This is such a frequently asked question that I decided to write a blog on it. Why is it not a number that can easily and simply be looked up? The answer lies in the fact that there are so many care providers offering a home birth service and that all their data are stored in different locations. That doesn’t sound as if it can be true right? So many home birth providers? In Ireland? Really? Read on . . .
The main home birth service is operated under the auspices of the HSE and known as the National Home Birth Scheme. This is run on behalf of the HSE by Self Employed Community Midwives (SECMS), and since 2012 the service has been audited each year by the National Perinatal Epidemiology Centre (NPEC) in Cork. This service embodied what used to be the independent midwives and the Cork and Kerry Home Birth Scheme until September 2008.
The total number of births from this service will also be listed in the total number of births collated as part of the National Perinatal Statistics Report now coordinated by the Health Pricing Office (HPO). The HPO figures for home births are always a little higher than the NPEC figures as they include all home births whether midwives were present or not, and whether they were working as SECMS or not.
The second provider from which we have published data is the DOMINO home birth service coming out of the National Maternity Hospital (NMH). This home birth service has been running since 1999 and is part of the very successful community midwifery care provided from the hospital.
The third provider is Waterford General Hospital. They have had a community midwifery service in place for a number of years and at one point were facilitating many home births a year.
The fourth provider is Wexford General Hospital, They also have a community midwifery service in place and offer a DOMINO service. Again at one point they facilitated many home births each year.
Last but not least is the private service provider UK Birth Centres. This UK based company provides a private home birth service through its sister marketing company in Ireland Neighbourhood Midwives and has been offering home births since August 2014. Its first home birth in the Republic was on 11th October 2014.
So five different providers, but not one unified figure that encompasses all of the data from all of the services. The HPO provide data from Part Three of the Birth Notification Forms filled out by all home birth midwives and NPEC provide a detailed audit on the National Home Birth Service run by the HSE whilst the NMH in turn provide data from their own home birth service. HOWEVER these data are not linked together in any way. Instead, the NMH home birth data are produced as part of the overall hospital report, and so an interested observer would need to be able to search the NMH annual report, and know to search it in order to find the NMH figure to add to the HPO/NPEC figure.
There are no publicly available figures from Waterford and Wexford, and finding out how many home births are facilitated there requires calling the appropriate DMOs (Designated Midwifery Officers) or requesting the information through an FOI request or asking the Department of Health.
There are also no publicly available audits from UK Birth Centres at present. Even though Neighbourhood Midwives, the Irish sister company would be aware of the figures, they are not able to publicly release any audits as they do not technically own the data. However, the basic data of total numbers are available through the Department of Health and Children (DoHC) and in future years one assumes they will be reported by HPO via the Birth Notification Form that every home birth midwife has to fill in.
So now maybe its becoming clearer , , , all these different sources need to be identified individually and then collated in some way.
For 2013 the NMH data and the SECM data have both been released, for 2014 the NMH data have been released and for 2014/2015 the UK Birth Centre data have been estimated. It is therefore possible to make a guesstimate as to the total number of home births in Ireland from the most up to date data available.
HSE National Home Birth Scheme
UK Birth Centres
A composite total figure would be 277 if the NMH figures from 2013 are used, or 262 if the if the NMH figures from 2014 are used. The average of these two figures is 270.
Whilst not exactly an absolute accurate figure, it is fair to assume that based on the most recently available data, an average of 270 babies are annually born at home in Ireland, which is nearly DOUBLEthat which is regularly quoted by the press, academia the HSE and the DoHC alike. This also means that instead of home births accounting for 0.2% of the total number of births in Ireland, home births actually account for more like 0.4% of the total number of births in Ireland.
If more resources could be provided for Wexford General Maternity there is no doubt that these figures would be greater again. And lets not forget that in the recent AIMSI Survey #WMTY2014, with 2832 respondents found that 43.6% of respondents would choose community midwifery care (home birth with an SECM or hospital scheme) if it were available to them, so do not believe the stories that no one has a home birth or that no one wants to have on either!
Note: The extra 7 births recorded by the HSE/HPO via Part 3 of the Birth Notification Form are probably accounted for by planned unassisted/free births.
This day last year; 12th September 2015 Self Employed Community Midwife Philomena had not long delivered a baby and had some 29 women in her care. Some of those women were about to give birth, some had simply booked her for their births that were over six months away and others were receiving postnatal care for themselves and their babies.
