Home
Birth
An Introduction
for Student Midwives
Every year
we receive a large number of queries from student midwives,
who are doing a project entitled "The Place of Confinement" and who request information on home birth. This leaflet is intended
to guide you in the right direction for further research.
By far the
most useful report to you would be Marie O'Connor's Women and
birth - A national study of intentional home births in Ireland
(1992). It addresses all the issues relating to home birth in
Ireland, giving both statistical data, historical information
and comments from mothers. It makes recommendations from the
findings and has an extensive bibliography. It was conducted
under the aegis of the Coombe Women's Hospital and was grant-aided
by the Department of Health. Unfortunately this document was
never published or made available to health professionals or
the general public. However, in 1995 Marie O'Connor published
a book entitled Birth Tides, which is based on this study and
would therefore be of benefit to you.
Student
midwives most commonly request information on ten topics and
so we cover these in this leaflet.
1) Hospital versus
Community in Ireland
The
title here implies that there is a dichotomy or element of competition
between the functions of hospital and community care. We feel
that there should be more links and communication between hospital
and community nursing staff, especially in midwifery. This could
be most readily achieved by the hospitals sending midwives back
out on the "district" to conduct antenatal and postnatal
care, and deliveries.
Resources
•Central Statistics Office for Hospital and Domiciliary
Births registered in Ireland.
• Maternity Hospitals' Annual Reports
• Birth Tides by Marie O'Connor
• The Future of Nurse Education and Training
2) Home Confinements
Selection of mothers
It could
be said that mothers are mostly self selecting, as home birth
is not usually presented to them as an option by G.P.s or hospital
staff. They decide that for them, home is the best and safest
place to give birth and the domiciliary midwives facilitate
them in this choice. Midwives do not automatically label "high"
or "low risk". Each mother is considered on an individual
basis and while previous obstetric history, if any, is taken
into account, (miscarriage and stillbirth, pre-eclampsia, Caesarean
section etc.) very few blanket restrictions are made on grounds
such as age or parity. Midwives set their own criteria for each
woman and if she feels a woman needs specialised obstetric care
at any stage of pregnancy, labour or postnatally, she can and
will refer her to hospital.
Midwives
believe that good general health coupled with careful and consistent
antenatal care is the key to safe home birth and so prefer to
see mothers as early as possible in their pregnancy and will
not usually take a woman after 36 weeks.
Other practical
considerations can also affect the selection of mothers. To
ensure a high quality of care and to reduce the possibility
of mothers going into labour at the same time, midwives must
limit their client numbers. This results in some women being
refused care.
Midwives also need holidays and they cannot take bookings
in and around these periods. The obvious solution to this problem
is more domiciliary midwives.
Money is also a factor. A midwife's fee is partially
covered by all health boards. This is despite the fact that
every woman is entitled to free maternity care under the 1970
Health Act. It is a disgrace that women are forced into hospital
care and delivery on purely financial grounds.
3) Home Confinements
Selection of homes
Midwives
attend mothers in benders in West Cork and mansions in Ballsbridge.
As long as there are basic facilities, some form of heating,
a water supply, a telephone nearby to call the midwife, other
aesthetic factors are irrelevant.
Distance between the midwife's base and mother's home
would be the first consideration. Each midwife decides on her
maximum radius and may charge mileage fees if the distance is
great, especially in rural areas. As most, if not all, the antenatal
care is done in the mother's home, the midwife has ample opportunity
to familiarise herself with the home and the whole family.
As the woman is free to move about within her home, any
room may end up being the "delivery suite". The place
of birth does not need any special arrangement or preparation,
old sheets to protect beds, chairs or carpets are useful. Some
women like beanbags to lean on. Please refer to the Water Birth
section for preparation for the use of birthing pools. Very
little technological equipment is needed. The midwife will carry
her own medical requisites. The mother may be provided with
a basic Maternity Pack from the health board.
4) Home
Confinements -
Back-up services
The
rate of hospitalisation among mothers for 3rd stage complications
was 4%, for newborns 3% and the incidence of perinatal mortality
and morbidity (convulsions) was nil (from Birth Tides
by Marie
O'Connor). As these figures suggest, emergency transfer rates
from home to hospital are low.
As previously mentioned a midwife may refer or transfer
a mother to hospital at any stage if complications arise. How
a mother is received once in hospital depends very much on who
is on duty. Most midwives report good reactions from hospital
staff on the rare occasions that they bring women in. However,
in the absence of having an honorary contract with a particular
hospital, the independent midwife may not be permitted to play
a part in, or attend, the birth.
While some G.P.s will agree to combined antenatal and
postnatal care, very few are willing to back up midwives during
deliveries. This is mainly for insurance reasons but also because
many feel they do not have the necessary training or experience.
