Women have waited 60 years for a maternity strategy. Creating a better future together: National Maternity Strategy 2016-2026, published last month, is a big disappointment.
The proposed new model of care aims to “place women very firmly at the centre of the service” but, instead, is uneasily stuck somewhere between the old-style active management of labour model which women have endured for five decades, and the “modern-day” services recommended by the Health Information and Quality Authority in its 2013 report into the death of Savita Halappanavar.
The 31-member strategy steering group were well informed by a review of international literature on models of care across many jurisdictions and a national public consultation comprised of feedback from 1,324 service users and health professionals so it is hard to understand how the group came up with a document that sees women’s bodies as defective and dysfunctional when it comes to pregnancy.
The literature review points out that there are “two highly polarised and differing philosophical understandings of the nature of pregnancy and childbirth internationally”. A “biomedical” model that views childbirth as inherently pathological, and a “holistic/social” model which sees childbirth as a normal process.
The new strategy uses the language of normality but adopts the biomedical model which divides all women into three risk groups – low, medium and high.
Theoretically, women with normal pregnancies can ask for permission to give birth in an alongside birth centre but who decides? Not the woman.
She must undergo a risk analysis and then health professionals decide. The Association for Improvements in Maternity Services (Aims) Ireland website notes “women who are of medium or high risk will not have any increased choices [as a result of the strategy]”.
Own interests
The whole concept of choice during labour is based on the assumption that women have the ability to judge their own interests best and that these are congruent with their babies’ interests. The biomedical model chosen by the strategy means women’s choices are hedged with unnecessary caveats.
“Pregnancy and birth is recognised as a normal physiological process and, insofar as it is safe to do so, a woman’s choice is facilitated.”
The effect of article 40.3.3 on choice is included. “Cases might arise where a woman disagrees with the treatment recommended by her healthcare provider and may wish to refuse consent.
“There is asymmetry between consent to and refusal of treatment in pregnancy because it involves the care and treatment of a third party. It is also more legally complex, as article 40.3.3 of the constitution recognises the right to life of the unborn, with due regard to the equal right to life of the mother.”
If a woman refuses a treatment/proce- dure and her refusal may have a deleterious effect on the baby the strategy “recommends that legal advice should be sought”.
The strategy sections – “what is working well” and “what is not working well” – were magically transformed between being reported on in the consultation report and appearing in the strategy. For example, “hospital consultant-led services” were ranked fifth out of 10 by respondents as “working well”, yet appear in second place in the strategy above “midwifery-led care and community midwives” which were actually ranked second by respondents.
Relegated
The top three out of 10 “what is not working well” items in the consultation report – “poor breastfeeding support in the hospital and community”; “limited care options and lack of choice”; and “over-medicalised model of childbirth” – are relegated to the bottom three in the strategy.
Was this deliberate? At best it shows a poor use of the consultation findings, at worst it is a cynical manipulation of respondents’ feedback. Why bother doing a consultation?
The strategy has a number of positive points. Annual surveys into women’s experiences of maternity services are planned.
This is good news because “Ireland is the only country in this [literature] review where national data are not collected on maternal experiences of maternity services”.
Breastfeeding will be better supported in the hospital and community. Greater attention will be paid to perinatal mental health and domestic violence. None of these improvements will make any difference unless the overall model of care changes.
A maternity strategy is either woman-centred or it is not. Pregnancy is either a normal physiological process or it is pathological.
The new national maternity strategy wants to have it both ways. Irish women deserve better. They do not want to wait another 60 years before the government and service providers decide to, for once, put their needs first.
drjackyjones@gmail.com
Dr Jacky Jones is a former HSE regional manager of health promotion and a member of the Healthy Ireland Council.