At 5pm on the 12th September 2014 Philomena Canning was instructed by the HSE that she was no longer to continue care of her clients as her state clinical indemnity had been revoked and she was to hand over all of their files immediately to the HSE. Initially Philomena assumed there had been a misunderstanding and she would be reunited with her clients within the week, but this didnt happen.
On the 24th September and then on the 29th September she went to the High Court to seek an injunction against the revoking of her indemnity, but she was unsuccessful. In return for the indemnity the HSE wanted her to be supervised and work with a second midwife. Philomena rejected this offer and the suspension of her indemnity continued until she lodged an appeal. The appeal was heard at the High Court on the 27th February and and on the basis of testimonies of expert witnesses provided both by the HSE’s and Philomena s legal team the injunction was granted with full costs.
Everyone thought this would mean that Philomena would return to practice. But this was not the case. The HSE were running a second investigation in parallel with the one that had just been discredited.
Many women and midwives came to support Philomena at the court acourt appearances and they were understandably frustrated and angry, A lot of questions were left unanswered also. Women wrote to th TDs to Leo Varadkar and to their local councillors. and yet the situation remains that Philomena has still not returned to practice.
Philomena remains keen to return to work. However, despite being reinstated by the HSE back in February 2015, she continues to be unable to return to practice as long as the second HSE report (promised in March 2015, relating to the “incidents” at the centre of her suspension), remains unforthcoming. Even though independent expert witnesses have fully supported every aspect of Philomena s practice in both cases, the HSE are persisting with this report. It would be professionally compromising for her to return to work. until the HSE’s systems analysis report is complete.
In July The Philomena Canning campaign made the following statement “We are concerned at this report delay, most especially given the very real impact for clients seeking a home birth that her absence creates, with particular concern for women seeking it through the public health system.”
The Philomena Canning Campaign continued “We urge supporters to now contact their local TDs requesting they place parliamentary questions to Minister Varadkar when the Dáil resumes, as to the cause of the delay in the HSE investigation report. We’d also encourage those seeking home births to request information from their DMOs and to email HSE investigation head firstname.lastname@example.org to seek information on when the report publication is expected, as this is the single obstacle in the way of Philomena’s return. She can not be in as position that leaves her clients open to further compromise after the immense difficulties faced in the aftermath of her suspension in finding replacement midwives, not least due to the HSE’s handling of it for the clients affected.”
What did Philomena’s removal from practice mean for women booked with her?
One woman was due to give birth over that first weekend when Philomena was suspended.. No carer was put in place for her. Others were due to give birth over the next couple of weeks and no carers were made available for them either. The women were anxious frightened and apprehensive. Mostly they were also without antenatal care, which is not best practice, especially at term.
Some of the women were able to find other midwives to take them on within the national home birth scheme, others had to birth in a hospital setting, some were able to birth with the NMH home birth scheme and some were fortunate enough to be able to access private midwifery care. The last of the 29 women booked in with Philomena gave birth with the Community Midwives at the NMH in April this year.
The manner in which women had their carer removed from them without any alternative care being provided still remains an appallingly dangerous and callous act on behalf of the HSE.
What did this mean for other women seeking home birth in the areas that Philomena served?
Since Philomena’s removal from practice women in the areas of South County Dublin, Wicklow, parts of Wexford, Kildare, Meath and Louth have been without a free homebirth service with full continuity of care. Women in these areas have been able to access a private home birth service, but this is not an option for all women. In particular women on a medical card who fall outside the administrative catchment area of the NMH’s home birth service have been particularly badly affected. Philomena’s suspension has further served to highlighted the inequity of care in term of maternity choices and service provision in Ireland today.
Have any of the questions surrounding Philomena’s case been answered?
No answers have been forthcoming, and meanwhile the HSE’s continued refusal to produce the systems analysis report further delays the process and continues to cost the taxpayer a ridiculous amount of money in legal fees. Only the Minister and the Department of Health and Children can reign the HSE in on this one, When we think of the lack of services available in our maternity system and the desperate shortages of capital and staff, squandering public money by dragging out this case any further is particularly abhorrent.
The National Maternity Hospital at Holles St (NMH) has been offering a home birth service since 1999 to low risk women living within Community Care Areas 1, 2 and 3 in South County Dublin.
Last week they released their home birth figures for 2014.
In the period January to December the NMH Community Midwives team facilitated 40 home births. These can be broken up into first time mother births (nulliparous) and second time mother or subsequent births (multiparous).
Seven first time mothers gave birth within the scheme and thirty three second or subsequent time mothers, totalling 40 home births in all.
