Register Statistics 2006, show there are 17,275 there were midwives in Ireland. However, it is worth noting that many are not currently practising their midwifery skills. Although midwifery is a requirement for Public Health Nurse positions, few P.H.N.s get the opportunity to use these skills in the community.

On page xv of the Bord Altranais report, The future of Nurse Education & Training in Ireland, there is a recommendation that midwifery should not be a P.H.N. requirement, it should be replaced by a maternity & childcare module. We at the H.B.C. do not support this recommendation as the local P.H.N.s may be the only Health Board employed personnel able or willing to attend home birth free of charge under the Health Act 1970.

Until there is a proper domiciliary service re-established, P.H.N.s should continue their midwifery training. We have made a submission to the Community Care Review Group (1995) expressing these views.

There are also proposals that midwives should be awarded degree status qualifications through universities. We would support this as long as a reasonable period of community/domiciliary midwifery was included in the curriculum.

At present, whilst students are expected to know about domiciliary midwifery from books, they are given no opportunity to accompany domiciliary midwives on their visits and deliveries. This has lead to a lack of awareness, low confidence and fear about attending domiciliary births amongst midwives.

We would also support a system of direct entry midwifery such as exists in the U.K. (choice of eighteen months after general nursing or 3 years direct entry) and many other European countries including Holland (3yrs) , Denmark (3yrs) , Germany (3yrs) , France (4yrs) & Greece (3.5yrs).

The direct entry system ensures that a midwife's main focus is on birth as a normal life event rather than a disease or malfunction. It is interesting to note that a doctor is legally allowed to deliver a baby without having additional obstetric training. The safety and legality of births attended solely by midwives who have made a specialised study of maternity care should not be in question.

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Domicilary midwifery
A domiciliary midwife will attend to all the woman's ante-natal care, attend the birth in the home, attend the woman and baby for approximately 10 consecutive days after the birth and thereafter for post-natal check-ups (6-10 weeks). This care usually amounts to 100 hours of work over the period of up to one year. The private fee charged is usually £400 - £1000 depending on various factors.

Because the Health Boards actively discourage their employees from attending home births, most domiciliary midwives are independent and in order to make a living, they must charge privately. Most midwives are unwilling to take on more than three to five clients due in any one month to reduce the possibility of women going into labour at the same time. In this rare event, another midwife may be called if she is available, but in general, they do not work in group or joint practices, principally because there are so few of them.

The work is of course very rewarding and fulfilling, but the strain of being on call 24 hours a day, 7 days a week etc., working outside the "system" with little or no community or professional support, travelling long distances and so on, takes its toll. Many midwives, reluctantly, have had to give up because of personal, family or financial demands.

In the home or community environment, a midwife has the greatest opportunity to practise her skills independently and professionally. In the Winterton report, it is recommended that midwives should have the opportunity to establish and run midwife managed maternity units within and outside of hospitals, including a more autonomous role for midwifery in domiciliary and lying-in care.

In April 1997, the Dept. of Health published "A Plan for Women's Health" and the "Report of the Mother and Infant Care Scheme Review Group". These recommend pilot schemes to evaluate hospital and community approaches to home birth.

No details of these pilot schems are available. At present, official Dept. of Health policy is to actively discourage home births both to the public and within the medical community. Health professionals, therefore, continue to give biased information to mothers about home births and certain obstetricians actually scare women into having a hospital birth when really they would opt for home birth.

The following is an example of a Dept. response to a request for domiciliary services, quoting the recommendations of the Comhairle na nOspideal Report 1976: "It is Department of Health policy that, on medical grounds, the delivery of babies should take place in consultant staffed maternity units. "

It is generally accepted that this policy has contributed to the marked decrease in the level of maternal, peri-natal and infant mortality." This is despite the evidence of such reports as the Winterton Report which states that: "On the basis of what we have heard, the committee must draw the conclusion that encouraging women to give birth in hospital cannot be justified on grounds of safety." (para. 33)

In 1966, 32% of all births took place in maternity units, staffed at consultant obstetrician level, having more than two thousand births per annum. By 1978, this had increased to 91%, reflecting the closure of smaller, local maternity units which were deemed unsafe and uneconomic:

Detailed histories of the foundation of the various Irish maternity hospitals can be obtained from the hospitals themselves. In brief, the "lying-in" hospitals were set up initially to cater for the very poorest and underprivileged women who lived in appalling conditions of squalor and overcrowding, had poor nutrition, no access to basic health or ante-natal care and had many children in close succession. For them, hospital care and birth did offer a safer, more hygienic alternative and gave them a much needed break from the family and home.

