THE RECENT RULING in the Aja Teehan v HSE case has instigated fervent discussion and commentary on the safety of Vaginal Birth After Caesarean (VBAC) and home birth. A great deal of the discussion centres around the risks associated with VBAC and whether a woman should be attempting a normal delivery, if she has had a prior c-section.
Many people believe that it is dangerous and unsafe to attempt this at home with a professional midwife but the available scientific evidence on VBAC refutes this as anecdotal and uninformed opinion.
Justice Iseult O’Malley ruled in favour of the HSE in this case because she felt that indemnity insurance “was at the heart of the problem”. She added that it is simply not possible for obstetricians and midwives to practice without insurance; therefore, the legal ruling could not be made on the clinical evidence provided in court and, instead, was made based on the absolute need to provide liability insurance for claims of obstetric negligence, which are projected to exceed €100 million in 2013.
Aja Teehan wants to have a professional attend her birth because the evidence shows this is safer than an unassisted birth. She is also willing to pay for this private service out of her own pocket. The problem is that a midwife attending her birth would be in breach of increasingly strict guidelines on eligibility for home birth set out by the HSE and would not be covered by insurance, while also risking a fine of up to €65,000 and five years jail time.
The much broader issue that this landmark case has highlighted is one of informed consent and patient autonomy in Irish health care. Aja Teehan challenged the HSE and Department of Health in the High Court on criteria which prevented her from an individual assessment and self determination to make an informed decision on how and where she births.
For many, this case was seen as a home birth issue – or a risk of VBAC issue. It is not. In finding against Aja Teehan, the High Court has determined that women are not entitled to individual assessment in maternity services and that women are not capable of making an informed choice where that choice falls outside of State insurance terms and HSE’s obstetric care model policies.
In all areas of health care, patients have the right to bodily integrity and self determination. This means that an individual who is mentally and physically capable discusses the risks and benefits of a proposed treatment plan and is ultimately given the right to consent or refusal of that treatment. Maternity care is complex with regards to informed choice in that there is risk associated with ALL care models – whether hospital or home birth.
Maternity care is also unique in that an estimated 85 – 90 per cent involved are healthy women, in healthy pregnancies with healthy babies. Best practice clearly states that healthy women in low-risk pregnancies have better outcomes with midwifery-led models of care, yet Irish maternity services have not developed models of care in line with this evidence. Obstetric-led care continues to dominate maternity care options. This is one of many examples of how our maternity system is based on expert opinion and perceived risk, not evidence.
In fact, there are many incidents that the HSE is willing to overlook in relation to practices that increase risks for women and babies. For example, many women make a decision to choose private obstetric-led care in spite of increased risks. Others will decide to have an epidural which provides effective pain relief but can have long term consequences for the baby. In addition, 30 per cent of women are given given an induction to start and to accelerate labour but this is associated with increased risk of surgical birth.
Michael Turner, who gave evidence for the HSE against Aja Teehan, wrote in the BMJ (November 2011) that women should have the final say in requesting a Caesarean section without medical indication regardless of increased risks to mothers and babies, on the grounds of informed consent, yet he is unwilling to recognise the same rights for women who request midwifery care models.
Home birth is only one of many midwifery care options in Ireland in which the HSE has placed blanket bans and has restricted access. The Midwife-Led Units (MLUs), DOMINO schemes (home birth through hospital) in Ireland all function with tight restrictions – women are denied individual assessment, regardless of their current pregnancy and previous birth outcomes, and denied access for reasons such as age over 40 at time of birth, parity (number of babies born), BMI over 30, previous big baby, IVF, previous history of LETZ (minor gynaecological surgery) and more.
Ireland has seen a significant and inexplicable increase in interventions in childbirth over the last two decades. For example, c-section rates have inexplicably climbed from 10 per cent in 1990 to 29 per cent in 2012. The epidural rate in Ireland was 10 per cent in 1987 and now is estimated to be in the region of 60 to 70 per cent. Recent research in Ireland has shown that there is a marked regional variation in obstetrical intervention for hospital birth, therefore, it is difficult to determine how and where interventions are more or less frequently adhered to within maternity services.
The choices that are repeatedly brought up for women in the birth literature are ‘How?’ and ‘Where?’ a woman will give birth. This has changed dramatically over the decades due to fluctuating evidence and sociocultural factors.
Ireland has moved to a more medicalised, obstetric-led maternity service over the last half a century while many other countries around the world – such as the UK, Holland and Canada – have developed choices of care that include midwife-led care (hospital units and community), Birth Centres and home birth. The evidence is overwhelmingly in favour of providing options for women so that they may have the birth experience that is most appropriate for them and that carries the least intervention in a safe, supportive environment.
In light of the evidence, the only barrier to Aja Teehan being given the ultimate choice in the birth of her baby lies with a culture that places enormous emphasis on liability cover and risk and sees no benefit in allowing women their ultimate right to how and where they give birth.
This article was written by Barbara Western of AIMS Ireland.
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