Irish Midwife
A vanishing species
© Marie O’Connor

Last Monday, 6 May, was the International Day of the Midwife. “International days” are occasionally invented for endangered species, and midwives everywhere are on the verge of extinction.

In Ireland, the Irish midwife has long been a vanishing species. Only 5 per cent of midwives are known to be in practice. There may be more. But if there are, their numbers are unknown. There are no official statistics on midwives in the workforce. Neither the Department of Health and Children nor An Bord Altranais can produce accurate figures. Their inability to prduce "manpower" statistics in midwifery is due to the general reluctance to treat midwives as independent professionals. This reluctance stems from the medical insistance that midwifery is a branch of nursing, that is, a profession that is or ought to be, subservient to medicine.

Such is the shortage of midwives in some of the Dublin maternity hospitals that patient safety is in jeopardy. Concerns for patient safety in these hospitals have been expressed as far back as the mid-90s. Last Monday, concerns regarding patient safety due to inadequate staffing were reported in Wexford Hospital's maternity unit.

As the shortage of midwives grows, so care assistants, whose training in midwifery is a matter of weeks rather than years, are increasingly seen as central to service delivery. New mothers are increasingly being looked after by care assistants. To what degree this is happening, no one knows. But it does suggest that choosing to give birth in one of the big Dublin hospitals may not be such a good idea.

It will be argued that nurses aides, as they used to be called, have been around for many years, doing a variety of non-professional tasks and that the system worked well. The difference between today and yesterday is that these care assistants are increasingly involved in aspects of patient care that used to be reserved to professionals. It’s called deskilling. Deskilling is a worldwide trend and it is happening in nursing and medicine as well as in midwifery.

But in the case of midwifery, deskilling has particular implications for women. Most women become mothers and midwives are the only ones who specialise in normal birth.

Three out of four women in Ireland have a baby at some point in their lives. So what has been the official response to the now chronic shortage of midwives in this country?

The heavily-hyped and long-awaited Health Strategy, published in 2001 in the run-up to the general election in order to maximise Fianna Fail's chances of re-election, contained no mention of maternity care. Midwives were fleetingly referred to, but only as employees within primary health care teams. Such midwives, of course, do not exist.

The turnover in Irish midwives is staggeringly high. One in three over the past two years, according to Professor Geraldine McCarthy of University College, Cork. Yet no research has been done on why midwives are leaving the profession. So-called ‘exit interviews” done in Dublin hospitals focus on where midwives go rather than why they leave.

The demand for midwifery places in Irish midwifery schools has fallen to an all-time low. Up to 45 per cent of a drop has been recorded in one school. Yet no research has been done on why nurses no longer wish to become midwives. The issue of why entry to midwifery is still restricted to nurses has yet to be addressed.

Midwifery will soon have the unenviable distinction of being the only health profession in Ireland without its own regulatory body. A "Nursing Bill" regulating midwives is currently being drafted by the Department of Health and Children. The draft Bill remains a closely guarded secret, despite the fact that transparency and openness have been both Government and public service policy for some years.

New legislation generally reflects legislative advances in other countries, but there are no known plans within the Department to incorporate the advances in midwifery legislation seen in other countries over the last decade in the forthcoming Act.

The legislation, which has been in the pipeline for several years, has now been deferred to 2004. No explanation has been given for this inordinate delay. The Department remains as inscrutable on this as on many other, equally pressing, matters.

Moreover, the usual process of consultation with interested parties that normally accompanies the drafting of new legislation has not taken place on the Nursing Bill, for reasons that remain unexplained.

The Bill is said to be based on the recommendations of the Nursing Commission, a body on which midwives were unrepresented. Yet midwives, inexplicably, have been assured that there will be “no consultation” on the new legislation.

Is the Department committed to the extinction of midwives? Or is it simply blind to their existence? Within the Department, midwifery is controlled by a "Nursing Policy Division", although nursing and midwifery are separate professions. Within this division, a lone midwifery officer, or advisor, who works on a part-time basis, reports to a Chief Nursing Officer. One part-time midwifery advisor can do little about the escalating crisis in midwifery.

Midwives lost their professional independence over half a century ago. Until then, incredibly, they were regulated from London by the Central Midwives’ Board. With the establishment of the Irish Nursing Board in 1951, Irish midwifery found colonised for the second time, this time by nursing. Since then, midwives have fought a losing battle to retain their status as independent professionals.

The Nursing Board, like the Department, refuses to treat midwifery as a separate profession from nursing. In a recent report on “manpower” to the Joint Oireachtas Comittee, midwives were consistently referred to "nurses". The position is similar with regard to the Irish Nurses' Organisation. In its report to the Benchmarking Commission, the INO treated midwives as nurses, making no special case for them.

Yet a senior midwife at the top of the scale earns only EUR30,000. For a profession that takes six years of university education to enter, this is a pittance.

The State has a long tradition of discriminating against midwives. Midwives lost their title in 1985, for instance, with the passing of the Nurses' Act. This Act made it legal to refer to a midwife as a nurse. Since then, the term 'midwife' in Ireland has all but disappeared from the English language. Many people in Ireland, as evidenced by the birth columns of “The Irish Times” thanking "nurses", no longer know what a midwife is, or does.

State discrimination is pervasive. The Maternity and Infant Care Scheme, for example, provides for the care of women in childbirth. Yet it fails to recognise midwives as professionals in normal birth, preferring instead to bestow on general practitioners, whose training in this area is far less, the benefits of private practice in maternity care. The same medical bias can be seen in the Second Interim Report of the Materity Services Task Force just released.

No forms exist for midwifery services. This is a clever tactic. The State can then claim, as it has done, that no “mechanisms’ are in place to provide midwives in private practice with the requisites that they need for the practice of their profession. Self-employed midwives beg for their ergometrine and borrow their syntocinon. As for oxygen, they might as well approach a deep-sea diver as request it from their local heath board, which has a legal duty to provide them with such items.

Looked at from an international perspective, Irish midwives are clearly lagging behind their counterparts in other countries. Prescribing rights are being talked about. Midwives already have them in many other countries. Yet here, a midwife cannot even advise a woman to take a panadol for after-birth pains. In yet another Alice-in-Wonderland scenario, the Nursing Board bans midwives from “prescribing” non-prescription drugs.

Meanwhile, Dublin hospitals are now so overcrowded that Dublin patients may soon be asked to travel to hospitals down the country to give birth. It is only a matter of time before some Progressive Democrat comes up with the idea of flying women in labour to hospitals abroad. As a solution to the chronic shortage of midwives, abolishing the restrictions on flying in pregnancy is surely the answer. That, and tax breaks for private units staffed only by obstetricians, as in Brazil.

©Marie O’Connor
Northern Standard on 8 May 2003

© National Birth Alliance An Chomhghuallaiocht Naisiunta Breithe