Wednesday, 8 October 2014

A Midwife for every Woman: A well evidenced letter by a 32wk pregnant woman affected by the Philomena Canning Case.

A well evidenced letter by a 32wk pregnant woman affected by the Philomena Canning Case.
#isupportphilomenacanning #WomenFirst #Midwife4EveryWoman

 The decision of the High Court to uphold the suspension of SECM Philomena Canning’s indemnity insurance highlights a number of important areas around maternity service provision in Ireland - the treatment of women within the maternity services, particularly those seeking homebirths, ...the treatment of self-employed community midwives, and the HSE’s non-adherence to its own protocols of investigating clinical matters. The rhetoric of the HSE is about safety and public health, yet developments in maternity care policy has consistently ignored the findings and recommendations of research reports, including the 2008 KPMG Report and the 2013 HIQA Report into the death of Savita Halappanavar. The HSE would do well to base its understanding of the concept of safety on the vast body of national and international research in favour of developing midwifery-led services, including home birth, instead of shutting down the practices of SECMs in the absence of evidence, and in doing so forcing women into a non-working hospital system.

There remains in Ireland a deeply entrenched social perception that pregnancy and birth are inherently dangerous, and that hospital-based care equates to safer care, regardless of the circumstances or women’s risk status. Women who want to have a home birth are often seen as reckless; the midwives who care for them as mavericks. The reality could not be further from this belief: the vast majority of women who decide to have a home birth are extremely well informed about the risks and benefits of both home and hospital birth, and the midwives who care for them are without exception highly skilled and experienced, and committed to providing excellent clinical care.

A growing body of high quality research in favour of home birth supports the view that planned home birth among low risk women is closely associated with significantly reduced interventions, and no increased risk for perinatal outcomes. Recent research in the UK, Holland and Scandinavia found that for women having their second or subsequent baby, birth in a non-obstetric unit significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy; a large scale longitudinal study into the association between planned place of birth and severe adverse maternal outcomes which reviewed the data for over half a million women found that low risk women with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital births. Further, there was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system. The issue of a wider supportive structure for home birth services has also been emphasised: midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulted in favourable outcomes for women planning both home or hospital births. These key elements – the existence of good communication and infrastructure between health professionals, and the creation of a safe environment that enables supportive relationships between women and caregivers – are foundational to good clinical outcomes. Philomena Canning’s commitment to communication, collaboration and transparency is clear in how she conducts her practice, including in relation to the current case in which she reported a woman’s transfer to hospital in accordance with HSE procedures. In contrast, the HSE has displayed no such commitment to collaboration, either with women, or with SECMs, and appears pitted against them at every turn. The track record of the HSE does not inspire confidence: the findings of the HIQA report on the wider maternity care services emphasised its lack of responsiveness and accountability, an institutional resistance to change, and an inability to learn from service users’ experiences. Greater home birth provision requires development of infrastructure to support integrated services: the lack of such services in Ireland are cited as the barrier to home birth development, yet the centralisation of maternity care services in large urban areas has resulted in many women living significant distances away from maternity units, and increasing numbers of babies being born on the way to hospital. In other words, existing infrastructure supports neither home nor hospital birth, nor does it support the women who are supposedly at the centre of service provision.

Any claims that the HSE may make that e.g. the woman is respected as the primary decision maker cannot be seen as anything other than a sham. Policy documents that are peppered by terms like “choice” and commitment to a “woman-centred care”, yet any autonomy that women are claimed to have is trammelled by the fact that her role as primary decision maker is conditional on those decisions being the “right” ones, according to the criteria laid down by the HSE, and based on the interpretation of evidence that strengthens its position. This places the HSE in a virtually impregnable position of power, not only as the primary decision maker in care, but as the body who can decide the criteria upon which those decisions are drawn.

The women in Philomena’s care are now in the position of having to decide what to do next. Many of her clients have not been contacted by the HSE at all. I received a text message asking whether I had any queries about the home birth service: I did indeed, and when I rang I had a number of queries – what are my options now? What the implications of the suspension of Philomena Canning’s insurance for my care and the care of my baby? What is the HSE doing to expedite this issue? Why has the HSE not contacted me in writing to inform me of any developments? I did not receive satisfactory answers to any of my questions; I was told that a text message is technically speaking, “written correspondence”, and that if I wanted to find out more details about the implications of the High Court decision, I should consult the national media. I was also told that I would be contacted by Wednesday evening with the details of replacement midwife. It’s Friday, I have not yet been contacted by the HSE.

There is no national home birth service, despite HSE claims that “The National Domiciliary Midwifery service is available to eligible expectant mothers who wish to avail of a home birth service under the care of a self employed community midwife”. There are currently fewer SECMs providing a home birth service than there are counties in Ireland. Why? Largely because the HSE has intimidated SECMs to the extent that few midwives are willing to put themselves in a position where their practice is under continual surveillance and where their professional autonomy is compromised and undermined at every turn. For the majority of Philomena’s clients, there are no other SECMs available at short notice, because they are in such high demand. Hospital-based Domino Schemes that provide a home birth service are equally over-subscribed, and the geographical inequity of home birth services means that women’s choices of care model are limited to whatever is available in their area. For most women in the area covered by Philomena, this means going into hospital. The most recent guidelines issued by the National Institute for Health and Care Excellence (NICE) in the UK recommend that low-risk multiparous women be advised to give birth at home or in a midwifery-led unit (free-standing or alongside a maternity hospital). Obstetric Units are considered inappropriate to the needs of women considered low risk, as they increase the likelihood of caesarean section and other interventions. These recommendations echo those of the 2013 HIQA report in Ireland which states that all women should have access to the right level of care and support at any given time. Since all women deemed eligible to access home birth services in Ireland are by definition low-risk, this suggests that the only option now available to us is the least appropriate, and therefore the least safe.

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