All the middle and upper classes continued to give birth at home with midwives. Then it became fashionable to have doctor attended deliveries and as a consequence, intervention and anaesthesia rates grew.( e.g., Queen Victoria extolled the virtues of chloroform and chamberlain's forceps).

As a consequence, complications increased and women from these classes too, were advised to deliver in nursing homes and hospitals in increasing numbers.

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History of
midwifery in Ireland

C18th - First initiatives in midwife training

1835-45 - Midwife education begins in Coombe hospital.

1870 - Formal midwife education begins in Rotunda hospital requiring 6 months course/attendance.

1902 - Midwives Act (U.K.) applied in Ireland giving first regulatory recognition to midwives.

1918 - Midwives Act (Ireland) set up Central Midwives Board - midwives had to have a qualification from a teaching hospital (e.g. Rotunda, Coombe or U.K.).

Hospital orientated training began to lead to more hospital births. The length of training was 3 months for trained nurse (later increased to 6 months) - 6 months for direct entry (later increased to 1 year)

1939 - Part one - 6 mths for registered nurse, 18 mths for direct entry - Part two - 6 mths for both of above - Full course - 1yr R.G.N., 2yrs direct entry.

1944 - Repealed previous legislation and recommended wider provision for training and refresher courses.

1950 - Nurses Act which defines a nurse as "a person registered in the register of nurses and includes a midwife and the word nursing includes midwifery". (This has lead to the lack of a cohesive professional body for midwives such as the Royal College of Midwives in U.K., detracting from their individual and professional role.)

Bord Altranais established and Central Midwives Board disbanded.

Midwives Committee formed

NB. - It was during these intervening years that the number of domiciliary births decreased rapidly (see figures below).

1985 - Nurse Act - supervision of domiciliary midwives (Section 57{2}) - prohibition on attending births (Section 58).

1990 - European Union Directive on Midwives - Recommendations include:

It is interesting to note how rapidly the hospitalisation of birth was accomplished:

To conclude, here are some comments from domiciliary midwives who have practised or who are practising in Ireland:

"It is not easy being self-employed in independent practice. The good side is being your own boss and the employer is the mother. There is great joy and fulfillment being autonomous and each mother and baby offers great challenges to the practicing midwife. When I want to take a holiday, I must look ahead nine months and not take any bookings for two months at least. This means going without income for two months. It is important to take a holiday as one is on call 24 hours a day, 365 days in the year.

I don't mind being on call - I'm used to it. One of the downsides to the job is the payment for the service. Some mothers do not pay and this is particularly difficult when I have built up a rapport with her. All in all, one needs to be confident, strong and independent and to be able to make decisions decisively."

"The greatest nuisance is being on call all the time. I have a family and every night I have to prepare things just in case I'm called out. One night I was out late socially, went to bed and was called out an hour later. On the positive side, it is such a privilege to share the birth experience with mothers and their families. I think that if the flying squads were re-introduced, more women would opt for home birth and more midwives would be willing to attend them."

"You get so much satisfaction from delivering a live healthy baby ... you don't measure these things in cash. I enjoyed every minute of it. I've delivered mothers and then their daughters. It is a miracle each time."

We hope that if you are a person or nurse considering midwifery, a student midwife, or a fully registered midwife, that this information has given you some insight into the area of domiciliary midwifery. Perhaps it has inspired you to consider practising. Even if you feel it might not be for you, seeing home births can give a completely different and useful perspective on hospital births.

Talking to a midwife already attending home births would be a way of finding out more about it. Ask her if you could accompany her on some of her visits.

Ask your nursing tutor for more information and question why student midwives are not given this opportunity as part of your general training. Discuss the possibility of setting up a midwives clinic in your hospital.

Remember that you are not an obstetric nurse, but a professional midwife capable of practicing in your own right.