Submission from Association of Maternity Services Ireland (AIMSI) to the National Steering Committee for Home BirthsDear All,
We have serious difficulties with both the proposed Memorandum of Understanding (MOU) and and the proposed "Agreement" between midwives and the HSE from a human rights perspective and we write to bring these to the attention of the NSCHB.
AIMSI represents the views of several thousand women who have contacted AIMSI (and the Home Birth Association) over the duration of this Committee's life span. We are the only stakeholders on this Committee who have actively sought to canvass the opinion and views of the service users of a Home Birth Service that will be defined by the new MOU and Agreement that, we understand, this Committee plan to sign off on on 26th March 2013.
1. AIMSI recognizes a women's fundamental right to choose where she gives birth. This is a human right that finds expression in international best practice, such as NICE (UK) and ACOG(USA), which clearly define a woman’s choice as final, regardless of recommendations.
The proposed MOU does not have any provisions that recognize and safeguard a woman's preferences, and the NSCHB has made no effort to accommodate women who want to exercise their choice as to place of birth. The official response to such women appears to be the exercise of coercion. During the lifetime of this Committee, suggestions, both implied and overt, verbal and in writing, have been made about how a woman who is reluctant to transfer to hospital in home birth might be coerced into doing so, either by the attending midwife or midwives, and/or involving "other stakeholders", included the Garda Siochana, which, as draft NSCHB guidelines were in breach of both the Constitution and European law. In practice, at least one mother has also been threatened with the seeking of a court order against her, making her unborn child being a ward of court at birth should she not agree to a hospital birth.. Indeed, the recent response to Mother A by the HSE suggests that court orders are becoming part of the official approach in Ireland to pregnant women who attempt to exercise their autonomy.
However, what may not be realized is that women who have experienced these tactics of coercion in Ireland are sharing their stories on social media to audiences of tens of thousands. Some pregnant women who read them have concluded that it is better NOT to engage with the HSE at all that their and their baby's best interests will be served by not availing of antenatal care and by birthing unassisted, without professional assistance of any kind.
This is surely not what NSCHB intends by way of outcomes to its intended sign off on the MOU and Agreement, yet, unless these documents are revised in such a way as to ensure that a woman's fundamental right to choose where she gives birth is upheld, an increase in the number of unassisted births, with their attendant risks, seems inevitable.
While the HSE recognizes the right to informed choice in medical treatment and health, maternal choice is recognized only if it reflects the prevailing model of obstetric care, apparently: the official approach does not seem to recognize women's right to make birth choices which reflect a midwifery model of care.For example, there appears to be no problem with c- sections on maternal request, despite the risks that this procedure carries.
2. But denying women their constitutional and human rights to autonomy, self determination, bodily integrity, etc leaves the State exposed to legal challenge. Both the MOU and the Agreement are in breach of Article 8 of the European Convention on Human Rights, which enshrines the fundamental right to bodily integrity. The MOU is also in in breach with the decision taken by the European Court of Human Rights in Ternovsky vs Hungary (2010), which found in favour of the right to choose the circumstances of becoming a parent. Here in Ireland, the Constitution enshrines the rights to autonomy, self determination, and bodily integrity, and the right to refuse medical treatment, yet the proposed MOU clearly breaches Article 8 of the ECHR.
3. For many women, one of the reasons they want to birth at home is because their previous experience of care in an obstetric setting left them with significant post traumatic stress. Ironically, these women may now find themselves in Tables 1 or 2 of the MOU, thereby preventing them exercising home birth choices in subsequent pregnancies, and forcing them back into the very same model of care that traumatized them in the first place.. Outlawing choice in this way runs the risk of further traumatizing women emotionally, which in turn will have knock on effects for already overstretched mental health and GP services.
4. AIMSI is particularly concerned, inter alia, about making mandatory a requirement that two midwives be present at every birth. The NSCHB's insistence on a second midwife who has signed the Agreement will severely curtail the home birth service in many areas of the country. This will lead to severe geographic inequities in service provision and will deny women their constitutional and human rights in childbirth.
This requirement is not evidence based: there is no good evidence to show improved outcomes for mother or baby when two midwives assist at a home birth. While this may have become practice in some parts of the country, due to local preferences, imposing this in the Greater Dublin area, where there are simply not enough midwives that meet the stringent criterion wrongly laid down by the NSCHB for the second midwives will potentially eliminate the choice of home birth services provided by SECMs in the region. NSCHB's unreasonable insistence that second midwives are required to have three years' prior experience in a Maternity Hospital will significantly reduce the pool of midwives available to act as second midwives: This requirement is also not evidence-based and appears to runs contrary to ABA's guidelines.
