectly normal in retrospect.’ This is still the basis for obstetric care in Britain and Ireland, and it is still said in all sorts of different ways. Active Management is alive and well in both countries. All births are potentially normal until the labours (or during pregnancy) show signs that they are deviating from normal. To assume that you cannot define normality until the labour is over is ridiculous, but it does allow obstetricians the opportunity to portray birth as a dangerous, uncertain, event. Peter Boylan’s failure to understand normal birth colours the whole book and the advice given. ‘There is no advantage to keeping the waters intact, indeed not having the waters broken could slow your labour significantly.’ The research does not support Peter Boylan’s claim. Amniotomy (breaking the waters) results in significant disadvantages: • fetal heart abnormalities are more likely in a healthy, term baby when the waters are broken (Kariniemi 19983, Barrett et al 1992, Fraser et al 1993, Garite et all 1993) • it can precipitate umbilical cord prolapse (Levy et al 1984); • it has little effect on the length of labour (Seitchik et al 1985, Rosen and Peisner 1987, Barrett et al 1992); • it does not reduce the caesarean section rate (Barrett et al 1992, Fraser et al 1993 and Garite et al 1993). And where is the evidence that a slow labour needs speeding up?
The first high quality study of eating and drinking in labour was carried out in Canada. The study concluded that ‘women enjoyed being able to control their own oral intake; no other benefits or harmful effects were found’. It has been stated that withholding food and drink from women in labour is unlikely to be beneficial. ‘Some women prefer to let the baby’s cord stop pulsating and to attempt to breastfeed in an effort to make the third stage as physiologically normal as possible. There are no great advantages to be had however, and it is probably simpler not to delay.’ Professor Peter Dunn’s research (Dunn, 1984 and Dunn PM, 1993) revealed that early cord clamping ‘traps around 100ml more blood in the placenta than could be the case if cord-clamping were deferred until cord pulsation had ceased. As 100ml of blood in the term fetus is equivalent to 2.5 pints of blood in an adult, it is not surprising to observe that, following immediate cord occlusion, the newborn infant typically exhibits signs of hypovolaemia [too low blood volume due to excess fluid loss] and hypotension [an excessively low blood pressure]’ (Dunn, 2004/5).
for medical staff to see what’s going on and to help accordingly.’ A randomised controlled study reported that for primiparas (mothers undergoing first deliver y), the duration of the expulsion period was significantly shorter in the group of mothers who remained seated in a birthing chair than in the group opting for the lithotomy position [on their backs]. The efficiency of uterine contraction for dilating the cervix is also greater in a vertical position than in a horizontal position … It has been shown that appropriate position [squatting] of the mother increases the capacity of the pelvis’ (Caldeyro-Barcia,1985). Interestingly, at a World Health Organisation conference in For taleza, Brazil, Professor Caldeyro-Barcia remarked that ‘there was only one position worse than lying on one’s back for birth and that was hanging by one’s heels from a chandelier’.
A ‘reasonable period of time’ is defined by doctors not by women. When doctors fail to understand that the standard interventions in labour pervert the course of a normal labour, and suggest that it is ‘assisting’ women those women then fail to realise that the, often traumatic, experience they have had was not ‘normal’ but caused by that ‘assistance’. As a result of this lack of knowledge they then stoically accept what happened, and some go on to book a caesarean or an epidural for the next birth because of the trauma they suffered.
The book omits to point out that fewer than one in ten women will succeed in having a normal birth in hospital. As the National is extremely coy about revealing its statistics one can only speculate how many women actually have a normal birth in that hospital. A normal birth does not include artificial rupture of membranes, induction or acceleration of labour, epidurals or episiotomy. But according to this book it does.
or perineal tear ; as the rate of episiotomy goes down, the rate of tear goes up! Look on the bright side though – you have a 50% chance of not having stitches, too!’ Not with a 20% caesarean section rate you won’t. This suggests that episiotomy prevents tears – it does not. A randomised controlled trial in Canada concluded that ‘there is no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation’. (Klein MC et al, 1993). ‘The slower recovery may be because your labour was long and you are exhausted or because you have a larger episiotomy than you would have had with a normal birth.’ If a woman has an episiotomy at all, no matter how small or big she will not have had a normal birth, it is notmnormal to perform genital mutilation during birth. ‘Of course, induction can often be very successful and result in a normal labour and a normal delivery.’ In a normal labour a woman’s uterus increases the strength of contractions as the labour progresses, an induction of labour drives the uterus at the highest levels immediately, the labour is no longer normal. Space prevents me from highlighting all the misinformation in this book, but here are a few: ‘There is no evidence that ultrasound harms the fetus in any way’ ... ‘There is no risk whatsoever associated with having a scan.’ A randomised controlled trial from Helsinki of over 9,000 women found 20 miscarriages after 16 to 20 weeks in the group that had routine early ultrasound scans and none in the controls (Saari-Kemppainen, 1990). Another randomised study of 2,475 women in London (Davies, 1992) of babies exposed to routine Doppler ultrasound examination of umbilical and uterine arteries at 19-22 weeks and 32 weeks reported 16 perinatal deaths of normally formed infants in the ultrasound group, and none in the controls. Despite being asked to explain these findings the researchers have not responded. ‘The position of the baby’s head before labour is of no consequence whatsoever.’ In that case why are women told that they have to have external cephalic version, or a caesarean section, when the baby is presenting by the breech? ‘The midwives will perform an internal vaginal exam to see if you are in labour, and if so, how dilated you are. This procedure is the only way to assess your progress in labour.’ Skilled midwives are very competent at assessing progress in labour without performing internal vaginal examinations, obstetric nurses, however, rarely have this skill. Midwives will be concerned about the following statements as they casually dismiss potentially important warning symptoms: ‘You may get visual disturbances in pregnancy such as flashing lights before the eyes or blurred vision. These are of virtually no consequence but mention them to your doctor if they bother you.’ Visual disturbances often accompany pre-eclamptic toxaemia and skilled midwives will be concerned, and would be seen to be negligent should they fail to investigate should a woman mention that she has this experience. ‘Sometimes the mother gets leverage by holding her own knees, or the two midwives let the mother push her feet against them to brace herself.’ Research clearly shows that lying on one’s back for birth restricts the birth outlet. ‘Good, good, take a deep breath – no talk or sound. Put your chin on your chest and push that breath into your bottom as long as you can hold it, then quickly two more times within this contraction.’ ‘... you should push as if you are severely constipated …your midwife and doctor will help coach you.’ ‘Working right up until labour is fine from a physical point of view and doesn’t harm the baby but is probably unnecessary.’ Finally, the message in this book is that the doctor knows best and you will do as you are told: ‘Vitamin K will be given to your baby soon after birth’ No question here then of the woman being asked whether or not she wishes her fit and healthy baby to be overdosed with Vitamin K. ‘…you can decide who you want to be with you. You can even have a relay of a few people with you if you wish – but only one at a time.’ So, you can choose who to have with you, but if you choose to have two people you will not be allowed to do so. Some choice! The following is a question posed in the book: ‘How can I get the most out of my antenatal visits? Be informed – read this book!’ On the contrary, by reading this book you will be misinformed and my advice is save your money, there are better books on the market. Beverley A Lawrence Beech
Davies, JA, Gullivan, S, Spencer, JAD (1992) Randomised controlled Doppler ultrasound screening of placental perfusion during pregnancy. The Lancet; ii: p1299-1303 Dunn, PM (1984) The third stage and fetal adaptation. In Clinch J, Matthews T (eds). Perinatal Medicine. Proc IX Europ Congr Perinat Med, Dublin, Ireland, September 3–5, 1984. Lancaster : MTP Press, 1985: 47–54 Dunn, PM (1993) Stress failure of pulmonary capillaries at birth. Lancet, 1993; 341: 120 Dunn, PM (2004) Clamping the umbilical cord, AIMS Journal, Vol 16, No4 Klein, MC, Gauthier, RJ, Jorgensen, SH et al. (1992) Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online J Curr Cliin Trials, 1992:1. O’Regan, M (1998) Active Management of Labour – The Irish Way of Birth, AIMS Journal, Vol 10, No2, Summer 1998, p1-8. Saari-Kemppainen, A, Karjalainen, O, Ylostalo, P and Heinonen, OP (1990) Ultrasound screening and prenatal mortality; controlled trial of systematic one-stage screening in pregnancy. The Lancet, Vol 339; p387-391. The Irish Pregnancy Book By Dr Peter Boylan Published by A & A Farmer Ltd ISBN 1-899047-88-3"
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AIMS Ireland survey on 'Availability of Information and Consent'
Information and Consent'.
again this month. It has now been announced that as of October 1st 2008, Insurance for Independent Midwives is to be provided by the State's Clinical Indemnity Scheme. All Self Employed midwives have been sent a "Memo of Understanding" (which defines the scope of practice to be insured) to sign. Independent midwives perform a vital and unique role in Childbirth in Ireland. Home birth is both safe and cost effective. Research has shown that Home Birth is as safe or safer than hospital births for low-risk women (approx. 85% of pregnant women)
Many women may no longer qualify for a home birth. Altering home birth by adding restrictions to the current system, will mean that we are putting further pressure on already limited resources. For many women, Home Birth is the only safe option. AIMS Ireland are asking that you contact The Minister for Health, The INO, local politicians and other influential bodies if you have concerns over this matter. You may now download a copy of the draft "Memo Of Understanding" here, and the Home Birth Information Booklet which includes "risk" criteria here October 2008 |
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Home Births
this month. It has now been announced that as of October 1st 2008, Insurance for Independent Midwives is to be provided by the State's Clinical Indemnity Scheme. All Self Employed midwives have been sent a "Memo of Understanding" (which defines the scope of practice to be insured) to sign. Independent midwives perform a vital and unique role in Childbirth in Ireland. Home birth is both safe and cost effective. Research has shown that Home Birth is as safe or safer than hospital births for low-risk women (approx. 85% of pregnant women). For many women, Home Birth is the only safe option.
Many women may no longer qualify for a home birth. Altering home birth by adding restrictions to the current system will mean that we are putting further pressure on already limited resources. AIMS Ireland are asking that you contact The Minister for Health, The INO, local politicians and other influential bodies if you have concerns over this matter. You may now download a copy of the draft "Memo Of Understanding" here, and the Home Birth Information Booklet which includes "risk" criteria here October 2008 |