Dáil debates

Wednesday, 9 November 2022

Saincheisteanna Tráthúla - Topical Issue Debate

Health Services

9:32 am

Photo of Holly CairnsHolly Cairns (Cork South West, Social Democrats)
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In August, we learned of a HSE proposal to limit home births to women and families who live within 30 minutes of a maternity hospital. This would have far-reaching consequences for families in rural areas who would be denied access to these maternity services. Home birthing will be prohibited in large areas of counties Cork, Kerry, Clare, Galway, Mayo, Donegal, Monaghan and Wicklow. This will impact thousands of families. The proposal was greeted with shock from midwives and women. The Midwives Association of Ireland and the Community Midwives Association have come out strongly against this plan.

On Sunday, there was a large protest outside Cork University Maternity Hospital. Families, parents, grandparents and children all turned out to oppose this attempt to remove people’s choices. Those who are directly impacted by this proposal do not want this. The healthcare professionals who run the service do not want this. Why is it being proposed? Who is pushing this agenda, and why?

This must be a political or a managerial decision, because it is not evidence based. Home births are safe. The current systems function well. They should be improved on and developed and not shut down. Community midwives provide an incredible service and this plan is doing them a considerable disservice. From experiences with friends and family, I cannot speak highly enough of the care and caution provided by community midwives. It is disgraceful that the HSE and the Government do not appreciate this.

The report on this proposal has no evidence base. It refers to an evidence review from 2015 and it states that at that time, "No studies were found that focused on transfers from stand-alone midwifery-led units, or home births and any adverse outcomes”. The report itself admits that it has no medical basis for this massive policy change, so why is it being proposed? I have to repeat the question. Who is pushing this and why? Can the Minister of State clarify if this is a political decision? The HSE is perpetuating a misconception that home births are not safe. They are safe. If it is so adamant expectant families need to be within 30 minutes of maternity hospitals, perhaps they need to look at providing maternity services in west Cork and other rural areas. The utterly ridiculous basis of the plan is that if home births can only occur within 30 minutes of maternity hospitals, then all pregnant women should never be more than 30 minutes from a maternity hospital, as they can go into labour at any stage.

We should have birthing clinics and midwife-led services across rural and urban areas, supported by well-resourced ambulance services. Why instead is the HSE being permitted by the Government to ban home births in rural Ireland? Rather than addressing the actual problems with the maternity services, time and energy is being wasted on this plan which has excluded midwives and has left thousands of families deeply worried about their reproductive choices.

Can the Minister of State outline what plans are in place to address the more than 100 unfilled posts in maternity services in hospitals in Munster? The staff shortages in our maternity services have been described as critical this week. Midwives in Tipperary University Hospital have warned that staff shortages are causing risks to the safety of women and babies. What is the HSE’s response? It is to force more families into already over-stretched hospitals. In this context, the plan is not only not evidence based, but it is also irresponsible and dangerous. The Minister of State has to stop it now.

9:42 am

Photo of Frank FeighanFrank Feighan (Sligo-Leitrim, Fine Gael)
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I thank Deputy Cairns for raising this important issue and I acknowledge her ongoing work in the area of women's health. As the Deputy is aware, the HSE's national home birth service moved from community operations to acute operations within the HSE earlier this year. The home birth service is now being integrated into the maternity networks in line with the national maternity strategy. The core aim of that strategy is to provide safe, high quality maternity care to the women of this country. As part of this transition, the HSE's national women and infant health programme, NWIHP, was asked to provide more specific guidance at national level regarding the appropriate distance a woman should live from a maternity hospital while accessing home birth services and to make a recommendation on this issue.

Using both obstetric and midwifery expertise, the NWIHP issued national guidance on home births on 14 July recommending, from a clinical perspective, that it would be safest that all women accessing the HSE's home birth services would reside 30 minutes or less blue-light distance from their nearest maternity service.

When making this recommendation, the NWIHP took into account a range of factors, including the historic transfer rate into maternity units of mothers who laboured at home in the national home birth service, the primary reasons why women were transferred, the method of transfer, the need to factor in ambulance response times, the time needed to transfer the woman into the ambulance and the time until assessed upon arrival at the hospital.

The HSE's recommendation addresses the balance of risk that needs to be considered for home birth services. For example, if a woman has an emergency in a maternity hospital, and if a category 1 caesarean section is required, the woman must get to theatre within 30 minutes. In the event of a serious risk to a mother or baby in the HSE's home birth service being identified by the self-employed community midwife, this recommendation is designed both to ensure the best possible chance of getting to a maternity hospital in a timely manner to ensure the best outcome for mother and baby and to ensure that the clinical determination of the self-employed community midwife is acted upon in a safe and timely manner.

