Respectful Maternity Care: Midwives for Choice

On a wintry evening last week I found myself trying to sneak out of the house to escape the inevitable 3 year old tantrum at my departure. I was off to attend a talk by Philomena Canning on ‘Respectful Maternity Care’. I’ll admit that as I swung onto the motorway and saw the queues of traffic, I was wondering if it was going to be worth the long journey across the city. Not to mention the trauma of a child wailing “You’re not going out. I stay with you. I’m coming too”.

I wasn’t sure what kind of discussion we would be having that night, or if I would learn anything I didn’t already know about maternity care in Ireland. Actually there was a lot to learn. The talk covered information on a global movement towards improving maternity care around the world, the current state of maternity care in Ireland, and probably most importantly of all – the impact of the 8th amendment on this particular area. As everyone in Ireland is aware, the issue of the 8th amendment is a hot political topic right now. But for most of the public, if you’re talking about the 8th amendment, you’re talking about the right to abortion. The discussion led by Philomena demonstrated to us that actually the 8th amendment has a bigger and wider impact on all our lives than most of us had considered. Specifically on the ability to provide improved maternity care in our country.

So what is Respectful Maternity Care? It’s a global campaign to promote basic human rights for maternity care. Instead of focusing solely on morbidity and mortality rates as indicators of the quality of maternity care provided, Respectful Maternity Care requires that dignity and respect be the core tenants of providing quality maternity care. Simply surviving a birth is not good enough. Researching maternity care around the whole world shows that exactly the same issues are reported by all women, regardless of culture or economic status. While many women have a positive birth experience, vast numbers would describe their experience as traumatic and having a lasting impact on them and their entire families. But once they leave the hospital, there is no attempt to record the effect of their maternity care on their physical and mental health going forward. As more and more women start talking in public about postnatal depression, it’s not hard to see that a traumatic birth while not necessarily the root cause of depression, certainly is not going to improve the situation.

Around 80% of pregnancies are classed as normal, and should not require seeing a specialist consultant. By herding everyone along to one location all together, women that only require the care of a local midwife are taking up the valuable time of consultants that could be spent giving higher quality care to the women that want or need some kind of medical advice or intervention. If a woman chooses to elect for pain relief or a c-section, for either personal or medical reasons, their quality of care is vastly improved if they’re not in an over-crowded ward. If a woman is healthy with a normal pregnancy then their quality of care is also vastly improved by being left to progress in comfort at their own pace with the option of transfer to a medical centre if they encounter any difficulty. Providing choice benefits everyone.

The main difference between a positive and negative birth experience is not whether pain relief was used, or how many, if any, medical procedures were carried out. It’s whether the woman and her partner felt informed about what was going on. That they were given all the options available to them along with the pros and cons of each. And that their wishes were respected when it came to choosing the best way to proceed, particularly where it’s a tough call on the best choice. While sometimes the end result may be the same, there’s a big difference between recovering from medical procedures that you agreed were your best option, and recovering from ones where you felt rail-roaded by people who did not take time to explain the situation and why it was medically necessary. Respectful Maternity Care is about providing as many options and choices as possible, and letting the parents decide which is the most appropriate for them.

This can sound like a “women’s issue”, but this is something that affects the whole family. Men often report being ignored, or their opinions totally dismissed during maternity care. The entire family is impacted by lingering physical or mental trauma after birth. Historically, maternity care was primarily midwife-led and community based. The move to centralised institutions where large numbers are being processed by insufficient resources has led to the idea of ‘active management’ where births are ‘on the clock’ and regardless of your particular situation, the outcome of the birth is often determined by pure luck. Which medical professionals did you encounter at each point, and what options (if any) they allowed you. In an understaffed hospital even a midwife with the best of intentions may have to prioritise managing the progression of a number of births at the right rate over providing quality of care to their patients. This is the reason why many women delay going to hospital for as long as possible. They know that once they’re admitted to the system they get put on the clock and lose a lot of choice about how the birth should proceed.

It seems obvious that Respectful Maternity Care is a basic right that should be afforded to everyone in every country, and would benefit all of society. The WHO and many other organisations agree and are promoting the cause. However introducing Respectful Maternity Care in Ireland hits a big stumbling block in the form of the 8th amendment, which is not compatible with the idea that parents are capable of making an informed choice about appropriate medical care for their family.

If I’m in a car crash with my child then I expect that any doctors dealing with our case will provide me with as much information as possible. Describe what medical interventions may be required for myself and my child, and the advantages and disadvantages of each. I expect that myself and my partner will be given as much time as possible to weigh up any risks and choose the best option for us, even if it’s not necessarily the option our particular doctor would choose. This is supported by law. If I’m incapacitated then my partner has the right to decide on my behalf. It’s generally our choice, within reason. However, if I’m in a car crash with my unborn child then this is not the case based on the 8th amendment. The 8th amendment allows for any medical professional to override the choice of myself and my partner to protect the unborn child. There’s an assumption that parents are not capable of weighing up the risks to their unborn child themselves, and are less entitled to make a call when there’s no clear best option to take just because their child is not yet born.

In birth, we get told that we must have an induction if there’s a mismatch between the due date based on a known conception date, and a scan with a machine that may not be entirely accurate. If labour is taking ‘too long’ as defined by a hospital policy, we can be told that we must be induced even at the risk of triggering further medical procedures. At a time when parents are already stressed, they can easily be pushed into interventions that may not really be necessary, or advisable for their situation. Only when an unborn child is involved, are parents so restricted. The 8th amendment can be applied in cases where the medical intervention is not as extreme as abortion, but the effects can be dangerous for both mother and baby. Nor does the 8th amendment prevent abortion in general, it restricts access to only some women based on access to information and ability to travel. Whatever side of the fence you’re on when it comes to abortion, the 8th amendment is not achieving the goals of either pro-life or pro-choice campaigns. Having it enshrined in our constitution does more harm than good.

While it’s important to consider the 8th amendment in terms of how it impacts the right to abortion in this country, it’s important to also consider the other implications. Midwives for Choice is a new group launching next Saturday 30th January. The group aims to represent both midwives and women working together, with a goal of moving towards Respectful Maternity Care in Ireland in the future. Their first challenge is to highlight the impact of the 8th amendment on maternity care to the general public. But this is only the first step in improving maternity care in Ireland. If you’re interested in adding your voice to the discussions, then you can register for the Midwives for Choice Official Launch at 11.30am in the O’Callaghan Alexander Hotel in Dublin.