The number of mothers who planned to have a home birth and booked in with the scheme stating their intention to have a homebirth was 60 (20 first time mothers and 40 second and subsequent birthing mothers). Women transferred out of the scheme for a variety of reasons; some were antenatal (eg post dates), others were during labour (eg slow progress, others were due to maternal request for pain relief or meconium staining in the liquor). There were no transfers due to fetal compromise following birth.
The overall rate of transfer to hospital care in 2014 was 33%. This can be divided into first time mothers and other mothers as follows; in 2014 the percentage of first time mothers who signed up for a home birth and who achieved one was 35%, (65% did not) and the percentage of second or subsequent mothers who signed up for a home birth and achieved one was 83% (17% did not).
In 1999 – 2011, of the women that booked for a home birth, the percentage of first time mothers who achieved a home birth was 46% and the percentage of second and subsequent mothers who achieved a homebirth was 83%.
The figures for 2014 match this percentage of achieving a home birth for multiparous women (83%). but a significantly lower number of first time mothers achieved a home birth as planned than in the time period 1999-2011 (35% compared to 46%). This could be due to a number of factors. Since the total population of first time mothers planning a home birth is so small (20), individual variations can have a large statistical impact.
Since the criteria for risk assessment has remained the same throughout the scheme, and the criteria of transfer have also remained the same it is hard to identify particular reasons. It is possible that as with other aspects of the Maternity Services, the Community Midwives in the NMH are under greater pressure with more and more ETH (Early transfer Home) clients and tighter schedules. Could this affect the transfer rate of first time mothers? It has also been noted that the NMH is not currently in a position to extend or expand the home birth service, so perhaps more emphasis is being placed on recruiting first time mothers for the less labour intensive DOMINO scheme rather than the home birth scheme. Hopefully, it is an anomaly that will be redressed in this year s figures!
In 1999 – 2011 taking the total number of births into account, the ratio of first to second (and subsequent time mothers) achieving a home birth with the scheme was 17% to 83%, This is repeated with minimal deviation in 2014, with the ratio being 17.5% to 82.5%.
The figures from the National Home Birth Scheme as presented by the HPO have not yet been released for 2014, so we cannot say what proportion of home births nationally the NM home birth scheme accounts for. However, the figures from 2013 for the National Home Birth Service were released by the HPO recently. and the number of home births attended by independent midwives on behalf of the HSE totalled 162 births. Assuming these figures are relatively consistent for 2014 it is reasonable to assume that the NMH home birth service accounted for some 20% of home births in Ireland. (Note there were some private home births carried out during 2014 by a private midwifery company but no figures are available on these yet, and since the service only started in the final quarter of 2014 the figures are not yet likely to be large enough to alter a 20% odd share held by the NMH)
The home birth service provided by the NMH is a public service run through the HSE. Its main appeals quoted by mothers are that it is free, that there is continuity of care should there be a need for transfer to the hospital, that ambulances are put on standby when the mother goes into active labour, that distances to the hospital are no more than 20 minutes in rush hour traffic, that the risk criteria are not as tight as those used in the MOU, e.g. a higher BMI is acceptable, and women over the age of 40 are routinely accepted onto the scheme and that hospital services are very easily accessed antenatally and postnatally.
The downsides to the service quoted by mothers is that not many of the visits occur at home, that there is a team of midwives so there is no guarantee as to which of them will be with you in labour, that since the scheme is run from a hospital that prides itself in active management, some of this ethos might pervade the community midwifery team and finally that even though the scheme supports women labouring in water, it does not support water birth itself, and women are asked to stand up out of the pool or get out of the pool for the birth if they have been labouring in water prior to the birth.
The Community midwives at NMH can be contacted at (01) 637 3177
In this guest blog Home Birth Mother Rachel Singleton shares her birth story.
For my first birth I had an emergency c/section due to a breech presentation. In order to secure a HBAC (Home Birth After Cesarean) for this my second baby, I had to birth in the UK. I was due to sit my midwifery final exams in TCD in Dublin in early December 2013 and William was due at the end of December. I was studying away the week before the exams when my daughter became very ill and couldn’t go to crèche. I was petrified of having to give birth in a hospital if I went into labour before I got to England. The stress of the whole situation caused my body to give off signs that labour was imminent and we made the decision to travel to the UK early – just in case – especially since my little girl had arrived at 37 weeks. This was December 3rd 2013.