While I understand that the HSE's recommendation has caused concern for some, it is important to note that a geospatial analysis carried out by the HSE indicates that coverage will remain for 83% of the female population of childbearing age. While the home birth service represents only 0.7% of overall births, the HSE and NWIHP recognise that it is an extremely important pathway for women.

I would like to note that while choice for women is an integral part of our maternity services and of the national maternity strategy, the need to ensure safety must always be paramount. The objective of this measure is to enable the continuity of the home birth services whilst ensuring the best outcomes for mothers and babies in line with the objectives of the national maternity strategy.

Photo of Holly CairnsHolly Cairns (Cork South West, Social Democrats)
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I do not understand what the Minister of State means when he says, “from a clinical perspective”, because like I said in my opening remarks, the report on this proposal has no evidence base. It refers to an evidence review from 2015 and I am going to quote it again. It says that at that time, "No studies were found that focused on transfers from stand alone midwifery led units, or home births, and any adverse outcomes”. When the Minister of State speaks about a balance of risk, I think he needs to specify what he is talking about because he too is perpetuating that misconception that home births are not safe. He says things like “best outcome”, “timely” and "safe”, but what is he basing that on, because there is no evidence to say that home births are not safe? I have to presume that the Minister of State does not actually realise the reality of them, which is that women are seen so often throughout their pregnancies and are very often referred to the hospital. This is only allowed to go ahead if the pregnancy is suitable for it. It is not what the Minister of State is making it out to be. That is something that he needs to look into.

I am still unclear about the motivation for this plan. Who is pushing for it? None of the relevant stakeholders wants it. Midwives are opposed to it. Families are protesting against it. Again, there is no evidence to support it. This is about quality maternity services and reproductive choices. Home births are safe. They are the preferred options for many families. The Government and HSE should be supporting people, not restricting their healthcare options. I really encourage the Minister of State genuinely to look into this instead of reading off that script, because it is misinformation.

A ban on water births is another limitation on reproductive choice. The Midwives Association of Ireland has called this ban "non-evidenced based, unethical and inequitable". The Minister of State must also be aware that the ban will put some women and infants at increased risk. There are people who for personal reasons and convictions will have a homebirth regardless and they will be intentionally left without healthcare professionals now if this goes ahead. This is about reproductive choices and maternity healthcare that is genuinely centred on women and families. Unless the Minister of State intervenes, it will in essence be his Government’s policy to ban home births in rural Ireland.

Photo of Frank FeighanFrank Feighan (Sligo-Leitrim, Fine Gael)
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The Government and the Department of Health remain fully committed to the implementation of the national maternity strategy, including the development and delivery of home birth services. The 30-minute blue light distance that has been recommended by the HSE’s national women and infant health programme seeks to ensure that as many women as possible who wish to can access HSE home birth services in a manner that ensures the safety-----

Photo of Holly CairnsHolly Cairns (Cork South West, Social Democrats)
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It is doing the opposite of that.

Photo of Frank FeighanFrank Feighan (Sligo-Leitrim, Fine Gael)
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-----of both the mother and the baby. In making this recommendation, the NWIHP has taken into account many factors associated with home birth services and having looked at those factors, using obstetric and midwifery expertise, the NWIHP has sought to address the balance of risk that needs to be considered before providing the choice-----

Photo of Holly CairnsHolly Cairns (Cork South West, Social Democrats)
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Could the Minister of State publish those factors, then?

Photo of Frank FeighanFrank Feighan (Sligo-Leitrim, Fine Gael)
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-----of home birthing experience and the safety of the service for the mothers and babies who are in the care of the maternity services. To conclude, I again acknowledge that this has caused huge concern for some and that a small number of prospective parents are disappointed as a result.

I thank the Deputy for raising this important issue but I reiterate that guidance issued by the HSE is based on a clinical perspective-----

9:52 am

Photo of Holly CairnsHolly Cairns (Cork South West, Social Democrats)
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It is not.

Photo of Frank FeighanFrank Feighan (Sligo-Leitrim, Fine Gael)
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-----and the recommendations will help deliver safe outcomes for those accessing the services. The Department of Health and I will continue to work with the HSE's NWIHP to ensure maternity services continue to develop in line with the national maternity strategy.

The Deputy raised a few concerns and, if she wishes to email them to me, I will raise them with the Department.

Photo of Holly CairnsHolly Cairns (Cork South West, Social Democrats)
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Will the Minister of State publish those clinical decisions he keeps referring to?

Photo of Frank FeighanFrank Feighan (Sligo-Leitrim, Fine Gael)
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I will raise the matter with the Department.