Wednesday, 31 December 2014

AIMSI statement on the removal of somatic support to a woman with an unviable foetus of 18 weeks gestation

AIMSI welcomes the High Court Judgement of the 26th December 2014 that somatic support be switched off for a woman who was declared clinically dead on December 3rd 2014. Our sympathies go out to her family and we hope that the family will now be able to grieve the loss of their loved one in dignity and peace.
AIMSI were disappointed that this case arose in the first place. It is a well known medical fact that a foetus of 15 weeks is not viable and we fail to see what possible reasons there could have been for medics to invoke the 8th amendment and put the woman's family, especially her children through such distress. The natural course of events is that when a woman dies in such circumstances, the foetus she is carrying dies with her.
This case highlights, the control over women's bodies in maternity care that the State presumes itself to have. Even though this woman was clinically dead, the State still presumed to have control over her womb, and medical professionals thought it appropriate to seek clarification on whether they should continue to use her body to incubate a 15 week old foetus. The Constitution is supposed to maintain the right to bodily autonomy in life and one hopes also in death. This does not appear to have happened in this case. AIMSI sincerely hopes that no other family will ever be subject to such distress in the Irish Maternity System.
Whilst this was a particularly macabre episode of an invocation of the 8th Amendment, AIMSI notes that the 8th Amendment is repeatedly used in the context of maternity rights to deny women the right to bodily autonomy in terms of decision making in pregnancy, in labour in birth and in the postpartum period. Women have reported being  forced into caesarean births, forced into invasive procedures during labour, threatened with social services and in some cases threatened with the Gardai and mental health services for trying to assert their right to bodily autonomy. The 8th Amendment is also repeatedly used to justify a swath of clinical practises during labour and birth which the international research based evidence does not support. Finally, in contrast to maternity guidelines and policies in other countries, where women are given the final choice over their care and that of their baby, the 8th Amendment in Ireland is used to suppress women's choice and give ultimate control over a woman's body when pregnant to the State.
AIMSI continues to call for a repeal of the 8th Amendment to ensure that women and their families are able to make informed choices about the care that they receive during pregnancy, labour and birth in Ireland.
December 31st 2014

Thursday, 18 December 2014

FAO: HSE - A helpful synopsis of well respected Clinical Guidelines on the use of Synthetic Oxytocin


AIMS Ireland are very surprised to see the HSE state that there are no national or international evidence based guidelines on the use of synthetic oxytocin in labour.

"A spokesperson for the HSE, which jointly operates the National Clinical Programme for Obstetrics and Gynaecology with the RCPI, told MI: “At present, we are not aware of any national or international guidelines to guide practice on oxytocin augmentation in labour. The programme supports the development and use of local guidelines at each maternity unit, but the programme hopes to build a national consensus on a standardised guideline over the next year.” Medical Independent - December 18, 2014

The comment comes from an article on surveys taken by the States Claims Agency to the 19 Irish public maternity hospitals on the use of synthetic oxytocin in labour following observations that there is a frequency in obstetric claims when the drug is used, suggesting synthetic oxytocin to be a contributing factor.

Syntocinon/ Pitocin /Oxytocin is a synthetic version of a hormone present in labour which stimulates contractions. Synthetic Oxytocin is routinely used in Irish maternity units to synthetically start (induce) or speed up labour. It is a common component of Active Management of Labour, in which a woman's labour is managed by health care providers, using intervention and drugs, to 'speed up' process. Synthetic Oxytocin is linked to an increase of adverse effects for women. A recent study has also suggested that synthetic oxytocin is an independent risk factor for adverse effects in full term newborns. With some Irish units reporting use of synthetic oxytocin in nearly half of first time mothers during labour, AIMS Ireland are deeply concerned that our national policy makers within the Health Service Executive appear to be unaware of clinical practice guidelines on its use.

In August 2013, AIMS Ireland reviewed the evidence and international guidelines for induction of labour and the use of synthetic oxytocin for the article "Induction of Labour - Is it Right for You?" as part of our 42 Weeks Campaign.

AIMS Ireland: Induction of Labour - Is it Right for You?

"A hormone drip containing synthetic oxytocin (Syntocinon®) should only be offered if the membrane sweep or prostaglandins have not been effective in starting labour. It is also offered to women who may have been induced by membrane sweep or prostaglandins but whose contractions and cervical dilation have slowed completely or appear to have stopped. It is not recommended for use until at least 6 hours after receiving prostaglandin gel or 12 hours after removal of the prostaglandin pessary. Whether to consent to induction of labour, or not, is a choice that at least 1 out of 3 women will have to make in her maternity care in Ireland."

AIMS Ireland felt it would be helpful to provide a synopsis of these practice guidelines from well respected sources.

International Guidelines on Induction and the Use of Synthetic Oxytocin

“The National Institute for Health and Care Excellence (NICE) in the UK recommends that induction of labour has a large impact on the health of women and their babies, and so needs to be clearly clinically justified."

NICE Guidance Recommendations 2014: Intrapartum Care

Key points: quoted directly from NICE

1.12.1 Do not offer or advise clinical intervention if labour is progressing normally and the woman and baby are well. [2007]

1.12.2 In all stages of labour, women who have left the normal care pathway because of the development of complications can return to it if/when the complication is resolved. [2007]
1.12.10 Do not routinely offer the package known as active management of labour (one‑to‑one continuous support; strict definition of established labour; early routine amniotomy; routine 2‑hourly vaginal examination; oxytocin if labour becomes slow). [2007]

1.12.12 Do not use combined early amniotomy with use of oxytocin routinely. [2007]

1.12.13 If delay in the established first stage is suspected, take the following into account:
  • parity
  • cervical dilatation and rate of change
  • uterine contractions
  • station and position of presenting part
  • the woman's emotional state
  • referral to the appropriate healthcare professional.

    Offer the woman support, hydration, and appropriate and effective pain relief. [2007]
1.12.14 If delay in the established first stage is suspected, assess all aspects of progress in labour when diagnosing delay, including:
  • cervical dilatation of less than 2 cm in 4 hours for first labours
  • cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours
  • descent and rotation of the baby's head
  • changes in the strength, duration and frequency of uterine contractions. [2007
1.12.22 If oxytocin is used, ensure that the time between increments of the dose is no more frequent than every 30 minutes. Increase oxytocin until there are 4–5 contractions in 10 minutes. (See also recommendation 1.10.3.) [2007]

1.10.35 If there are any concerns about the baby's wellbeing, think about the possible underlying causes and start one or more of the following conservative measures based on an assessment of the most likely cause(s):
  • encourage the woman to mobilise or adopt a left‑lateral position, and in particular to avoid being supine
  • offer oral or intravenous fluids
  • offer paracetamol if the woman has a raised temperature
  • reduce contraction frequency by:
    • stopping oxytocin if it is being used (the consultant obstetrician should decide whether and when to restart oxytocin) and/or
    • offering a tocolytic drug (a suggested regimen is subcutaneous terbutaline 0.25 mg). [new 2014]

WHO: recommendations for induction of labour

Key Points: Quoted directly fromWHO
* Induction of labour should be performed only when there is a clear medical indication for it and the expected benefits outweigh its potential harms.