Days and weeks passed and nothing happened, my due date came and went, the birth pool which had sat in the living room was now hidden under the bed upstairs well out of sight. My husband had to return to Ireland for a meeting on the 3rd of January. After all this time waiting we didn’t think William was going to show up at all!!! I got up at 6am on the 3rd of Jan 2014 and dropped Mark to the airport and came home for a nap.
I awoke feeling slightly odd; seeing as Mark was in Ireland I thought I would check to see if my cervix had started to dilate, I was shocked and horrified to find that I was 4cm dilated, after a NAP!! Then the contractions started!!
The reality of birthing in a home that isn’t really your home is that you can find yourself alone. That’s exactly the reality I faced. I was alone – well I had my 22 month old daughter for company, but essentially I was alone.
I rang Mark and told him to come back to England ASAP. Alone with my daughter, I brought her downstairs for breakfast. NOW contractions had started coming regularly and hard. I had to lie on the floor each time one took over my body, my daughter would stand over me rubbing my head asking “K mommie?”
The next task was the pool. I had stored it out of sight under the bed up stairs, I went up and dragged it out – between contractions – pulled it down the stairs and set about trying to blow up the pool up. First the seat, then the two lower sections. Then, on my own and alone I had to fit the cover, Finally I blew up the last section of the pool.
Contractions had started about 11am and this was now about 1pm.
I did call my midwife and my mother in-law and both were trying to get to me.
Pool finally up and now the contractions were very powerful and all-consuming; my poor daughter was toddling around the room entertaining herself while I tried to fit the hose to the tap in the kitchen to fill the pool in the living room.
Finally fitted I dragged the hose from the kitchen into the living room. I went back to the kitchen and turned on the tap – back to the living room – too cold, back to the kitchen turn up the hot, back to the living room, too hot now – and so on until I had the temp right.
Mark called, there were no flights till 3pm or 8pm; we were in real danger of him missing the birth and of me being alone the whole time. My daughter is the only real witness to my labour. By now I was in the pool and in a world of my own as she watched on. Finally, my mother in-law arrived, she took Lottie and left me to it. Alone, but in my own lovely labour space, and in a way I was exactly where I wanted, and needed to be.
I was alone for most of the actual labour, which I quite liked, but this was a tough labour, with my daughter’s labour I had felt no pain with contractions, but this time around it was so intense I remember thinking I would like to have the forceps, or at least an epidural. Each contraction I worked through I had to talk myself into staying where I was. I just wanted a break from the contractions!! Being alone was though, and as I was finding the contractions hard work I would tense up with each one and breath heavily, trying to contain or control each powerful wave, and that was using a lot of energy. The powerful feeling inside me was so strong, it felt like my body was trying to take off and I was trying to hold myself onto the ground.
At 2pm I check myself again and I was fully dilated and still alone. Mark was in Dublin airport waiting for his now delayed flight. By 15:15 a midwife was with me and Mark was still in Dublin!
With the midwife by my side now she told me to try and relax with each contraction instead of tensing, so with the next one I let my body relax and go floppy; I just gave into the power of the contraction. This was birth scary and empowering. Relaxing didn’t make it less intense but it helped me give into labour and let go. I had to succumb to the power of what was going on in my body and give up trying to contain it.
Soon after 3pm I began pushing, pushing removed all the pain of the contractions but it was hard work and I was exhausted, I have never pushed so hard in my life and each time a contraction came I had to work hard to do it. If I pushed there was no pain, but I was also too tired to push, so I made a deal with myself, push with every second contraction, take the pain on the others, Mark STILL wasn’t with me.
Asking where he was and waiting for him, kept me in the here and now and prevented me entering that relaxed detached state where you let labour take over. I had to stay present and worry about where Mark was and when, or if, he would make it. I pushed for what seemed like hours and got, I felt, nowhere. The reality was that I had been pushing for almost two hours. At this point I was declining fetal heart monitoring as I couldn’t stand to be touched and I knew my baby was OK. It seems ridiculous now, but I was talking to him and we were working together to complete his birth. Having someone put a Doppler to my stomach every 5min was only disrupting this delicate process.
In the UK two midwives are always present for a birth and as it appeared that Mark would miss the birth, I asked that the second midwife to start photographing the birth, once she started she kept going until he was born and we have ended up with a lovely record of the birth.
When I really felt I could no longer push any more Mark finally arrived. It was now 5:15. I had been desperately missing him to pull on, his strength helped me push and I needed him to ground me and give me renewed strength.