There is no flying squad since circa 1972.The reasons
for this are outlined in the E.H.B. Domiciliary Births review
1983. In the rare event of two women going into labour at the
same time, another midwife may be called, if there is one in
the area, or one woman may be forced to deliver in hospital.
5) Fees
For more
details on this issue please see the sections entitled "Midwifery
Training and Practice" and "Arranging a Home Birth".
You could also contact your local Health Board and V.H.I., for
further information on fees and reimbursement.
6) Home birth
in Europe
Ireland
is one of the few European countries that does not have a direct
entry training system for midwives. We would like to see a reintroduction
of direct entry with a comprehensive community / domiciliary
midwifery module. For further information see
• World Health Organisation publications
• An Bord Altranais The future of Nurse Education
and Training in Ireland.
• The Winterton Report (House of Commons Health
Committee report on Maternity Services)
7) Role of the
midwife
Apart from
the high level of knowledge and skill required in this profession,
a midwife should recognise how privileged she is to be a birth
attendant and respect every women's right to give birth in the
manner of her choice, with empowerment, dignity and joy. She
must also learn how to be "with woman"; to educate,
to support, to encourage, to observe and, most importantly,
to wait, intervening with the natural process of birth only
when absolutely necessary.
• The Midwife Challenge.Sheila Kitzinger (1988)
• Sensitive Midwifery.Caroline Flint (1987).
• Spiritual Midwifery Ina May Gaskin (1977).
• Breaking the Spell of Fear. Ina May Gaskin (1994)
8) Hospital
Confinement
Health
professionals involved in maternity care should enable women
to make an informed choice on the type of maternity care most
suitable for her. If she decides that hospital is appropriate,
more freedom and flexibility is needed within that setting.
The midwife's role in hospital should be no different
than that outlined above. However, fulfilling that role is more
difficult due to the hierarchical structure of staffing, the
lack of continuity of care, the larger numbers of women in her
care and the larger number of women and babies traumatised by
difficult and complicated births. The midwife has more difficulty
asserting herself as a professional in her own right in a hospital
setting where the consultant obstetrician usually has the final
say in decision making. The introduction of midwife clinics
in hospitals is welcomed as a step in recognising the role and
responsibilities of midwives.
9) Early discharge
We would
like to see a more flexible approach toward early discharge.
Women should not be bullied into signing disclaimer forms if
they wish to leave early. The introduction of a "Domino"
scheme, whereby a familiar midwife remains with a woman through
labour at home, accompanies her for delivery in hospital/birth
centre and returns with mother and baby shortly after the birth,
would ensure the continuity of care that most women prefer.
However, some prominent Masters of maternity units have publicly
said they would offer planned early discharge to women, as an
incentive to them not to have home births. It is important to
realise that no matter how homelike or flexible hospitals become,
there will always be a demand for home birth.
Whether
a woman gives birth at home or in hospital, more postnatal community
support is necessary. Visits by Public Health Nurses are mainly
for surveillance purposes and are clearly inadequate in providing
the kind of practical help that new mothers need, especially
in relation to breast-feeding.
The HBA recently conducted a breast-feeding survey amongst
members and found that voluntary organisations and the domiciliary
midwives provided the best information and support in this regard.
Domiciliary midwives visit mother and baby for several consecutive
days postnatally, a service far superior to that given to mothers
discharged from hospital who might receive one or two visits
from a P.H.N., if she is lucky. A home help service, as is provided
in the U.K. and Holland, would be a bonus to both home and hospital
delivered women.
10) Future of
the maternity services
The "Report
of the Mother and Infant Care Scheme Review Group" and
"A Plan for Women's Health" both published in April
1997, recommend establishing pilot schemes to evaluate hospital
and community approaches to home births. No details are available
as yet (June '97). We would like to see a more autonomous role
for midwives in hospitals, community midwives working in group
practices and a separate professional body for midwives. One
effect of their current grouping with R.G.N.s in Bord Altanias,
means that they are classed as paramedics by the health insurance
and so their clients are not eligible for fee refunds. It is
most important that midwife status is not further reduced to
that of "obstetric nurse" as in many parts of the
USA.
Further
resources
• A National Breast-feeding Policy for Ireland.
• The Future of Nurse Training and Education
in Ireland
• Irish AIMS (Association for Improvements
in Maternity Services).
• Irish Childbirth Trust.
• The Winterton Report (House of Commons Health
Committee).
We
would like to wish you every success with your project and training.
We hope that you have gained a better understanding of home
birth issues and that you will consider domiciliary midwifery
as a future career.
Postal correspondence
should be addressed to:
The Home Birth Association of Ireland
36 Springlawn Court,
Blanchardstown
Dublin 15.
homebirth AT eircom.net
