Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)

I move amendment No. 25:

In page 39, lines 24 and 25, to delete all words from and including "who" in line 24 down to and including "rules" in line 25.

We had detailed exchanges yesterday and this morning, but I regard this as one of the most important amendments before the House. Section 40 states that "no person shall, for reward, attend a woman in childbirth unless the person is (a) a registered midwife". I wish to delete the words after that. They are, "who maintains adequate clinical indemnity insurance in accordance with the rules". Paragraph (b) refers to registered medical practitioners, but I do not note anything stating that a medical practitioner must maintain adequate clinical indemnity insurance in accordance with the rules. This is a further indication of the almost two-tier attitude towards health professionals in some disciplines and midwives, most particularly, in the context of this Bill. The amendment is an important one. This section could severely curtail the ability of women to access midwife-led childbirth.

I have consulted widely with a number of midwives and midwives' representative groups. They have provided me with a range of important information. I have no doubt midwives wish their opinions to be reflected strongly at this time. We want to ensure that childbirth is safe and that all those providing care and assistance for women in childbirth are properly qualified, registered and accountable. That is an absolute essential. Let there be no doubt about that.

We also accept that indemnity is necessary. However, I argue that it should not be made a statutory requirement, as is provided for in the Bill. The better alternative is to make indemnity a requirement in service-level agreements, such as the current memorandum of understanding governing services provided by self-employed midwives.

Section 40(1), as drafted, paves the way for criminalising autonomous midwifery practice by setting terms of imprisonment. It is horrific to look at what is prescribed here. Terms of imprisonment of up to ten years are prescribed for midwives who assist in given birth situations and who break the extremely restrictive rules that underpin indemnity. It has been noted that doctors, for whom insurance is not legally compellable - something the House may not know - face no such threatened penalties. Nor is there any provision for other registered medical practitioners in the drafting of this legislation. Making midwifery indemnity a statutory requirement does not serve the public interest.

Section 40(1), as drafted, would enable the insurer, in this instance the State, to dictate the terms and conditions of childbirth for maternity service users. In other words, this tells women the limited options they may have and the circumstances that must apply. How far does the nanny state have to go? This intrusiveness in the rights of women is quite ridiculous. It is because of what has been described by the Community Midwives Association as "the minute and inflexible conditions attaching to this insurance". It is unobtainable, for instance, if a mother turns 40. We had echoes of that in the outrageous practices and the denial of compensation when horrendous acts were carried out against women by an obstetrician and gynaecologist in my region. The former Minister for Health and Children, under advice from outside this institution, decided that women over 40 who suffered those outrageous acts were not entitled to compensation. What is it about women at 40? I am sure when I go home I will be put out of the house for saying what I am about to say. My wife and I were very happy to be parents of a child after both our fortieth birthdays, and it was not just the next year either. I do not understand the notion that issues arise when women hit 40. There are none. It is a woman's right to decide and her health that will determine her decisions on any matter that may present.

This measure is very poorly thought out, or else it is something else entirely and is quite purposely being pursued to effect certain control, not only of midwives but of women's choices as to how and in what circumstances they wish to give birth. That is not on.

Section 40 (1), as drafted, restricts self-employed midwives from accepting various categories of mothers as clients. It further obliges self-employed midwives to abandon their clients in mid-labour - think about it - should they exhibit some change in their condition that is prohibited by the terms and conditions of the midwife's indemnity. A midwife could be attending a woman when a circumstance might present that, under the indemnity, excluded her from continuing to give hands-on care at the risk of ten years in prison. This is bizarre.

Making indemnity a statutory requirement threatens women's safety in childbirth. Section 40 (1), as drafted, leaves a mother whose midwife's insurance has just lapsed with two alternatives. She may give birth at home without professional attendance or face unwanted medical treatment in hospital. Women who do not fit the indemnity criteria are already opting to give birth at home without professional attendance. That fact is easily established.

Section 40 (1), as drafted, prohibits attendance by uninsured midwives, even in cases of sudden or urgent necessity. If a midwife whose indemnity had lapsed, in a social situation or going about her normal business, were to come upon a woman who found herself in sudden or urgent need, she would not be able to assist. She would run the risk of a massive fine or a term of imprisonment. The rest of us could rush to give assistance but the midwife, perhaps the only person in the company who had the necessary skills and knowledge, could not. This is absolutely outrageous.