Now I pushed in earnest. It felt like forever, then the midwife said the head had crowned but wasn’t fully extended, The head felt massive and I was scared to push it out completely but had no choice. Then I felt a massive “pop” and the head was out, I remember saying to the midwife “Oh no, I think I ripped”. Then the contractions stopped and I had a rest, my son had decided to come as a compound presentation with his hand right up by his face. This was part of the reason that pushing took so long and so much effort. After a while I heard the midwife say to Mark, “If the baby doesn’t come with the next contraction I’ll need her out of the pool”, I started to panic, thinking I was going to have a shoulder dystocia. The next contraction came and the midwife pulled William’s hand straight to assist him out. When he was finally born I physically couldn’t pull him up from under the water due to a combination of my exhaustion and his sheer size, we later found out he was a 4,1kg or 9.3 lb baby; a massive size for a first vaginal delivery with a compound presentation!
Then we all sat in shock, amazement and thanks. We were all here to see Williams first peaceful breath in (almost), our own home!
The window for Home Birth after Caesarean (HBAC) in Ireland has opened again for some women
Prior to the Memorandum of Understanding (MOU)between self employed midwives and the HSE (which was drawn up in 2008 for the national homebirth service), women routinely availed of home births following a caesarean section, subject to an individual assessment by an independent midwife. The MOU stated that HBACs are too risky based on the HSE’s internal risk assessment and that all VBAC attempts should take place in a hospital setting.
The HSE’s risk assessment on VBAC in the community in turn informs the State’s Clinical Indemnity Scheme (CIS), which will not offer indemnity to self employed community midwives working in the community to attend HBACs. However, the self employed community midwives who carry out home birth care on behalf of the HSE are required by legislation (The Nurses and Midwives Act of 2012) to be fully indemnified in order to offer care in the community Currently, the only available indemnity for a self employed community midwife is that offered by the CIS. Self employed midwives are therefore prevented from taking women on who have had a previous caesarean birth, even if they have successfully birthed at home before. Therefore in Ireland as of 2008, there have been no indemnified HBACs attended by self employed community midwives.
Instead women travelled outside the jurisdiction to avail of a HBAC, or they birthed alone without professional medical attendance. Read Rachel Singleton s journey to the UK to have her HBAC here.
She lost that high court case, and went on to have her baby in the UK.
Aja ‘s case threw into the limelight the issues surrounding the safety of VBAC and also the VBAC rates in Ireland. Until March 2014, there were no VBAC rates released by the HSE. However last year the HSE released its VBAC rates to AIMSI
The figures show that VBAC rates are very low, although AIMSI issued a caveat with the data saying that it was possible that some of the hospitals with a 0% VBAC rate may have had problems with data coding. The highest rate for VBAC in Ireland is in the National Maternity Hospital with a rate of 33%. Some hospitals however, have a very low rate indeed of less than 5%. Coupled with a high primary cesarean rate, these figures are understandably worrying for mothers who are hoping for a normal delivery on their first baby or for a VBAC on a subsequent baby in hospital. A point also worth bearing in mind with respect to the interpretation of published VBAC rates is whether the VBAC rate is based on all women with a previous cesarean, who birthed in that hospital or whether the rate quoted is just based on those women with a previous caesarean who have already been pre selected for a trial of labour in that hospital. So, a maternity unit might have a high rate of repeat cesarean and only allow a very small number of low risk women to attempt a VBAC and so that hospital may then achieve a high VBAC “rate.”
Why are the VBAC rates in Irish Maternity units so low? Part of the reason is our heavily medicalised approach to birth, but also partly because of the fear that health care professionals have of uterine rupture. However, the quoted rates of uterine rupture are often erroneous. It is often routinely quoted as 1 in 200 (0.5%). However, the research indicates that it is nowhere near that high in large maternity hospitals where women are properly screened. Neither of course, is it anywhere near that high at home.
“In a woman with one previous caesarean, the decision to opt for a planned elective repeat CS or a planned trial of labour may be influenced by the perceived risk of UR. National guidelines and large reviews quote different risks, for example, 0.2-1.5% (SOGC 2005), 1.0% (WHO 2005), 0.2-0.7% (RCOG 2007), 0.5-.7% (RANZCOG 2010), 0.5% (AHRQ 2010), 0.5-0.9% (ACOG 2010). In the setting of a large Irish maternity hospital with strict guidelines for a TOLAC, the UR rate was 2 per 1000 overall, and 1 per 1000 for women in spontaneous labour who did not receive oxytocin augmentation”
(Turner et al, 2006). Quoted in http://www.hse.ie/eng/about/Who/clinical/natclinprog/obsandgynaeprogramme/guide5.pdf
Furthermore, if a uterine rupture should occur, the National Obstetric Guidelines Suggest that the the chances of a baby dying as a result are very low at 0.001%.