* In applying the recommendations, consideration must be given to the actual condition, wishes and preferences of each woman, with emphasis being placed on cervical status, the specific method of induction of labour and associated conditions such as parity and rupture of membranes.
          * Induction of labour should be performed with caution since the procedure carries the risk of  uterine hyperstimulation and rupture and fetal distress.

WHO evidence:

Evidence related to the use of intravenous oxytocin for induction of labour at term was available from a Cochrane systematic review (15). Compared with placebo or expectant management, the use of oxytocin alone was associated with fewer vaginal births not achieved within 24 hours of induction of labour (three trials, 399 participants, RR 0.16, 95% CI 0.1–0.25), fewer admissions to a neonatal intensive care unit (seven trials, 4387 participants, RR 0.79, 95% CI 0.68–0.92), and increased risk of caesarean section (24 trials, 6620 participants, RR 1.17, 95% CI 1.01–1.35) (EB Table 2.1.1).

The use of intravenous oxytocin alone has also been compared with prostaglandins (EB Tables 2.1.2, 2.1.3, 2.1.4). Overall, the use of prostaglandins was associated with a reduced risk of vaginal birth not achieved within 24 hours and fewer caesarean births.

ACOG Induction Guidelines revised in 2013

From ACOG press release: "A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery," notes Dr. Ramin. Although rare, there are potential complications with some methods of labor induction. "These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus."

Guideline on Induction:

2013 ACOG: Study Finds Adverse Effects of Pitocin (Synthetic Oxytocin) in Newborns:

“Induction and augmentation of labor with the hormone oxytocin may not be as safe for full-term newborns as previously believed, according to research presented today at the Annual Clinical Meeting of The American College of Obstetricians and Gynecologists. Researchers say this is the first study of its kind to present data on the adverse effects of Pitocin use on newborns...As a community of practitioners, we know the adverse effects of Pitocin from the maternal side,” Dr. Tsimis said, “but much less so from the neonatal side. These results suggest that Pitocin use is associated with adverse effects on neonatal outcomes. It underscores the importance of using valid medical indications when Pitocin is used.”

ACOG: Oxytocin for Induction PDF:


"The side effects of oxytocin use are principally dose related; uterine tachysystole and Category II or III FHR tracings are the most common side effects. Uterine tachysystole may result in abruptio placentae or uterine rupture. Uterine rupture secondary to oxytocin use is rare even in parous women"

* Uterine Tachysystole is when a woman's uterus is over-stimulated resulting in more than the normal pattern of contractions in a period of 30 minutes.

"Low- or high-dose oxytocin regimens are appropriate for women in whom induction of labor is indicated"



"If uterine tachysystole with Category III FHR tracings occur, prompt evaluation is required and intravenous infusion of oxytocin should be decreased or discontinued correct the pattern (32). Additional measures may include turning the woman on her side and administering oxygen or more intravenous fluid. If uterine tachysystole persists, use of terbutaline or other tocolytics may be considered. Hypotension may occur following a rapid intravenous injection of oxytocin; therefore,
is imperative that a dilute oxytocin infusion be used even in the immediate puerperium."

"The use of a checklist is highly recommended when administering oxytocin. Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that
require its discontinuation. The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institution’s protocol."

 So, with all this information available to consumers at just the click of a mouse how is it that the National Health Service Executive, with governance to make policies affecting the care of women and babies in our maternity services, are not?


Full Article: State Claims Agency surveys maternity services on oxytocin

Thursday, 9 October 2014

Midwife-Led Birth is Safe Birth

Midwife-Led Birth is Safe Birth. At Home, Hospital or Freestanding.
Safe for women and babies. Better outcomes for women and babies
Cost effective for health services.

Read the latest evidence:...

NICE recommendations re home births in England and Wales, Intrapartum Care, May 2014:

Low-risk women (women without medical conditions or other factors that put them at increased risk) who have given birth before should be advised to plan to give birth at home or at a midwifery-led unit (freestanding or alongside).


Findings from the National Perinatal Epidemiology Unit, Oxford, Birthplace Cohort Study, 2011

For women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother


HSE Mid-U Report:

The 'MidU' ('Midwifery Unit') study showed that midwifery-led care, as practised in these units, is as safe as consultant-led care but uses less intervention in pregnancy and childbirth.

Women's satisfaction with the facilities was apparent in the study and 85% of those attending the MLUs said they would recommend the care they had received to a friend, compared with 70% of those having usual care. Although facilities in the MLUs were quite luxurious, the cost of care for each woman was €332.80 less than in the usual hospital system

Wednesday, 8 October 2014

A Midwife for Every Woman: Open Letter by one of Philomena's Clients, 38wks pregnant, to the HSE - Re: failures to date.

Open Letter by one of Philomena's Clients, 38wks pregnant, to HSE - Re: failures to date. #isupportphilomenacanning #Midwife4EveryWoman #WomenFirst

One of the women who was booked in with Philomena Canning has written this brave, honest, open letter and asked AIMSI to publish it on our page based on her experiences with the HSE to date, on trying to access a replacement midwife, the failures she has encountered thus far, and th...e blatant disregard for patient safety. The woman has asked for her name to be included but to remove identifiable references of the replacement midwife.

We feel this letter highlights the failures of the HSE to provide these 25 women with appropriate care solutions following the removal of Philomena Canning's indemnity.

Dear Ms Clarke,

Further to our conversation yesterday I wish to clarify some details of my care.

You called me yesterday to inform me that you had sourced me a midwife, and that this midwife was immediately available to me for the duration of my pregnancy. This is something I clarified with you again when you arrived to my home to drop off a home birth pack.

I have since spoken to the midwife (name provided) which you said was available to me.

On our first phone call (Midwife's name) did not know who I was, had never heard of me and was very apologetic that she couldn’t take me on as a client. As I am sure you can understand, this was very distressing for me. On a later phone call with (Midwife's name) she thought perhaps a mistake had been made and she had been given a wrong name and she could attend to me up until the 20thth October when she is due to go on night duty.

I am 100% completely dissatisfied with this ‘solution’ to the unlawful removal of my midwife Philomena Canning. The replacement midwife cannot provide me with continuity of care, as she is not available for the full duration of the 37-42 week window. This is completely unsafe and puts myself and my baby in danger. You told me yesterday that if I went into labour I could call this midwife and she would come to me. Again completely unsafe, as I have never met this woman, she has never met me and I still don’t have any prescription for the emergency drugs needed if I have a PPH. If I went into labour and followed your advice then the HSE would be liable for the bad management of my care should something go wrong. Furthermore, as per your own protocol under the heading ‘Issues to be discussed in pregnancy’, as I have not had a visit from any SECM midwife in more than four weeks, the following have not been discussed with me.

