Wednesday, 5 February 2014

Why has the Labour Ward gone to the Dark Side?

AIMSI welcomes this guest blog post from Dan Oakes, RM and Founder of Neighbourhood Midwives

Following the recent revelations about Irish maternity care in the news and social media, I wondered why there are so many different approaches to providing care to a mother in labour. The stories range from having an empowering midwife to a controlling obstetrician, a cruel midwife to a lifesaving obstetrician. Can it be that hard for all caregivers to provide consistent, respectful care? Or is something else at play here?

I am an avid video game enthusiast. I particularly like strategy/city building games. In many of the games I play, the player must choose to rule the subjects in their kingdom either with an iron fist or gentle care. Usually the cost of being a good ruler is higher in terms of time and money, but subjects are far more productive than the kingdom run by an evil player.

These observations are not exclusive to the fictitious video game world. They come right out of what we know of human history and science. Let's look at the situation through the lens of the Stanford Prison Experiment. Zimbardo (2008) writes in The Lucifer Effect: Understanding How Good People Turn Evil that it is not the bad apple that ruins the barrel, rather a bad barrel contaminating the apples. Does this theory mean it is the system that turns practitioners into monsters? Suffice it to say, we can all relate that it takes more time and effort to be kind to our fellow human beings; in fact, it is much easier to be flippant, uncaring and brusque, especially when we are under tremendous pressure.

Are the people helping women in labour in Ireland under tremendous pressure? In the recent prime time report on Portlaoise, the HSE reported that the midwives there are working at a ratio of 1:75. Considering the maximum ratio should be 1:28, I would hazard that not only are the staff under extreme pressure, but also actively encouraged to do whatever it takes to get mother and baby out of the delivery rooms as quickly as possible.

So why does it matter if practitioners are mean, taciturn and overworked? Politicians would say all that matters are the results - baby and mother alive at the end of the day. There. Job done. At what cost? If someone behaves horribly to a woman in labour, her levels of cortisol go through the roof. Cortisol is an antagonist to oxytocin and oxytocin is needed for strong contractions. This means when the woman is stressed by an unrelenting battleaxe in the labour ward, her contractions turn off or become weaker. Labour is lengthened, or stops altogether and then the artificial oxytocin is started. While research is still out about the safety of this particular drug, practitioners know it has a terrible effect on the baby. When syntocinon is used, we have to strap on a continuous fetal heart monitor (CTG) because the effect on the baby has to be measured to determine if the benefit continues to outweigh the risk in a given situation. Research proves that the use of the CTG increases the likelihood of Caesarean section. Again politicians say big deal: our caesarean section rates are acceptable, have you not seen our infant mortality rate?

Caesarean sections are a much larger drain on the system than vaginal deliveries. Emerging research is showing vaginal birth is the key to our immune systems as adults. Without vaginal birth, non-communicable diseases will bankrupt our health system. Not to mention, emergency caesareans can leave mothers and fathers mentally and emotionally scarred. Fewer caesareans would also leave more money to address the atrocious care ratios.

The HSE promises they are looking for strategies for reducing the caesarean rate in Ireland. How about starting with anger management and communication training for all the midwives and Ob/Gyns?

For more information on maternity services in Ireland, please see
To read real stories of the Irish maternity services, please see here: 'Shout Back - Your Say'
and here: AIMS Ireland