The overall rate of rupture-related death with a TOLAC is low and has been estimated as 1 in 1000 approximately (Landon et al 2004; Scott et al, 2011). One study reported no serious neonatal morbidity in 78 cases of UR when less than 17 minutes elapsed between a prolonged fetal heart rate abnormality and delivery (Leung AS et al, 1993). In a Dublin study of 4021 women undergoing TOLAC,
there were no cases of HIE or intrapartum death (Turner et al, 2006). Quoted in http://www.hse.ie/eng/about/Who/clinical/natclinprog/obsandgynaeprogramme/guide5.pdf
It is not surprising that with the stresses and limitations placed on successful VBAC in hospital so many women are keen to have a VBAC at home; a HBAC. Many women who have previously birthed at home, but who may have been required to have a cesarean due to an isolated issue with a previous pregnancy e.g. transverse breech would also like to have a HBAC.
We already know that opting for a home birth for any woman will reduce her chances of a cesarean, so opting for a homebirth as a HBAC should be no different. It might in fact be the best treatment a woman with a previous cesarean needs in order to avoid a repeat unwanted cesarean.
A study way back in 1997 in the UK “Home Births – The report of the 1994 Confidential Enquiry by the National Birthday Trust Fund Edited by Geoffrey Chamberlain, Ann Wraight and Patricia Crowley
Parthenon Publishing, 1997.” looked at the safety of home births and part of the study included looking at the outcomes of a small number of HBAC mothers (53). The study found that 72% of them gave birth at home without incident and 28% transferred into hospital care (antenatally or during labour) where some of them went on to have a VBAC in hospital.
The primary risks associated with uterine rupture are unlikely to occur at home, for example there will be no oxytocic drugs used, there will be no induction of labour, there will be no CTG, and there will be no labouring by the clock. Equally as important, the mother will not be left on her own, but will be closely observed throughout her labour by a midwife who knows her and her baby, and who has given her and her baby full continuity of care, and as in a hospital setting she will have been screened as suitable for a HBAC. However, in the unlikely event that a mother having a VBAC should have a uterine rupture; hospital would definitely be the safer place to have one, due to potential issues with transfer times from a community setting.
There is also no getting around the fact that a woman with a previous cesarean is of a higher risk than a woman without one. Mary Cronk, MBE, independent midwife and breech presentation expert once commented at a HBA conference that a breech presentation was a “normal” presentation, but a woman with a previous cesarean was not. A previous cesarean is a risk factor that will follow the woman antenatally in all of her labours, so does this make birthing at home less safe than hospital for women with a previous cesarean? That we don’t know. We do however have data from Ina May’s birth centre The Farm, where she has carried out 2100 births with no uterine rupture and a section rate of 4%. And more importantly what we do know is that women should have the choice to birth where they feel most safe and most supported, and what we do know is that women should be entitled to an individual assessment.
Also recent research reported in the ICAN website (March 2014) suggests that the success rate for HBAC is higher than might previously have been thought.