- Monitoring in Labour
- Third Stage Management
- PPH/Shoulder Dystocia
- Vitamin K
- PKU test
- Preparation for Breastfeeding
- When to Call

In fact, none of these issues have been discussed.

This is YOUR protocol and yet You are not following it.

Just to reiterate the facts here.

I have not had an antenatal appointment with a SECM midwife in 4 weeks and 2 days.

Your own protocol has not been followed with regards to Issues to be discussed during pregnancy.

You have assigned me a midwife who is not available for the duration of my pregnancy.

This midwife is taking clients on under duress.

This midwife is not as experienced in homebirth as Ms Canning.

This midwife does not know me or has ever met me to date.

You have advised me to call this midwife should I go in to labour. Which could be today.

Some other issues I would like to clarify. The replacement midwife is not trained in water birth and is not as experienced in homebirth as Ms. Canning due to her only taking on approximately six clients per year and also due to the fact that she is in employment at the (names an Irish maternity unit). This again in my opinion is unsafe. In order for a homebirth to take place there must be a build-up of trust and care between the midwife and client. This has not happened here. In fact, even though I spoke to the midwife yesterday, no antenatal appointment has been organised at all.

I find it extremely distressing that you have removed my midwife at this stage of my pregnancy, I am now entering my 38th week. I find it absolutely unacceptable that you are using the removal of insurance against Ms Canning and yet expect (Midwife's name) to take on the responsibility of my care, which would break many of the rules of the memorandum of understanding. You are creating an environment that would leave both myself and (Midwife's name) vulnerable. (Midwife's name) vulnerable to the removal of insurance in similar circumstances to Ms Canning, and myself vulnerable to an unsafe birth and dangerous outcome if a homebirth were to go ahead under these circumstances.

Lastly, I want to make it very clear, that should I decide to take the HSE up on its ludicrous offer of a midwife that appears to be unavailable. Should anything adverse happen to me or my baby, I will be holding the HSE fully liable.


Lesleyann Wylie
Kilpedder, Co. Wicklow.

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.

AIMS Ireland Statement (Sept 24, 2014) Philomena Canning

AIMS Ireland statement published to social media September 24, 2014

Philomena Canning #isupportphilomenacanning

AIMS Ireland is disappointed to learn that while grieving families struggle to get information from authorities about how their partners, mothers and children have died, the HSE has chosen to illegally pursue a midwife who has followed protocol and appropriate practice guidelines set out by the HSE themselves.

In the same week of the long campaigned for inquest of Dhara Kinlevan, we also learn that an independent midwife has had to seek an injunction against the HSE who have broken their contract with her without implementing their own due process.

Philomena Canning has been prevented from practicing following transferring a woman to hospital, whom was discharged 10 hours later. We note that the HSE are quick to close down the evidence based practices of independent midwives with no full inquiry yet rely on a cattle prod from the media to launch investigations into continued bad practice and questionable maternal deaths under obstetric care.

Minister Varadkar and the HSE need to take a long, hard, objective look at where their priorities are in maternity care. It is clearly not with women and babies.

Women First: A Midwife for every Woman.

#Midwife4EveryWoman #WomenFirst #isupportphilomenacanning

The HSE have broken their contract with women booked in for homebirth. It is of no fault of the women that Philomena Cannings indemnity has been suspended. You have read their powerful stories on the AIMS Ireland facebook page.

No contact. No antenatal care in the final stages of pregnancy. Poor communication.
No appropriate care solutions.

These women meet HSE criteria for Homebirth under the MOU. These women choose homebirth.

The HSE are 100% responsible for finding these women a midwife.

Suggesting to these women that they attend an obstetric led maternity unit is NOT an appropriate solution.

HSE, the onus is on you.
Women first.
We demand a Midwife for every woman.

Tuesday, 7 October 2014

Breaking News: Maternity Group calls for review into Maternity Services in budget 2015: Appropriate Maternity Care could save Exchequer 18.6 million per annum.

Maternity Group calls for review into Maternity Services as Budget 2015 continues to ignore Patient Safety and appropriate care options.


Appropriate Maternity Care could save Exchequer 18.6 million per annum.

The Association for Improvements in the Maternity Services Ireland (AIMS Ireland) are demanding an immediate response from the Government in budget 2015 on calls for a review into patient safety and appropriate care models in Irish maternity services.

AIMS Ireland’s calls follow fresh reports following the judgment of medical misadventure into the death of Dhara Kivlehan, the approaching inquest into the death of Sally Rowlette, investigations into the death of a baby in Mullingar, and failures by the HSE to provide appropriate care solutions and clinical care to 25 women following the removal of indemnity of Philomena Canning.

Krysia Lynch of AIMS Ireland “We are not using our Budget effectively in our maternity services. Our insistence of an obstetric care model has had profound effects on costs and patient safety. Ninety percent of women have no option than to book into obstetric led care, which is more expensive and is shown to have greater rates of intervention. These interventions are very costly in human and financial measures.”

She Adds, “We are not getting value for money. We are not getting widespread access to full service provision. Most importantly, we are not reaching the bar in terms of offering safe maternity services.”
Ireland’s obstetric-led model of care is outdated and is of very little benefit to the majority of women. While there may be an estimated 10% to 15% of women and babies who are in need of obstetric-led care, this care model is not recommended for the majority of women and babies, is shown to increase risk factors and adverse events to mothers and babies, and costs significantly more than hospital and community based midwife-led care options.

Austerity budget measures have increased these risks to patient safety in recent years. Irish obstetric led units are significantly understaffed to unsafe levels. Safe Childbirth recommends midwife to woman ratios of 1:28 for high risk case loads and 1:25 for low risk case loads; the majority of Irish units do not meet these standards of care with some units exceeding midwife to woman ratios of 1:50. Midwives express their concerns to AIMS Ireland, describing clinical care under these extreme pressures as ‘fire-fighting’.

The HSE’s Mid-U study found that the same birth, for the same woman, costs over €300 MORE for women in hospital based Obstetric led care options compared to Midwife-Led care. Midwife led care options use less interventions, are safe, and have high satisfaction ratings from women. Ireland has the highest birth rate in the OECD with roughly 73,000 births per annum. Subtracting the 15% of births where obstetric led care may be warranted, this leaves just over 62,000 births where midwife-led continuity of care would be best practice and safest for mothers and babies. This adds up to a potential cost savings of over 18.6 million euros.

