Home births suffer Irish setback

Parents are in uproar as a midwife is suspended after a difficult home birth. Angana Rakshit reports
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A midwife who specialises in home deliveries has won the support of parents across Ireland after being suspended for allegedly putting mothers and babies at risk during labour. Fellow independent specialist midwives fear the case could mean the end of childbirth choice.

Ann Kelly, who worked safely for 25 years as a midwife, was ordered to stop working by the Irish Nursing Practice Standards Committee when hospital doctors complained she had failed to get a mother to hospital early enough during the delivery.

The plight of Mrs Kelly, who has won increasing support from parents who have rejected the culture of childbirth as an illness, reminds observers of the case of British obstetrician Wendy Savage who was similarly supported by her patients but vilified by the medical establishment for her backing of mothers' choices.

Ann Kelly worked for 12 years as a midwife in Dublin, and delivered safely 350 babies at home before being ordered to stop. Only two cases were ever referred to a hospital unit, but doctors intervened to prevent her practising further after she attended a mother in labour for three days. Hospital staff were alerted when the woman was finally taken to hospital, and were alarmed even though there were no problems with the delivery.

They complained that Mrs Kelly had breached the Midwives Code by failing to send women with abnormal labour problems to hospital. The abnormalities listed include breach birth, foetal distress, and labour lasting more than 12 hours.

The mothers concerned do not wish to complain and their babies are all well. But the key to the problem is in the definition of abnormality which, for the Dublin doctors, centres around a set formula, and for Ann Kelly and her colleagues is a matter of the individual woman and baby.

Mrs Kelly and her supporters have been stunned by the action against her. She has had no deaths in 350 home deliveries. "I'd like to ask the hospitals if they can match her figures,"said one of her colleagues. "I imagine that they have taken this action because we do not follow the strict rules of hospital procedure in labour - but the women who want us, want us for that reason. There are so many women who fear childbirth, and many who have had horrible experiences. Our job is to empower the women and deliver them a baby in a safe way which enhances their experience."

Home births have become increasingly popular in Ireland. Last year demand was twice as high as the capacity which the 14 independent midwives working there can supply. And although the state contributes pounds 400 towards the cost of a pounds 900-home birth, independent midwives currently draw their clients from patients who would otherwise go privately.

But what really concerns them is that Mrs Kelly's suspension will lead to the end of home births in Ireland - and the end of real choice for women. Although the 1970 Irish Health Act states that a woman should have the right to give birth where they want to, some midwives are likely to want to change their way of working.

"The handful of domiciliary midwives who are in the game will be scared off," said a legal source involved in the case.

Midwives who advocate home deliveries say that their job is made harder by the reluctance of hospitals to deal with their patients by, for example, failing to provide out-patient care such as scans for women who wish for home births.

Mrs Kelly's supporters also point to the distinct differences in the way in which doctors and midwives are treated if there is any question about a patient's treatment. The Lancet reports that if a hospital doctor is involved in a perinatal death there may be an internal meeting behind closed doors. But for a midwife, any death, even if unpreventable and not the result of any mistake, is quickly notified to the legal authorities.

In Britain, midwives face similar problems. Although the government backed real choice in childbirth in its 1992 paper Changing Childbirth, independent midwives have been effectively prevented from working by their professional body. Their insurance premiums rose to a prohibitively high pounds 11,000 per annum when they were dropped, without ballot, from the Royal College of Midwives. Doctor Peter Boylan, Master of the National Maternity Hospital, in Holles Street, admits that the unregulated nature of the independent midwives alarms him. "Home births are like riding a motorbike without a helmet," he says. "You get away with it for so long."

Doctor Boylan makes no bones about his policies. "Women do have a choice, but if they do not listen to the professionals they must be responsible for the consequences."

"You are told you can do whatever you like, as long as you stay on the bed," said one mother who recently gave birth in hospital. "But you're definitely a passenger. For an intelligent woman who is in tune with her body and baby that can be insulting. As for squatting, the midwives told me they did not know how to deliver in that position, but it was really because they didn't want to kneel down."