“The Midwives Alliance of North America (MANA) recently published data from a large and well-tracked series of planned home births, the result of a home birth registry program that was initiated in 2004 . The data set included nearly 17,000 planned home births attended by a mix of midwives including CPMs (79%), CNMs (15%), and other unlicensed midwives. Within this cohort were 1054 women with a history of cesarean section who were planning a . . . “HBAC” . . . Within this subgroup, 87% had successful vaginal births, with 94% of those births occurring at home and the remaining 6% occurring after a transfer to a local hospital. This success rate is substantially higher than the 60-80% success rate reported across other large hospital-based cohorts and likely reflects the high level of commitment to and support of natural birth, both from the mothers and their care providers.” http://blog.ican-online.org/2014/02/28/new-survey-shows-high-success-rate-for-vbacs-at-home/
Amy Haas in an article for Midwifery Today identified the following risk factors for HBAC 1. Previous infection of uterine scar site (weakens scar) 2. Pregnancy less than 18–24 months after previous c-section (causes greater stress on scar) 3. Induction of any kind (causes stress on scar) 4. Placenta covering uterine scar (cause physical stress on scar) 5. 42 weeks+ gestation (associated with greater risk of cesarean) 6. More than one previous cesarean (if no previous vaginal birth)
She also identified the following low risk factors 1. General health (if a woman is in good health then her chances of a successful HBAC are high) 2. Reproductive history 3. Number of previous c-sections(the fewer the previous sections the greater her chance of achieving a successful HBAC) 4. Previous vaginal births (the greater number of previous vaginal births the greater the chance of achieving a successful HBAC) 5. Time since last c-section (More than 24 months since a previous section will enhance a woman’s chance of a successful HBAC) 6. Infection experience (no previous scar infections will increase a woman s chance of a successful HBAC) http://www.midwiferytoday.com/articles/HomebirthAfterCesarean.asp
This blogger agrees that HBACs are on the whole safe but suggests two potential risks for HBAC
The other two main risks of HBAC are the family’s distance from a hospital, and the abilities of their care provider to support normal birth, to detect signs of problems and to address them in a timely, competent way. So, it is wise to carefully select HBAC assistance; most of the information you need is the same information about midwives that all families need with respect to a midwife’s training, knowledge, and usual routines. You should also ask about each available midwife’s knowledge and experience with HBAC. https://womynwisespeaks.wordpress.com/informed-choice/hbac/
For a few months in the late summer last year (2014) a private midwifery company, UK Birth Centres/Neighbourhood Midwives had clinical indemnity to offer HBAC as an option to women in a few locations in Ireland, and then out of the blue this indemnity was unexpectedly withdrawn. A couple of mothers managed to have a HBAC with the company, but many HBAC clients hoping for care in the community were devastated at the thought of having to go into hospital care and face into our medicalised maternity services with their low hospital VBAC rates.
However, today there is hope for HBAC women again as the clinical indemnity enabling UK Birth Centres/Neighbourhood Midwives to provide an individual assessment process for a HBAC service to women with a previous cesarean section is in place again.
“Neighbourhood Midwives are delighted to announce that our partner UK Birth Centres are now able to offer even more homebirth choices to families in Ireland, including mothers with a previous caesarean birth (VBAC). As always, the safety of our clients is our paramount responsibility and we will continue to offer individualised assessment to all our potential clients. Mothers with a more complex history, such as a previous caesarean birth, should be assessed by a specialist and fortunately we can now offer that service if needed. We intend to roll out our new choices cautiously to help maintain our 100% safety record, so mothers with more than one previous caesarean births will be offered support in hospital or private birth suite options when available in their areas.” UK Birth Centres/Neighbourhood Midwives
At present the company are only offering individual assessment for HBAC to women with one previous cesarean. Women hoping for a HBACx2 are currently not eligible for the service, however, hopefully this will change with time, and women looking for HBACx2 will also be able to avail for the individual assessment process.
Our national guidelines on VBAC(2) state that it should be supported when the head is engaged, the cervix is favourable, when there is a history of prior vaginal birth and when the onset of labour is spontaneous. So all women hoping for a HBAC(2) should be aware of these during their negotiations in a hospital settings.
“Evidence for VBAC2 has shown that women choosing VBAC vs VBAC2 have similar rates of uncomplicated vaginal birth. The rate of major complications is slightly higher if you have had more than one previous Caesarean Section. However, while the risk of major complications is higher for women with 2 previous Caesarean Sections, when compared to the risks for elective Caesarean Section, the absolute risks of major complications are quite low.”
Women planning a VBAC in hospital settings, find that their birth choices are routinely held to ransom by the HSE’s National Consent Policy which cites the 8th Amendment to the Irish Constitution, (and therefore the safety of the unborn as defined by obstetricians and other HCPs rather than by the mother herself). Sometimes women are even threatened with high court actions. These women, will now be able to exercise autonomy in their birth choices and will hopefully have the option of a HBAC with UKBC/NM.
Obviously, this is only a choice for those who can afford it as it is a private service and so many women without insurance or women that are medical card holders may be priced out of the market. Hopefully by demonstrating safe outcomes, this private service might encourage the HSE;s public homebirth services to look more favourably at restoring a public HBAC service.
The window for Home Birth after Caesarean in Ireland has closed again for now. For a few weeks, UK Birth Centres/Neighbourhood Midwives had clinical indemnity to offer this option to women in a few locations in the country. However, the clinical indemnity enabling them to do so has been withdrawn preventing them from offering this option in the UK, NI and the Republic.
Two women were able to have a home birth after a caesarean with this model of care during the last month.Women with previous caesarean currently on the company’s books and availing of continuity of care throughout their pregnancy will be assessed on an individual basis to continue care. Women who were planning only 5- 6 weeks care with the company at the end of their pregnancy and are not yet receiving care will not be able to continue with their planed model of care, but will have to attend hospital services.