Krysia Lynch ends, “Why is the Government failing to address these issues? This is the question we should all be asking. Why is our Government insisting on continuing with a care model which is not evidenced, is consistently struggling to provide safe clinical care to women and babies, and puts severe pressure on the public purse with no added benefit?”
AIMS Ireland contacts:
Krysia Lynch PRO: 087 754 3751
Jene Kelly 087 681 9095

Wednesday, 24 September 2014

AIMSI Statement: HSE breaks contract with Midwife without implementing their own due process

AIMS Ireland is disappointed to learn that while grieving families struggle to get information from authorities about how their partners, mothers and children have died, the HSE has chosen to illegally pursue a midwife who has followed protocol and appropriate practice guidelines set out by the HSE themselves.

In the same week of the long campaigned for inquest of Dhara Kinlevan, we also learn that an independent midwife has had to seek an injunction against the HSE who have broken their contract with her without implementing their own due process. Philomena Canning has been prevented from practicing following transferring a woman to hospital, whom was discharged 10 hours later.

We note that the HSE are quick to close down the evidence based practices of independent midwives with no full inquiry yet rely on a cattle prod from the media to launch investigations into continued bad practice and questionable maternal deaths under obstetric care.

Minister Varadkar and the HSE need to take a long, hard, objective look at where their priorities are in maternity care. It is clearly not with women and babies.

Friday, 12 September 2014

"Big Baby" - Would you put money on that doc?

Induction of labour is a common but serious obstetric procedure. Induction is a big decision that can have serious effects on the health of both a woman and her baby. The research shows that for babies and many women, the best outcomes are when labour starts on its own. Induction for 'big baby' is a  common intervention in Irish maternity care practice. Recommendations of induction of labour for 'big baby' are often based on inaccurate predictive practices of foetal weight measurements; either clinically by a care provider or by ultrasound. There is also significant research which suggests that a care providers beliefs has a direct effect on the way a labour is managed and birth outcomes. In other words, if an obstetrician believes a baby is big, and believes that a 'big baby' is prescriptive of complications, the woman's labour is managed more medically, increasing risks of interventions and surgery, and sometimes contrary to a woman's own beliefs or medical indication.

"I was induced at 39+6 because my baby was measuring 7lbs at my 36 week appointment and they were really worried I would have a hard time as the baby was too big. It scared me and I thought the induction would be the best option. I had a really tough induction cause my body just wasn't ready. Gel, broke waters, and needed a drip. My daughter got into distress and I just narrowly escaped a section but had episiotomy, which then tore as well, and forceps. She was born at 40 weeks and I was really horrified when she was weighed and I was told she was only 7lb 8oz. I felt so cheated. I was told I must have had a lot of waters. My next baby was a homebirth and there was no discussion of weight and it was lovely to not have that fear hanging over me. I didn't doubt myself and had a gorgeous waterbirth at home at 41weeks giving birth all on my own to a healthy 8lb 4oz son."

Research has found that care providers and ultrasound predictions are inaccurate in estimating the size of a baby - predictions of a 'big baby' are wrong HALF of the time. (1)

There is also research to suggest that when women estimated their baby's weight they were more accurate than clinical estimates by care providers or ultrasound measurements. (2)

Despite this, many women report to AIMSI that care providers insist on their recommendations of induction based on clinical predictions which are shown to be inaccurate.

"I was told from about 35 weeks that my baby was measuring big and would be a 'good 10lber'. This was my first baby but I am tall and my mother had us all at home - we were all 9lbs odd - without any problems. My obs wanted to induce me from 39 weeks but I didn't think the baby was that big and I really felt I could do it...or at least try! He wasn't happy when I declined induction and told me that I was risking permanent damage. I gave birth to my son at 40+3 without induction and had a fantastic birth with a minimal tear. He weighed 8lb 4oz"

Induction of Labour is shown to increase the risk of needing a Caesarean Section, increases the risk that the baby will be admitted to NICU, increases risk of forceps or vacuum birth, and means that the woman's labour is now considered 'high risk' which changes how the labour and birth are managed. Recent research has shown that synthetic oxytocin, like Syntocinon or Pitocin, often used in induced labours, is an independent risk factor for distress in babies.

In fact, research has shown that induction increases the risk of Caesarean Section 2 fold in first time mothers. (3) ACOG 2009

Ireland's 'self-induced' strain on services

Research in the USA has shown that an uncomplicated caesarean section costs 68% more than an uncomplicated vaginal birth (Childbirth Connection 2011). Women with uncomplicated vaginal birth have shorter hospital stays, less instances of re-admission, and few infections. (3)

Over-reliance of medical interventions is a key component of strain on under-resourced maternity services in obstetric led maternity units in Ireland. It is vital that we reduce the medicalisation of the primary experience with first time mothers in order to reduce maternal morbidity rates and strain on services. Reduction in induction of labour for non-medical reasons is a start - as well as adopting appropriate care options for women such as midwife led care.

 The HSE's Mid-U report found that midwife led care is the most appropriate care option for the majority of women, uses less interventions - which in turn reduces caesarean section, is more cost effective than obstetric led care, and has high satisfaction ratings from women who used it.(5)

Would YOUR obstetrician put money on it?

Given what we know, AIMSI recommends a new tactic.

What if women asked the OB for €1000 for every ounce under the estimated birth weight the baby is born at?

Would YOUR obstetrician put money on it?


What is induction?

An induction of labour is when a doctor or midwife uses various methods to artificially initiate or accelerate labour such as:
  • a membrane stretch and sweep
  • a pessary or gel
  • artificial rupture of membranes (ARM)
  • a hormone drip
The Evidence Can Help You Make A Decision
“The National Institute for Health and Care Excellence (NICE) in the UK recommends that induction of labour has a large impact on the health of women and their babies, and so needs to be clearly clinically justified. “
If you are considering an induction of labour or have been offered an induction of labour without medical necessity, it is worth looking at the benefits & risks.

Induction of Labour – Benefits
  • You can arrange to be home for a specific event
  • Helpful in organising care for other children/work/help when you are home
Induction of Labour – Risks
  • higher rates of Caesarean section
  • increased risk of your baby being admitted to NICU (neonatal intensive care unit
  • increased risk of forceps or vacuum (assisted delivery)
  • contractions may be stronger than a spontaneous labour
  •  your labour is no longer considered ‘low risk’ – less choices in where and how you birth, restricted birth positions, continuous monitoring CTG, time limits for which to labour in.
Risks specific to your baby

Recent research has shown that the use of oxytocin in labour is an independent risk factor for distress in babies. This means that the baby does not tolerate labour as well when oxytocin is used. This can have implications on the way you give birth and on your baby’s condition after being born.
Other research shows that the use of oxytocin increases your chances of asking for an epidural. In a Cochrane Review, both oxytocin and epidural are discussed as having implications on breastfeeding your baby. You can read more about this here

1) Evidence Based Birth - Big Baby

There is tons of research on the inaccuracy of foetal weight prediction but this article from Evidence Based Birth is fantastic as it looks at all the relevant research, all of high quality, and clearly illustrates the findings all in one article.