At a time when many of the country's maternity units are threatened with closure, prohibiting emergency care by, for example, retired midwives does not make sense. Reference to the 2010 Royal College of Physicians in Ireland/Health Service Executive report on acute medicine will confirm this. Section 40(1), as drafted, significantly narrows the terms and conditions under which midwifery can be practised. The existing memorandum of understanding is anti-competitive in that it significantly restricts the client base of self-employed midwives and this, in turn, significantly restricts women's access to the services of such midwives. Self-employed midwives are and seek to be, insured. We are not arguing here for anyone not to be indemnified. The community midwives state and others in the sector agree, that safeguarding mothers against uninsured practitioners is easily achieved within a birth community that is relatively small and tightly knit.

Section 40, as drafted, would effectively deny women choice in maternity care. This is not in the public interest. Hospital maternity services are at risk all over Ireland. Plans are advanced to close many of the country's maternity units, as I know only too well in my county and community. Community services must be developed to take the place of these services and the Bill as it stands restricts this possibility.

Women not living in urban areas across rural Ireland have needs in childbirth that must be addressed. Some face journeys of two hours in labour to access in-patient care, such journeys often ending with a medical induction or a so-called, elective Caesarian. By effectively stifling midwives' right to offer services in the community, section 40 denies women the right to access community care from midwives. Self-employed midwives have been unable to access insurance on the private market in recent years. This is the situation today. The only indemnity currently available to them comes from the State and this is based on what can only be described as narrow HSE home birth services.

Section 40, as drafted, prevents midwives from providing all kinds of services in the community such as post-natal care and in Ireland the levels of post-natal care are among the lowest in Europe. The section, unless amended, will deny large numbers of women the freedom to give birth at home. It could lead to a rise in the number of unattended births. Mothers who do not fit the State's terms and conditions are already opting to give birth at home unattended. No mother should have to give birth at home without professional assistance. Section 40, as drafted, locks in an insurance package based on a HSE contract that ensures that indemnity can lapse from moment to moment depending on the progress of a woman's labour.

My amendment No. 25 is designed to reduce the risk posed by the current arrangements. These HSE terms and conditions are operated in such a way as to prevent midwives from exercising their clinical judgment and even from exercising their duty of care to mothers and babies. Self-employed midwives who feel ethically bound to continue to assist a home birth mother whose labour does not conform to insurance rules, for example, now face jail under this Bill. This is a recipe for unsafe care. Just in case the ten years' imprisonment did not shock Members, a significant fine can be applied to midwives who are outside of the terms of the HSE position. I do not have the figure to hand but it is noted in my notes.

Awards against midwives in the community are few and far between. Over the past 30 years, payouts in respect of self-employed midwives have come to less than €250,000 in total. This can be compared to other health professionals. I cited one instance earlier in my contribution with regard to an alternative to the midwife, an obstetrician gynaecologist who cost the State millions of euro in compensation. That was one consultant in a particular place and, sadly, there are many other examples. By criminalising midwives who practice outside the State's onerous terms and conditions, section 40 denies women the right to opt for a physiological service, one that is low-tech and drug-free. This is a right that has been recognised by the European Court of Human Rights. Section 40 even prevents midwives from offering services such as breast-feeding advice in the community, cutting women off from their services. The breast-feeding rates among community midwives' clients are among the highest in the European Union while national rates are among the lowest.

While midwifery-based care leads to better health outcomes for mother and baby and greater client satisfaction, it also reduces costs. Making midwives the main care-givers in the majority of births would save millions of euros. Data from the Netherlands show that while one woman in every four had a home birth, home births made up only 5% of the total cost of care. Here in Ireland a bed in one of the big teaching hospitals costs in the order of €1,000 a day. Therefore, a 10% home birth rate would result in savings which are difficult to calculate but would be in the range of between €7 million and €14 million annually, depending on the numbers born. This is without factoring in the cost of unnecessary Caesarian sections which I have already referred to in an earlier amendment. The Bill, as drafted, cuts off this possibility and I strongly urge the Minister of State to accept the bona fides of the argument, the absolute need to regard the registered midwife as a responsible professional who seeks to ensure the best possible care and attention for her client, the woman in labour. The addition of the statutory requirement for indemnity insurance is unnecessary. That it is quite purposely singles out midwives and ignores all of the other so-called medical practitioners, is insulting to the midwife profession as a whole.

See this speech in context