The company’s indemnity for other home birth clients remains in place and they state that they plan to continue to offer care to women who fall outside the HSE s rigid MOU criteria.
Women seeking care from the HSE need to source a midwife, or a hospital based home birth scheme and then be assessed for eligibility. Only women with low risk pregnancies are considered suitable for home birth by the HSE in Ireland. Once accepted on the National Home Birth Scheme or on a hospital scheme women are visited at home during their pregnancy or they visit a midwives clinic.
Women seeking private midwifery care, will need to contact the private midwifery company and be assessed for eligibility. Eligibility criteria are less strict than those set out by the HSE, and allow for more individualised assessment. Once accepted, women will need to arrange a payment plan and negotiate a date when private care with the company will start. Until that time women will need to receive care from other sources; either public (GP or hospital), semi-private( hospital care) or private (hospital care).
In all cases women must also book in with a maternity unit or a maternity hospital so that their midwife can refer them in for more specialised care should the need arise. This will also be the unit that will take over the woman’s care should she or her baby require it. HSE patients are automatically treated as public patients in hospital care and codes of governance exist between the hospital and HSE home birth providers. Private midwifery patients can also choose to book in as public patients in the hospital.
The National Home Birth Service is a public service and consists of 10 visits with a midwife (taken during the antenatal and postnatal period) and the birth itself. The duration of care lasts from booking to 2 weeks postpartum. Extra visits during the pregnancy are taken with the GP and are free of charge as they are covered under the Maternity and Infant Scheme. However, women may chose to avail of more visits with their midwife antenatally or in the postpartum via a private arrangementwith their midwife. Many women, for example, wish to extend their care until 6 weeks postpartum when breastfeeding is more established. The service includes an anomaly scan taken at about 20 weeks and many midwives ask their clients to take a dating scan at about 12 weeks
When labour starts a woman will be attended by her midwife and by a second midwife if one is available. Most midwives offer the option of a waterbirth. If you need to transfer to hospital care during labour your midwife may be able to continue care for you in a hospital setting, but equally may not be; it will depend on what local governance arrangements have been put in place.
After the baby is born the midwife will come and visit you for a period of two weeks. During this time you will also be required to have your baby checked by a GP or a paediatrician and you will also be offered the opportunity to have your baby’s hearing screened at a local hospital.
Hospital home birth schemes are public services and are available via The National Maternity Hospital, Dublin, Waterford General Hospital and Wexford General. The service consists of routine antenatal visits once a month until week 34, when visits for first time mothers may then be every two weeks (36 and 38 weeks). After 38 weeks women are seen weekly. The duration of care lasts from booking to 2 weeks postpartum. Extra visits during the pregnancy are taken with the GP and are free of charge as they are covered under the Maternity and Infant Scheme. The service also includes an anomaly scan at 20 weeks and other early scans such as dating scans and nuchal scans if required.
When labour starts you will be attended in your home by two midwives. If you require transfer to hospital your midwives will continue to attend you and transfer with you. Hospital schemes do not tend to offer waterbirths, but do offer the option of labouring in water. After your baby is born, you will be attended at home for about 10 days, and you will have access to free hospital postnatal services such as lactation consultants, physiotherapy and baby massage classes.
Waterford Domino/Home Birth Service Phone Janet Murphy 087 9243538
Wexford Maternity UnitPhone Sue Ryan 053 9153000
A newly founded private midwifery company, Private Midwives Ireland offers home birth to women in some areas of the Republic, notably Dublin, the North East at present. Their fees vary depending on when you start care and how many antenatal and postnatal visits you decide to take on. They charge approximately €6,000 for a full midwifery service from early booking to 6 weeks postpartum. However, starting care at 20 weeks can reduce the fee to around €5,000 and starting care at 35 weeks can cost as little as €3,500. This is a fully privatised service and women receive all their antenatal care at home or with their GP. Women can book in for an anomaly scan at about 20 weeks with their local unit, or arrange one privately.
Women can opt for this service having taken care in a hospital setting previously (usually publicly).
When labour starts you ill be attended at home by a midwife and a second midwife. Most midwives offer the option of waterbirth. If you need to transfer your care to hospital care during labour your midwife will not be able to continue care for you in a hospital setting but may by prior arrangement attend as your doula.
More information on Private Midwives Ireland can be found here
Other home birth services may be offered locally. For more information contact the following.