On the article based on 'big baby' and the prevalence of induction or caesarean based on weight estimate prediction Rebecca looks at the most relevant quality evidence on 'big baby' and concludes:

  • Ultrasounds and care providers are equally inaccurate at predicting whether or not a baby will be big. If an ultrasound or a care provider predicts a big baby, they will be wrong half the time.

  •  If a care provider thinks that you are going to have a big baby, this thought is more harmful than the actual big baby itself
    • The suspicion of a big baby leads many care providers to manage a woman’s care in a way that triples her risk of C-section and quadruples the risk of complications.
    • Because of this “suspicion problem,” ultrasounds to estimate a baby’s weight probably do more harm than good in most women.
  •  Induction for big baby does not lower the risk of shoulder dystocia and may increase the risk of C-section, especially in first-time moms

  • A policy of elective C-sections for big babies likely does more harm than good for most women
    • It would take nearly 3,700 elective C-sections to prevent one permanent case of nerve injury in babies who are suspected of weighing more than 9 pounds 15 ounces
    • For every 3 permanent nerve injuries that are prevented, there will be 1 maternal death due to the elective C-sections

  • Full article here:

    2) Women who had given birth before were able to predict their baby's birth weight more accurately than health care providers and ultrasound estimates.

    3) Non-Medically Indicated Induction and Augmentation of Labor:

    4) Quotes are from women contacting AIMS Ireland, used with permission, anonymously.

    5) MID-U study:

    Wednesday, 10 September 2014

    CTG: Common routine intervention in Irish maternity units despite 99% false positive rate

    A strong, evidence-based and referenced piece of research which lays out the case that "electronic fetal monitoring is based on 19th-century childbirth myths, a virtually nonexistent scientific foundation, and has a false positive rate exceeding 99%. It has not affected the incidence of cerebral palsy. Electronic fetal monitoring has, however, increased the caesarian section rate, with the expected increase in mortality and morbidity risks to mothers and babies alike".

    CTG is one of the most common routine interventions used in obstetric led Irish maternity hospitals with women of all risk groups. It is not evidence based practice and it's been shown to do more harm than good.

    Routine use of CTG and admission trace is not supported by evidence nor is it recommended practice in Irish National Clinical Guidelines. Despite this, the overwhelming majority of obstetric led units in Ireland routinely use this intervention. Its use is so normalised in Ireland many women, HCPs, and indeed the Courts, do not consider routine use of CTG and Admission trace an 'intervention' and base standards of care and practice on CTG readings despite a 99% false positive rate.

    Some Irish obstetric units have taken this a step further, when women make an informed refusal on admission trace or CTG an intervention 'bartering system' is put in place - telling women they can only refuse the CTG if they have an ARM (also not evidence based or best practice).

    Women giving birth in Ireland and their babies deserve evidence based care.

    Healthy Births for Healthy Mums & Babies.

    #demandevidencebasedcare #informedchoice #informedrefusal
    Read the article here:

    Cerebral Palsy Litigation

    Change Course or Abandon Ship

    Wednesday, 20 August 2014

    The Constitution is not the only legal enemy of Irish Women

    The Constitution is not the only legal enemy of Irish Women

    by Breda Kerans, AIMS Ireland

    It has been said many times that this is no country for pregnant women, and it is true. Most of us are very familiar with the role that the 8th Amendment to the Constitution plays in removing rights from pregnant women in terms of abortion rights. Some people are familiar with how this same amendment removes a woman’s right to informed consent and refusal to medical procedures during pregnancy and birth. But I would imagine that most people outside the dry and dusty corridors of the courts would be familiar with the role a man called Mr. Bolam plays in the removal of pregnant women’s rights.

    In 1957 Mr. Bolam was a patient in Friern Hospital. Friern was a mental health institution in the UK. He underwent electro convulsive therapy, to which he had consented. However he was not given any muscle relaxant & was not restrained. As a result he sustained serious injuries. He sued on the grounds that a. he was not given relaxants, b. he was not restrained and c. he was not informed of the possible risks.

    Mr Bolam lost his case. Mr. McNair, judge, took on board the evidence of expert witnesses, which stated that some medical opinion was opposed to using relaxants or restraints. They also stated that many did not warn patients of small risks, unless asked.

    The judge summed up the point of law to the jury as follows: "….he is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. I do not think there is much difference in sense. It is just a different way of expressing the same thought. Putting it the other way round, a man is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion who would take a contrary view. At the same time, that does not mean that a medical man can obstinately and pig-headedly carry on with some old technique if it has been proved to be contrary to what is really substantially the whole of informed medical opinion."[1]

    The jury delivered a verdict in favour of the hospital. That passage is quoted very frequently, and has served as the basic rule for professional negligence over the last fifty years. So with that judgment, the Bolom principle entered both legal and medical practice.

    This is the principle which was can see running through many judgments against women who have questioned the medical procedures carried out on them in Irish maternity hospitals. The Bolom principle has been criticized by many, in that it is heavily weighted in favour of the professional and not in favour of the patient. In effect it is merely necessary for a medical professional to find a number of expert witnesses to attest that the practice carried out was one they themselves would do. It is irrelevant if such practice is not recogonised best practice. It was seen very clearly in the case taken by Ciara Hamilton, Co Kerry who sued the HSE over her care at Kerry General Hospital, Tralee, when she was having her second baby in 2011. The midwife caring for her carried out Artificial rupture of the membranes on her, causing cord prolapse and a subsequent emergency C-section became necessary. Following Judge Ryan’s, the Irish Examiner reported: Mr Justice Ryan found that it was reasonable for the midwife involved to seek reassurance with an artificial rupture of the membranes. The midwife was the person entitled, authorised and qualified to make the decision, the judge said. “In the circumstances, I do not consider that the midwife was negligent.” He said he accepted the evidence of the midwife supported by two expert witnesses that the treatment provided by the midwife was not deserving of criticism or condemnation and that the prolapse of the cord was a rare but known complication of the procedure. “The midwife responded in a competent manner, as did the hospital,” Mr Justice Ryan ruled. He added that the management of Ms Hamilton accorded with a practice supported by a responsible body of expert opinion. [2] This is the Bolom principle at work. It would be a similar principle at work in a court ordered Caesarean or other procedure. The judge would take into account that the medical procedure recommended was supported by a responsible body of expert opinion, not that it was grounded in best practice. And there can be a very big difference between what a few expert witnesses agree is reasonable practice and what is defined as best practice by internationally respected bodies such as NICE or the WHO. These guidelines are based on huge bodies of research. Don’t all women deserve to be treated with the best evidenced based care?

