This week's ruling on home births highlights an ongoing row between obstetricians and independent midwives, writes Kitty Holland
Some months after Jo Kavanagh gave birth to her first baby, Lia, she found herself in a Dublin bookshop. In tears. "I picked up a copy of this book, Misconceptions, by Naomi Wolf, all about how birth has become dominated by medicine and what that does to a woman. I began reading it and found tears streaming down my face." She was, she says, suffering varying degrees of depression for more than a year, caused by the manner of her daughter's birth.
The birth of Lia three years ago at a Dublin maternity hospital left her feeling "betrayed and cheated". She had given a birth plan to her consultant, but "almost everything I asked \ not to be done was done".
She was given the drug oxytocin to speed up the birth (which she says made the pain worse), her waters were broken, she was given an epidural and her daughter was taken from her for several minutes straight after being born and given back wrapped in a towel. "I had no skin-to-skin contact with Lia when she was born. I had no encouragement from the staff." She felt she had given birth in an atmosphere of threats and fear. "In the end I felt violated, hurt and taken advantage of at the most vulnerable time of my life." She left the hospital with "an overwhelming feeling of sadness, that never really left until after the birth of my second child".
When she found out she was pregnant again two years ago, she "couldn't bear the idea of going into hospital". She contacted midwife Philomena Canning who agreed to meet her and her husband at home and told her she could have her baby at home.
Jo describes a "magical" experience of having her baby son at home. She had a birthing pool in her living room; Canning came to her home at about 4 a.m. the morning of the birth and, at about noon Charlie swam into the world - "the midwife plopped him on my tummy and because I'd had no epidural he wasn't sleepy. He was wide awake and he stared up into my eyes. I felt bathed in the most amazing feeling of bliss I ever had. And I couldn't take my eyes off him."
There's no doubt it went wonderfully for Jo and her family. For others, however, it doesn't go so well, as some concerned about the lack of regulation of the home birth sector have been telling the Department of Health for years.
In the heated stand-off between advocates of home birth and those concerned about its absolute safety, this lack of regulation, like the women and their babies in the middle, seems to have been lost.
This week's Supreme Court judgment, that health boards were not statutorily obliged to provide home birth services, has refired the determination and vitriol on both sides.
Determined to refute any assertion that home births are less safe than hospital deliveries, Marie O'Connor of the National Birth Alliance strongly criticised a study by former Master of the Rotunda Hospital, Dr Peter McKenna.
His findings, published in the Irish Medical Journal in August, that the death rate among babies delivered at home in the Dublin region was as high as one in 70 over a three-year period, she says will be "rubbished" in an article she has co-written to be published later this month in a "leading international midwifery journal". She, and others such as Krysia Rybaczuk of the Home Birth Association and Canning, dispute Dr McKenna's figures, saying he is using "statistics for his own political ends, i.e., to eliminate self-employed midwives, his sole competitors, in the community". His figures, she said were "at variance" with other studies on home births in Ireland.
Dr McKenna has consistently said that his figures are factually correct and he "absolutely and utterly" rejects assertions he is anti-midwife.
Other studies show the death rate among babies born at home to be about one in 400, compared with one in 1,600 born in hospital.
Since 2000, the Rotunda has drawn its concerns about the safety of the home birth services to the attention of the Department on three occasions. It said the deaths of four babies delivered at home "could have been averted" if delivered in hospital. At least two of the mothers, says Dr McKenna, should not have been given the go-ahead to attempt home delivery.
The hospital wrote: "We believe that home birth can work but only if the professionals undertaking them adhere to agreed guidelines and have their practice regulated by an appropriate authority. We do not believe this to be the case at present and we do not accept the supposition that if the parents of the deceased babies find no cause for complaint that there is no case to answer for the home delivery service."
The hospital's concerns have not been addressed by the Department. Currently the 15 private independent midwives in the State are not supervised by any authority.
Obstetricians such as Dr McKenna as well as Dr Peter Boylan former Master of Holles Street and Dr Declan Keane, current Master of Holles Street, are gravely concerned that independent midwives are agreeing to deliver babies at home that the doctors believe should be in hospital - breech deliveries, twins and deliveries "too far away" from their nearest maternity service.
Independent midwives reject these criteria for refusing to allow women to give birth at home. Birth is on the brink of "becoming an operation" when in fact it is one of the most natural things in the world, says O'Connor. "Women are being penned into ever-larger units of production and the quality of care is being compromised."
Dr Keane insists he and his colleagues are not trying to undermine midwives. He agrees, in an environment where half of first-time births are now delivered by Caesarean section, forceps or vacuum delivery, that birth has become over-medicalised. "For the vast majority of women pregnancy is a normal physiological experience. I would feel far more should be seen out in the community by their GPs with minimal contact with obstetricians. But that's a funding issue. For the Department of Health to put a midwife in every GP practice, well, that would cost an awful lot of money."
It's a sentiment Jo agrees with. "I think it's awful that the only choice for women is either active birth management in hospital or an expensive home birth. There's no half-way house. There should be midwife-led birthing units where obstetricians are on hand only if needed."
Women and their babies have become "victims", she says, caught in a row between obstetrics and independent midwives. "They really should sit down together and sort it out."