There has been much discussion following yesterday's High Court case of Aja Teehan vs HSE, much of which is uninformed, incomplete, and one-sided.
AIMSI would like to put forward the following points to this discussion.
1. This is about the right to self determination on the circumstances of becoming a parent - hospital or home, with a doctor or midwife, with pain relief or not - every woman must make the choices which she feels is best for her and her baby. The HSE can provide guidance and recommendations, however the ultimate decision must be the woman's.
2. In the discussion thus far, "risk" has played a heavy focus. There are no absolute risks in childbirth and each care option poses specific, individual risk potential. Informed choice means women understand the benefit and risks of each care option, selecting the care option that she feels most comfortable with.
The risks cited have been only with regards to giving birth at home after a previous Caesarean Section (HBAC) - mainly to do with uterine rupture.
* The rate of uterine rupture in Ireland is low. The rate is 2 per 1000 women overall, or 1 per 1000 for women in spontaneous labour who did not receive oxytocin augmentation (Turner et al, 2006). That means that 999 women will not rupture out of 1000.
* Of the small percentage of women who do rupture, even a smaller percentage of women will lose their baby or require a hysterectomy. In the rare instance of rupture, 94% of babies survive. Guise et all 2004 via Midwife Thinking
* Uterine rupture is associated with women whom have had a previous caesarean section, however, uterine rupture can occur with women with no previous Caesarean history.
* The risk of uterine rupture during a VBAC is actually lower to those of other possible birth complications of which are present in all vaginal births. First time mums are at risk for complications that are equally serious to uterine rupture and occur at a similar rate. For example, placental abruption, (Deering 2013) cord prolapse, (Beall 2012) and shoulder dystocia. (Allen 2011)
* VBAC is safe. Overall, around 70% or more of women who try VBAC will give birth vaginally. If a woman has given birth vaginally previously, this rises to 90% (9 out of 10 VBAC women will birth vaginally)
* None of the risks cited above are reasons to undermine a woman's right to choose how or where she births.
3. The discussion of risk has been incredibly one-sided. The risk of going to hospital and/or the risk of a repeat Caesarean Section are real and substantial.
* Risk of hospital - Kilkenny is a maternity unit which has been flagged as having a disproportionate rate of Caesarean Section.
Kilkenny has a VBAC rate of only 2% (best practice recommendations is 70%)
43% of first time mothers in Kilkenny have a Caesarean Section
32% of second+ time mothers in Kilkenny have Caesarean Section
These rates are well above the National average and recommendations for best practice.
Hospital care in Ireland is obstetric led in practice and policy and include many routine interventions which increase distress to babies in labour and increase the risk of adverse affects with women - intervention, assisted delivery, or caesarean section. Routine means that the practice or procedure is done as a normal practice on every woman, not down to medical necessity or evidence. Other practices may not be routine for every woman, but are frequent in use despite risks. For example recent research by the ACOG has shown the use of oxytocin - for induction of labour or to 'speed up' labour - is an independent risk to babies and increases NICU admission.
* Risks of Repeat Caesarean Section - the risks associated with Caesarean Section increase with each section. They include:
~ increased risk of ectopic pregnancy in future pregnancies
~ increased risk of placenta previa (when the placenta covers the cervix)
~ increased risk of placental abruption (when the placenta comes away from the uterus before the baby is born)
~ increased risk of placenta accrete (the placenta grows into or through the wall of the uterus)
~ increases likelihood of problems for women – haemorrhage, blood clots, infection, scar pain
~ increased risk of severe complications - severe morbidity - such as hysterectomy
~ increases time of hospital stay and the instances of re-admission
~ longer recovery period
~ increases the likelihood of problems for babies – admission to NICU, breathing problems, cuts from incision
* Death - while the risks are relatively small, as with all major surgical procedures, there is a risk of death. The risk of death in a woman following a Caesarean section is believed to be less than 1 in 2,500. The risk of death in a woman following a vaginal birth is believed to be less than 1 in 10,000. There is a higher risk for emergency Caesarean Sections vs planned Caesarean Sections. Cunningham FG, et al. (2005).
* Severe Maternal Morbidity Audit report from Cork's National Perinatal Epidemiology Centre took a national audit of Irish maternity units looking for instances of severe maternal morbidity (complications). Severe maternal morbidity is essentially the 'near misses'. The audit found that the most instances of severe maternal morbidity in Ireland was postpartum (after the birth) and the main mode of birth was by Caesarean Section.
Despite the substantial increased risks of repeat Caesarean to mothers and babies the HSE recognize the mother's right to self determination in these cases - women are not denied repeat caesarean where requested by the mother. The risks of going to hospital for a VBAC is an increased likelihood of a repeat Caesarean, and the implications this has on mothers and babies. Given Kilkenny's rates of Caesarean and VBAC, this risk is magnified.