    For that to happen in Ireland then two things must happen. Firstly the 8th amendment to the constitution must be removed. Secondly we must demand that our courts move away from the Bolom principle, which as Ruth Fletcher of Queens University of London notes “continues to adopt a more professional oriented, rather than a patient oriented, standard of care” [3]

    These issues are at the very heart of why pregnant women in Ireland have little or no rights to informed consent or refusal in any meaningful way. Until both this issues are tackled we will continue to see woman after woman abused in our hospitals and in our courts. [1]

    Think the 8th Amendment is only an abortion issue? Please read.

    What does maternity rights have to do with the 8th Amendment?

    AIMSI have been asked this many times over the last year. Further discussion has been ignited this week, following events in which an abortion was denied to a suicidal teen who became pregnant following a rape. Many consider repealing the 8th Amendment only in the context of reproductive health and abortion. But the 8th Amendment is a piece of legislation which directly affects every pregnant women, over-lapping on choices for contraception, abortion, and in continued pregnancy, labour, and birth.

    With the 8th Amendment in place, pregnant women do not have the same rights as non-pregnant women. Pregnancy immediately reducing a woman's right to make informed decisions on her care and decisions which will affect her and her baby in pregnancy, labour, and birth.

    AIMS Ireland strongly campaigns for recognition of informed choice in maternity care. The issue of informed consent/informed refusal and coercion (threats of legal/child protection orders) to obtain consent are prevalent in reporting to AIMSI by women accessing services and health care providers who offer witness accounts of consent violations. Many of the interventions performed without consent have implications for the health and welfare of the birthing woman and or baby.

    The HSE's published National Consent Policy restricts informed consent and informed refusal of treatment for pregnant women. It is important that all women are aware of this Consent Policy and the legal ramifications of the 8th Amendment (Article 40.3.3 of the Irish Constitution) on their right to informed decision making in their maternity care. See as follows:

    Page 41: 7.7.1 Refusal of Treatment in Pregnancy

    "The consent of a pregnant woman is required for all health and social care interventions. However, because of the constitutional provisions on the right to life of the "unborn" (12), there is significant legal uncertainty regarding the extent of a pregnant woman's right to refuse treatment in circumstances in which the refusal would put the life of a viable foetus at serious risk. In such circumstances, legal advice should be sought as to whether an application to the High Court is necessary.

    Citation: (12) Article 40.3.3 of the Irish Constitution (1937)

    Relevant factors to be considered in this context may include whether the risk to the life of the unborn is established with a reasonable degree of medical certainty, and whether the imposition of treatment would place a disproportionate burden or risk of harm on the pregnant woman."

    AIMS Ireland firmly believes that in order to offer full support to women and campaign for improvements in maternity services, we must recognise all women in their right to autonomy of choice. The 8th Amendment of the Constitution, Article 40.3.3, affects all pregnant women, their birth choices, their right to accept or refuse a test or treatment, their right to individual assessment, their right to be pregnant or not.

    At the our 2013 AGM, the committee asked its members to ratify AIMS Ireland’s stance to support all women in their right to autonomy of choice and to call for the repeal of the 8th Amendment to ensure women’s human rights in childbirth in Ireland. The motion was unanimously carried by AIMS Ireland members.

    We hope that the discussion around the 8th Amendment is broadened to include the rights of women in continued pregnancy, labour, and birth and practices which violate these rights within Irish maternity services.

    Sunday, 17 August 2014

    AIMSI Statement on Irish Independent article 'Pregnant woman refused abortion gives birth by caesarean' August 15, 2014

    AIMSI made this statement in relation to this article by Dearbhail McDonald posted online late Friday August 15th, 2014 in the Irish Independent:

    In May 2013, AIMSI made a submission to the Joint Oireachtas Committee on the Heads of Bill that would eventually become the Protection of Life During Pregnancy Act (2013). One of the statements made in this submission was that “as long as Article 40.3.3 remains as an impervious legal barrier to a woman’s right to a termination...the risk to a mother’s life will precariously hang in the balance. The stark reality for a pregnant woman in Ireland is that Article 40.3.3 hangs like a spectre over her care as there are myriad instances where this ambiguously worded and legally flawed amendment overrides a pregnant woman’s human rights.”

    This chilling case is a bleak reminder of how this legislation is profoundly flawed. Rather than doing anything to help mitigate the stigma attached to both mental health difficulties and abortion, the legislation continues to distance the medical profession and the government from the woman at the heart of the matter and it further perpetuates a negative stereotype. The discrimination of women who find themselves in this emotionally devastating position – of carrying an unintended pregnancy and of seeing no way out of this difficulty - only serves to isolate women at an extremely vulnerable time and to highlight power differences between a woman and so called ‘experts’. While there is very little detail reported on this story, there is enough to tell us that a woman’s right to bodily autonomy, consent and dignity continues to be eroded in the name of legislation that is supposed to protect her life. The fact that current legislation was used to deny a woman her legal right to an abortion, due to risk of self destruction, and then used to force her to undergo major abdominal surgery (presumably against her will) is unconscionable in a civilised society. 

    The main thrust of the argument for supporting the rights of women across the maternity services, whether they are choosing a home birth, a cesarean section, an intervention-free birth or an abortion is summed up succinctly by Anand Grover, UN Special Rapporteur on the Right to Health. At a UN General Assembly in August 2011, Mr Grover presented a report, in accordance with the Human Rights Council entitled: Right of everyone to the enjoyment of the highest attainable standard of physical and mental health. This report is seen as a milestone in the area of rights to reproductive and sexual health as it plainly articulates the reasons why legal restrictions in this area constitute a violation of a woman’s right to health and an “unjustifiable form of State-sanctioned coercion” (UN, 2011, p. 5). The report is disparaging of the human rights violations that are perpetuated in the few remaining countries, such as Ireland, where abortion is completely criminalised or where it is only allowed to save the life of a woman. Anand Grover said at the UN General Assembly meeting, when presenting this report: 

    “Realization of the right to health requires the removal of barriers that interfere with individual decision-making on health-related issues and with access to health services, education and information, in particular on health conditions that only affect women and girls. In cases where a barrier is created by a criminal law or other legal restriction, it is the obligation of the State to remove it. The removal of such laws and legal restrictions is not subject to resource constraints and can thus not be seen as requiring only progressive realization. Barriers arising from criminal laws and other laws and policies affecting sexual and reproductive health must therefore be immediately removed in order to ensure full enjoyment of the right to health.” (UN, 2011, p. 2)
    AIMSI fully supports the reproductive rights and choices of ALL women and we will continue to advocate and campaign for these rights. 

    United Nations Human Rights Council (UNHRC), 66th Session. Interim report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Anand Grover (A/66/254)3 August 2011.

    For more information and commentary on this case, please see the following:

    Doctors for Choice Ireland blog post 17/08/2014 -

    Friday, 8 August 2014

    Is this 2014 or the dark ages in Ireland? Guest Blog by Noreen Barron

    Is this 2014 or the dark ages in Ireland?