The requirement to have a second midwife will leave women in a very vulnerable position. Should a second midwife not be available at the last minute, women will be forced to transfer to hospital in the height of labour, an unsafe and traumatic scenario. The inevitable result will be more babies born before arrival in hospital. Birthing in the back of a car or on the side of a road with one midwife or a paramedic team with minimal training in the management of childbirth is infinitely less safe for mother and baby than birthing at home with one SECM. Another issue that has been raised is that women should be able to chose whether or not they wish to have a second midwife, whom they may not know, in attendance at their home birth. Many women specifically choose home birth so that they will have continuity of care from a known and trusted midwife.
5. Our presence on this committee was to bring the perspective of the service user to the table so that this could be factored into the new instruments (MOU and Midwife's Agreement) that will define the home birth services that these women and their families will have available to them. AIMSI has repeatedly been denied that opportunity, however. The MOU was drawn up in September 2008 under severe time pressure, at the behest of the then Minister of Health, Mary Harney. It was always AIMSI's understanding that the MOU was an interim document and that issues, such as VBAC at home, would be revisited and re-assessed. This review process excluded all such issues from consideration, leaving large groups of women excluded from the State's home birth services.
The only two groups that have not been consulted in the drafting of these key documents are the service users and the service providers (as in SECMs), even though both groups are theoretically represented on this HSE National Steering Committee. Consultation means more than engineering a fait accompli, it means parity of esteem, with each participant an equal partner in the drafting process. This has never applied to the NSCHB, however, where some delegates have always been "more equal" than others. AIMSI has been persistently denied the opportunity to consult these documents during drafting; and once drafted, the organization was informed that no changes were permitted; with repeated requests for the most recent versions falling on deaf ears. Two days before these documents are scheduled for final approval, AIMSI has still not seen the final drafts.
In conclusion, AIMSI cannot reasonably be expected to sign off on any document that will radically affect the provision of the State home birth services without proper prior consultation and without being afforded the opportunity to input into these highly important contractual agreements. Until these issues are resolved, AIMSI will not be a signatory to any instrument seeking to restrict the provision of State home birth services that flies in the face of women's human rights in childbirth.
Krysia Lynch and the AIMSI National Executive
cc. Laverne McGuinness, National Director of Integrated Services, HSE
cc. Dr James Reilly, Minister of Health,
Update 11am Monday 25th March: AIMSI has received a letter from a woman to Patient Focus, the other consumer representative on NSCHB. Please see below - posted with permissions.
Dear Sheila O' Connor and Patient Focus,
As a Mother and pregnant Mother, I strongly object to the MOU and how it will be implemented as categorical exclusion rules. This means my maternity system is and will continue to treat me as a sheep in a herd. It denies me individual assessment for care options, it denies me an equal input into my care options, it denies my Midwife autonomy work in her professional it denies me evidence best practice.
If you vote for the MOU to go through, you will part-take in an ongoing battle of women's oppression and you will be in support of denying Women their Human Rights.
You will NOT represent me.
This MOU is flawed, how it has been drafted is flawed, it's current implementation is flawed and it's news content is flawed. Given the recent statement via AIMS Ireland, I cannot and could never say that anyone voting in agreement with the MOU represents me.
Your deeply concerned about our birthing future
If you would like to send a similar letter, please consider the following recipients:
Sheila Sugrue - National Midwifery Lead, Ireland: email@example.com
Michael Turner - National Obstetric Lead, Ireland: firstname.lastname@example.org
Sheila O'Connor - Patient Focus, Consumer Rep: email@example.com
James Reilly - Minister for Health: firstname.lastname@example.org
Michael Shannon - Chair of NSCHB: email@example.com
AIMSI have been approached by a legal firm who are looking for women/a woman to make a complaint to the Committee on the Elimination of Discrimination Against Women (CEDAW). We are looking for women who are prepared to make a complaint to the CEDAW because of a threat that their right to autonomy will be violated or because their rights have been violated. please contact: firstname.lastname@example.org
* Please see earlier blog posts on draft HSE guidelines for consent in pregnancy for further background.