It is up to each woman to weigh the risks of HBAC, VBAC in hospital, repeat Caesarean Section comparatively in order to decide what is right for her.
4. It has been suggested that a woman should not expect the HSE to pay for a Homebirth.
* This woman has secured a private midwife and is willing to pay for a homebirth. She is not legally allowed to. The State has made it ILLEGAL for a midwife to attend a woman outside of criteria (VBAC one of many) as the midwife is not insured to do so. Midwives who attend women without insurance are punishable by law with a €60,000 fine and/or 10 year prison sentence.
* The HSE has said women who fall outside criteria still have the right to have a homebirth, they just can't have a midwife attend them legally. What are the HSE advocating exactly? Homebirth has been shown in many studies to be as safe as hospitals when the woman is attended by a professional midwife and a good transfer system is in place. Unassisted homebirth is associated with more risks.
* In terms of cost, a Caesarean Section is believed to cost the health service double that of a vaginal birth (Turner), yet the public, State, HSE do not put barriers up for women in this mode of birth.
* women can access public or private obstetric led care in every region and maternity unit. The same choice should be afforded for midwife led care - MLU, DOMINO, Homebirth
* The Mid-U study found that the same birth, for the same woman, costs over €300 more for women in a consultant led unit (CLU) vs a midwife led unit (MLU). But women in the MLU had less intervention, less adverse effects, and higher satisfaction rates.
* In a 2007 case study at NMH’s DOMINO scheme 5,500 bed days were saved by Community Midwifery Services in NMH Holles St. (Early Transfer home and DOMINO). The study also found Caesarean rates are significantly lower e.g. 2007 LSCS in NMH 18.92%, LSCS in DOMINO NMH 5.86%
5. An Equitable system means that women have access to all care options and equal care regardless of where they live or ability to pay. If we are happy to support the cost and choice of women having consultant led care and surgical modes of birth, interventions (despite added cost and risk), then we also support women who decide to have midwife led care options in hospital or the community.
6. The HSE are stating that the criteria created for homebirth eligibility is based on evidence and practice in other jurisdictions. AIMSI would like to know what jurisdictions.
* The HSE criteria appears to be directly pulled from NICE in the UK with one difference, NICE recognizes informed choice and specifically states the final decision is with the woman and must be respected.
* When querying the HSE eligibility tables, AIMSI directly cited this point. The HSE directly stated that the tables were not based on NICE.
* Best practice clearly states that patients should be assessed on an individual basis on their current health, current medical conditions, as well as their previous history. The HSE are not providing women with individual assessment, a fundamental principal in evidence based care.
7. The ECHR (European Court Of Human Rights) found that it is a human right to privacy, and the human right to privacy encompasses the right to choose the circumstances on becoming a parent. Any State which has signed up to the European Convention, has agreed to be bound by the judgement of the court. However, as Ireland has slightly different legal agreement, the Constitution rises above the European Convention in Irish law.
The HSE have invoked article 40.3.3 in their argument to argue that the State has an obligation to protect the life of the woman, as well as the foetus.
We have seen the HSE invoke the Constitution in maternity care before, including recently circulated guidelines for consent which state:
* Draft Guidelines on consent for pregnant women state: "The Consent of a pregnant woman is reqired for all health and social care interventions. However, because of the constitutional provisions on the right to life of the 'unborn', there is legal uncertainty regarding whether a pregnant woman's right to refuse treatment extends to the refusal of treatment which puts the life of the foetus at serious risk. This matter can ultimately only be decided by the Courts. Thus, where a pregnant woman refuses treatment and this refusal may impact on the life of the foetus, it is essential that the consequences of the refusal are fully and clearly explained to the woman, and legal advice should be sought if she persists in the refusal"
8. There is an assumption that this case has been taken to force the HSE to grant a request for homebirth. It is not. From Aja Teehan " I'm looking to have their decision to deny me a homebirth quashed, and retaken again in accordance with law."
References and further information
VBAC Facts: More VBAC Facts: http://vbacfacts.com/13-myths-about-vbac/
Cuidiu Birth Statistics per unit in Ireland: http://www.bump2babe.ie/statistics/
Midwife Thinking: VBAC: Making a Mountain out of a Molehill: http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/
1. Deering, S. H.; Smith, C. V. Abruptio Placentae, 2013. Medscape. http://emedicine.medscape.com/article/252810-overview#a0199.
2. Beall, M. H.; Chelmow, D. Umbilical Cord Complications, 2012. Medscape. http://emedicine.medscape.com/article/262470-overview#a30.
3. Allen, R. H.; Chelmow, D. Shoulder Dystocia, 2011. Medscape. http://emedicine.medscape.com/article/1602970-overview#a03