    Guest Blog post by AIMS Ireland member, Noreen Barron


    The recent high court ruling by Judge Sean Ryan has made a mockery of a woman's human and legal right to informed consent and refusal. Ryan's judgement also sets a very dangerous and frightening precedent for any woman giving birth in Ireland. In a nutshell, pregnant women in Ireland no longer have any legal or human rights to bodily autonomy.


    Essentially what this means is that the bodies of pregnant women belong to the state and it is the state who will decide what procedures will be performed on a pregnant woman. A woman's consent, whether informed or not, is negligible and not needed. This is demonstrated by Ryan stating that: The midwife was the person entitled, authorised and qualified to make the decision. Read that statement again and again until the reality of it sinks in. It means that women are not the people who are entitled, authorised or qualified to make the decision about whether or not a medical procedure is performed on them. His ruling is morally and ethically reprehensible.


    I dont believe that the majority of women realise the gravity of Sean Ryans ruling, because if they did, there would be a major outcry. At least I hope there would be. Maybe that outcry will only happen when enough women suffer the effects of the fact that they have absolutely no legal say anymore about what happens to them during pregnancy or birth when issues arise. They will be performed on whether they like it or not. Maybe they'll even be strapped down, or dragged by the police to the hospital ... who knows where this precedent will lead?


    We have seen evidence of what other countries are capable of when it comes to pregnant women, Adelir Carmen Lemos de Goés, from Brazil, was forced to have a caesarean section against her will for example. And right here in Ireland, Waterford Regional Hospital brought a woman to the high court in 2013 in order to force her to have a caesarean. She decided to have the procedure herself before a judgement could be made, under extreme distress I am sure, but rest assured of the fact that a hospital prepared to go to those lengths is not a good sign for any pregnant woman. Women should be absolutely outraged at this recent ruling.


    Along with this appalling ruling, Ryan has also sent out a clear message that if any woman dare have the audacity to stand up for themselves and sue the state, they will have the states costs awarded against them. Now, is it just me, or does that seem like a bullying tactic? Might that decision have been made in order to deter other women from coming forward because they dont want to be saddled with massive legal bills? Is it not intimidatory? Does that decision have anything to do with the fact that we are in a recession because we bailed out the private debt of banks and there's not much money left in the coffers for women who have been injured (or have died), both physically and psychologically, as a direct result of the state's actions or inactions?


    What is interesting about legal precedents being set, is that, on any particular day, and with any particular prejudices, a single judge can decide on a legal matter, set a precedent, and the entire legal system will follow suit from thereon. No judge undergoes any psychological evaluation to make sure that they are up to the very important job of settling legal matters and setting legal precedents. Perhaps it is a good idea that this be changed? After all, the law is a very serious matter and it affects each and every one of us, which is why we need to care very much about the people who make and implement the law.

    Wednesday, 6 August 2014

    Not a 'consent' issue

    As much as you may not like something, there is some comfort in knowing what you are up against. You can work towards change. You can acknowledge it – face it head on. You can rally in a united stance. But this week finds pregnant women and maternity advocates in a strange limbo. We now face the unknown.  A High Court judgement has changed everything - setting a terrifying precedent with broad implications for birthing women in Ireland.

    High Court


    On Friday last, a woman who sued Kerry General hospital over the care she received while giving birth to her second child, lost her case in the High Court. The woman had her waters artificially ruptured – ARM- (also known as “breaking the waters”) and needed an emergency caesarean section due to a cord prolapse. Further details have emerged that the woman was a known carrier for Group B Strep (GBS). (Mind the Baby Blog) The woman has indicated that she did not consent to the ARM and that it was allegedly performed by a midwife during a routine vaginal examination without discussion and without the woman's knowledge that the intervention was about to take place. Justice Ryan ruled that the woman did not make a case against the HSE and is responsible for full costs.


    From the Examiner:


    Mr Justice Ryan said the midwife at Kerry General Hospital and the hospital responded in a competent manner to the situation which arose when Ms Hamilton was having her second baby.”


    “Mr Justice Ryan found that it was reasonable for the midwife involved to seek reassurance with an artificial rupture of the membranes. The midwife was the person entitled, authorised and qualified to make the decision, the judge said.”


    “He added that the management of Ms Hamilton accorded with a practice supported by a responsible body of expert opinion.”



    “The midwife was the person entitled, authorised and qualified to make the decision, the judge said.” Read that again.
    And again.
    It will come to haunt you as the reality drips in.

    In that one statement, Justice Ryan has eroded every right of birthing women in Ireland. Where we once thought we knew where we stood, with the National Consent Policy, we now are fighting a ghost. A notion of entitlement over birthing women’s bodies. An unapologetic exemption to use medical intervention where a midwife sees fit. And seemingly regardless of best practice or evidence! The midwife is the person entitled, authorised, and qualified to make the decision. Not the birthing woman. Not the woman in labour. The midwife. Not the woman who has to live with the consequences. The midwife. Because a judge says so.


    This judgement is a ruling for Active Management of Labour. It laughs in the face of evidence based practices and high quality research. It mocks science. Who are these ‘responsible body of expert opinion’ who disregard international best practice? 

    This is a ruling in favour for Active Management of Labour. This is a ruling for routine admission policy. This is a ruling for speeding women up, intervention, interference. This is also a ruling which contradicts the Irish National Consent Policy, leaving a Nation of women without clear understanding of our rights.



    Every Irish citizen has the right to informed consent during medical treatments. This means tests, procedures, and interventions are to be discussed clearly with an individual, both the benefits and risks, in order for them to make the best decision for themselves at that time. This includes the right to informed refusal. For pregnant women in Ireland, these rights are diluted and challenged by the Irish Constitution and Article 40.3.3, both of which are enshrined in the National Consent Policy.

    The National Consent Policy states:

    Page 41: 7.7.1 Refusal of Treatment in Pregnancy

    The consent of a pregnant woman is required for all health and social care interventions.
    However, because of the constitutional provisions on the right to life of the "unborn" (12), there is significant legal uncertainty regarding the extent of a pregnant woman's right to refuse treatment in circumstances in which the refusal would put the life of a viable foetus at serious risk. In such circumstances, legal advice should be sought as to whether an application to the High Court is necessary.

    Citation: (12) Article 40.3.3 of the Irish Constitution (1937)

    Relevant factors to be considered in this context may include whether the risk to the life of the unborn is established with a reasonable degree of medical certainty, and whether the imposition of treatment would place a disproportionate burden or risk of harm on the pregnant woman.

