Seanad Éireann - Volume 188 - 13 March, 2008
Senator Déirdre de Búrca Senator Déirdre de Búrca
Senator Déirdre de Búrca: I welcome the Minister of State to the House. The matter I am raising on the Adjournment concerns the future of the domiciliary birth service, which is more commonly known as the home birth service, in this country and, in particular, the immediate threat that indemnity cover will be removed for independent midwives who really provide the home birth service to women who choose to birth their children in their own homes.
The model of maternity care in this country has changed significantly over the past 100 years or so. We have moved from what was largely a system of home births to one which is now largely a hospital-based service. In 2001, which is the last year for which I have complete figures, fewer than 1% of births occurred at home. There is a need to reorient the maternity care services to provide a woman-centred model of maternity care which facilitates choice among women and also continuity of care.
Independent midwives have been told that indemnity cover will be removed from them at the end of this month. This will leave them with a choice between operating without indemnity cover, which would not be desirable, or ceasing to practise. I am sure the Government would not like to see this situation arise. I call on the Department of Health and Children to provide at least an extension of cover until the issue can be resolved. I know there are certain issues relating to clinical governance and so on which need to be resolved, but I ask that this would happen.
Looking back at what the Government has done, I know an expert group on domiciliary or home births was set up in January 1997 and that three pilot projects were set up. In 2003, a domiciliary births group was established which made recommendations arising from an evaluation of the outcomes of those pilot projects. The evaluation confirmed the feasibility and safety of home births and stated that when these home births were adequately resourced, there were high levels of satisfaction for clients and staff.
There are issues relating to home births. They are most suitable for low-risk women and there is an issue about identifying women for whom home births are most suitable. The recruitment and retention of experienced and competent midwives is another issue that arises. Unfortunately, the profession of midwifery is suffering a collapse of morale because of the lack of recognition of the expertise that midwives have, particularly in terms of providing woman-centred care in the community. The role of the midwife is integral to models of care which promote normality in the birth process. This is the major objection some women have to the hospital-based model of care towards which we have increasingly moved. They believe birth is medicalised and almost industrialised rather than being a natural, normal process that occurs in the most natural way possible which supports women in the process of giving birth.
It is important that any home birth service that is provided nationally is backed up by a modern hospital system in case a transfer proves necessary. Unfortunately, independent midwives who operate in the community frequently complain about a lack of co-operation from local general hospitals in terms of providing scans or tests for women whom they are preparing for home birth.
A range of maternity services could be provided in the community, including home birth services but also including midwife-led units which are very close to that and which are either attached to or part of general hospitals. We need an expansion of community-based midwifery-led services. I asked the Government today to clarify what its vision was for the future development of home birth services. Judging from the situation the domiciliary birth service is in at the moment, it appears the Government may be neglecting it to such an extent that it will disappear and the choices available to women will be restricted to hospital-based choices.
I mentioned clinical governance. An Bord Altranais has a competency framework which governs the practise of midwifery but there is a need for clinical governance structures which should be established at national, regional and local levels to support the development of new models of maternity care.
There appears to be no statutory basis for the provision of domiciliary births. The Nurses Act 1985 requires health boards to supervise midwives who practise outside health care institutions. However, there are no regulations to implement this provision. There are a variety of arrangements in different Health Service Executive areas throughout the country concerning the payment of grants for home or domiciliary births. This is unfair. A woman living in one part of the country might find it easy to access a grant for a home birth while a woman in another area might find it difficult to do so. This practice needs to be standardised throughout the country. I have mentioned how indemnity cover is a problem for independent midwives who are largely involved in supervising and carrying out home births.
As a party in Government, the Green Party is asking for evidence that the Government has thought through and is proactively pursuing a policy to develop and support domiciliary births and other models of maternity care that are not exclusively hospital-based in order to provide choice to mothers of the most natural possible systems of maternity care, which in the long run will be in the interests of the mother and child. It would also be considerably less expensive than hospital births. There are increasing fears of litigation leading to considerably more intervention in the birth process, including the use of caesarean sections, etc. If we had more natural birth processes that were supervised and with the right supports available if necessary, it would be considerably more economical for the State. The Government must address this issue. If action is not taken now and a clear vision is not articulated and pursued by the Government we will see home births die out and we will see independent midwives disappear, and the country would be poorer for it. I look forward to the response.
Deputy Michael Ahern Deputy Michael Ahern
Deputy Michael Ahern: I thank the Senator for raising this matter on the Adjournment. I will be responding on behalf of the Minister for Health and Children, Deputy Harney.
The Minister supports choice for women in childbirth. However, the option of domiciliary births must be provided in a safe and secure manner. A national implementation committee on domiciliary births has been set up by the HSE to implement the recommendations of a 2004 report on domiciliary births. The committee has set up four sub-groups dealing with selection criteria and evidence base; legal, indemnity and grants; training and support for midwives; and development of maternity services. Membership of both the national implementation committee and the sub-groups includes key stakeholders from the HSE, primary community and continuing care, the National Hospitals Office, population health, HR specialists, consumers of the service, midwives, obstetricians and neonatologists as well as the State Claims Agency, and the Department of Health and Children.
There are approximately 19 midwives practising independently and they attend 200 to 300 births annually out of a total of 70,000 births nationwide. The Minister is aware of concerns regarding indemnity insurance for independent midwives. Independent or self-employed midwives are not employees of the public health service. As the independent midwives are private operators who do not have service level agreements with the public health service it is not possible at present for them to come within the ambit of the clinical indemnity scheme administered by the State Claims Agency. The Irish Nurses Organisation provides a certain level of insurance cover to independent midwives who are members of that organisation. The INO had indicated that it would not be providing insurance cover after 31 March. However, I understand that it has been in touch with its insurer about extending this cover until the end of September.
Officials from the Department of Health and Children are working with the HSE to put in place a robust national clinical governance framework in order to ensure that the practice of independent midwives is brought into close working relationships with maternity services delivered by the HSE and the voluntary maternity hospitals. Subject to this being achieved it would then be the intention to bring the independent midwives within the scope of the clinical indemnity scheme by means of an extension of the cover under the scheme to the HSE.
Senator Déirdre de Búrca Senator Déirdre de Búrca
Senator Déirdre de Búrca: While I thank the Minister of State for the response, only the question regarding indemnity cover for domiciliary births was answered. I also asked the Minister to outline her vision for the future development of the service and I am afraid nothing in the response gave me any hope for the future of the service other than the hope that a system will be put in place to extend indemnity cover. I ask that the matter be brought to the Minister’s attention and perhaps at a future state I can table another motion and get some more detail.
The Seanad adjourned at 2.25 p.m. until 2.30 p.m. on Wednesday, 19 March 2008.
Seanad Éireann 188 Home Births.