    AIMSI have been vocal in our condemnation of the National Consent Policy, and article 40.3.3, both used to violate women’s rights in pregnancy and childbirth. We have supported women threatened with the High Court. We have supported women who have been doorstepped by Child Protection. We support the survivors of symphysiotomy, brutally maimed in childbirth, in their quest for justice. We have supported women in their right to continue pregnancy, or not, and to decide how and where their baby is born - from planned caesarean section to homebirth after caesarean. We support women. We have actively campaigned on all these issues - all of which are bound by the same constraints. This is the reality of what Ireland has collectively signed up for, and as a result, pregnant and birthing women live with the consequences of restricted rights. From Symphysiotomy, Neary, Mother and Baby homes; all examples of rights lost.

    Despite all this, there was some slight reassurance that a birthing woman’s right to consent and informed refusal was recognised at all in a National Consent Policy, despite these limitations.  The Consent Policy stating a pregnant woman could consent or refuse treatment unless refusal “would put the life of a viable foetus at risk”. 

    But Friday’s judgement completely contradicts this rational.

    In fact, Friday’s judgement does the complete opposite.

    We are now in a situation where a woman can refuse a procedure, (or indeed even have a procedure done with no opportunity to consent or refuse), which is shown to increase risk to her baby, but the midwife can over-rule her and do it anyway.

    This woman says she did not consent to have her waters broken. The woman says she didn't even know that this was about to happen, but that the midwife did it anyway. Despite the woman having known risk factors in which an ARM would put her baby at risk. And Mr Justice Sean Ryan says this is OK. He has essentially enshrined Active Management of Labour into Irish law. He has handed women’s decisions and bodies over to health care providers to do as they please.

    This is NOT OK.

    This month, the UN Human Rights Committee had harsh criticism on the Irish Government in its failure to secure civil and political rights. Ireland was flagged on 19 areas with a heavy focus on the rights of, and, crimes committed against pregnant women in Ireland. Ireland was publically and globally dragged over the proverbial coals. Our dirty laundry out for all to see; a unified call for the Irish Government to make good – demands for justice – send a signal of change…… This judgement is Ireland’s answer. No, we do not take women’s rights seriously and No, we will not change.

    ** Edit Note 5:30pm, Wednesday August 6th. AIMSI has received confirmation that the woman in this case has alleged that she was unaware the midwife was going to break her waters - ARM was performed during a routine exam with no discussion or opportunity for the woman to consent or refuse treatment.

    AIMS Ireland have been inundated with support and offers of help for the Hamilton family following the loss of their case in the High Court against Kerry General. A fund had been established to help them with their legal costs. You can donate at the link below. Please share wherever you have seen discussion and support on this important issue:

    Further Information on amniotic fluid, ARM, Cord Prolapse, and Group B Strep (GBS), and AML

    Protecting your baby – the important job of amniotic fluid.

    Amniotic fluid is a clear, slightly straw coloured fluid which surrounds the baby in pregnancy. During  pregnancy, the baby is protected in the amniotic sac, which is in the uterus, and is made of two membranes. These membranes seal around the baby and the amniotic fluid. The baby floats in the amniotic fluid safely within the amniotic sac for the duration of your pregnancy.

    The amniotic fluid is constantly circulating and the amount corresponds to the baby’s growth. At the beginning of a pregnancy, the amniotic fluid will only be a few millimetres. At its peak volume, around the 36 week mark, there may have around 800ml to 1000ml of amniotic fluid. This gradually decreases until the baby is born. The baby uses the amniotic fluid to practice ‘breathing’ – swallowing fluid into the lungs and urinating it out. For this reason, the fluid levels are constantly moving.

    The amniotic fluid protects the baby in the following ways:

    - acts as a cushion for any sudden blows, shocks, bounces received

    - maintains the right temperature around the baby

    - helps mature the baby’s lungs

    - protects the baby from infection – such as GBS/Strep B

    - helps the baby explore movements in pregnancy – to strengthen bones and muscles

    - helps mature the baby’s swallowing reflux

    What is ARM?  One of the most common forms of routine interference in labour is an artificial rupture of membranes (ARM) – sometimes referred to as ‘breaking’ or ‘releasing’ your waters. To do this, the health care professional, inserts a plastic hook into the vagina and cervix to make a tear in the bag of amniotic fluid.

    What the Evidence Says

    Evidence does not support artificial rupture of membranes for women in normally progressing spontaneous labours or where a woman’s labour has become prolonged. The evidence shows that ARM does not shorten the first stage of labour.

    ARM is on the NICE “Do Not Do” list and is shown to increase risks to women and their babies.

    Despite this, most Irish units follow an Active Management of Labour policy as routine.

    Active Management of Labour (AML) is an approach to labour which was created in National Maternity Hospital, Holles Street, in Dublin and is now practiced in many obstetric led units. The principal of AML is to manage the time a woman is in labour to prevent ‘prolonged’ labour. The definition of ‘prolonged labour’ has changed over time. In 1963, prolonged labour was defined as 36 hours. This was changed to 24 hours in 1968 and was finally reduced to 12 hours in 1972. The main principals of AML are that you will have your waters broken, be given frequent vaginal exams to track your progress, and that your labour is considered to be progressing if you dilate 1cm per hour. Continuous electronic foetal monitoring is also used. Women who are not dilating 1cm per hour, have labour accelerated with a drug called syntocinon.


    Risks of ARM:

    * possible increase of caesarean section
    * many women report ARM makes contractions stronger/more painful
    * increases your baby’s risk of exposure to infection in vaginal track (Group B Strep and others)
    * does not shorten first stage of labour
    * increases a risk of cord prolapse
    * may increase risk of distress in the baby and cord compression
    * your health care provider may introduce time limits to your labour once an ARM is done
    * introduces further interventions
    * ARM may cause your health care provider to recommend continuous electronic foetal monitoring
    * ARM may cause your health care provider to restrict your mobility or from using a birth pool or bath


    What is Cord Prolapse? A cord prolapse is when the cord is carried by the breaking waters before or beside the baby’s head resulting in compression of the cord which cuts off the baby’s oxygen supply. Artificial rupture of membranes (ARM) is a risk factor for cord prolapse.

    What is Group B Strep?

    GBS is a common streptococcus bacteria which can cause illness which lives in the digestive system, rectum & vagina.

    * In the cases in which GBS is transferred to the baby, it can lead to serious health implications and be life threatening in about 1-2% of cases.

    * The University of Oxford suggests 3 out of every 10 adults carry GBP and about 1 in 2,000 babies a year in England and Wales are infected. 1 in 17,000 babies in the UK will die of GBS a year.

    * Babies are at increased risk of being exposed to GBS if the waters are broken (ARM). The waters act as a protective barrier for babies, keeping the baby away from the infection in the vaginal tract.

    * other risk factors include: baby born before 37 weeks, previous baby born with GBS, high temperature of mother in labour, prolonged rupture of membranes, urine testing positive for GBS.


    Related Reading:







    Mind if I break your waters? Information on Artificial Rupture of Membranes: